Strengthening Intersectoral Collaboration to Improve Complementary Feeding Policies and Practices in Nigeria: An Ecological Systems Perspective

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While Nigeria has introduced several national policies promoting intersectoral collaboration, implementation challenges remain, and key indicators continue to lag. Although existing literature recognizes the multisectoral drivers of complementary feeding, there is limited insight into how policymakers and stakeholders can effectively harness intersectoral collaboration to strengthen policy implementation and practice. Objectives This study aims to explore how intersectoral collaboration can be operationalized to strengthen the implementation of complementary feeding policies and practices by examining stakeholder perspectives on key challenges and enablers, mapping collaboration across sectors and levels of government, and understanding how systemic, community, and household-level factors shape feeding outcomes. Methods We employed a qualitative case study design, informed by Bronfenbrenner’s Ecological Systems Theory, to explore the multilevel influences on complementary feeding practices in Nigeria. Semi-structured interviews (n=20) were conducted with purposively selected stakeholders, including policymakers, primary health workers, caregivers, and representatives from non-governmental organizations, to ensure sectoral diversity. Thematic analysis was conducted, with findings organized across the micro-, meso-, and macro-levels of the ecological framework. Results At the microsystem level, caregivers described cultural norms, limited support networks, and financial barriers shaping feeding practices. The mesosystem level revealed fragmented service delivery and inconsistent community engagement. At the macrosystem level, challenges included limited funding and weak policy enforcement. However, participants also identified emerging political will evidenced by the Vice President’s leadership of the National Council on Nutrition and initiatives such as Nutrition 774, national coordination platforms, and grassroots innovations, as potential facilitators of improved intersectoral collaboration. Conclusions Improving complementary feeding in Nigeria requires coordinated action across household, community, and policy levels. Empowering frontline workers, strengthening feedback loops, and clarifying sector roles can close the gap between policy and practice. Sustained progress hinges on dedicated funding, shared accountability, and leadership that rewards collaboration. Complementary Feeding Intersectoral Collaboration Ecological Systems Theory Child Nutrition Health Policy Nigeria Background Complementary feeding, as defined by the World Health Organization, is the practice of providing children with solid or semi-solid foods in addition to breast milk or formula when breast milk alone is no longer nutritionally sufficient ( 1 ). This typically starts around 6 months of age. Globally, nutritional outcomes during this critical period remain suboptimal: about one in three children aged 6–23 months receives a minimally diverse diet, a key indicator of appropriate complementary feeding practices ( 2 ). In Nigeria, nutrition indicators remain particularly poor. According to the 2024 Nigeria Demographic and Health Survey, only 12% of children aged 6–23 months meet the minimum dietary diversity standard–consuming at least 5 out of 8 food groups daily, and only 42% receive meals with adequate frequency ( 2 ). These deficiencies contribute to persistently high rates of undernutrition with one-third of Nigerian children under five stunted, and 7% of children are acutely wasted ( 3 ). Inadequate complementary feeding has lifelong consequences, including impaired cognitive development, weakened immunity, and increased mortality ( 4 ). While interventions for improving complementary feeding are well established, less attention has been paid to how coordinated action across sectors can support their effective implementation ( 5 ). Policy landscape Over the past three decades, Nigeria has launched several initiatives to improve child nutrition, including the Baby-Friendly Hospital Initiative (1992), National Breastfeeding Policy (1998), and Infant and Young Child Feeding Policy (2005) ( 6 ). More recent efforts include revising the National Food and Nutrition Policy, establishing a national nutrition budget line in 2016, and launching the National Multisectoral Plan of Action for Food and Nutrition (NMPFAN) in 2021. This plan outlines roles for key ministries and promotes pooled “basket funding” to support coordinated action.( 7 ). These efforts reflect growing recognition of malnutrition as a multisectoral issue. Yet, progress is limited by fragmented coordination, siloed implementation, and weak cross-sector collaboration ( 7 ). This is not unique to Nigeria. Similar challenges have been observed in India, where weak convergence across sectors and limited local-level accountability have impeded the implementation of nutrition programs, including those focused on complementary feeding ( 9 ). In contrast, Peru’s CRECER (“to grow” in spanish) strategy, grounded in clear roles, shared goals and political will led to significant reductions in child stunting ( 8 ). To improve complementary feeding at scale, sectors must work together to deliver diverse diets, education, and integrated services. ( 10 ). This study examines how such collaboration functions in Nigeria and where it can be strengthened. Understanding the barriers to implementation requires a systems lens to capture the layered complexity on the ground. Conceptual Framework This study uses Bronfenbrenner’s ecological systems theory to examine how complementary feeding is shaped by interconnected factors from caregivers and communities (microsystem) to health and food systems (mesosystem), and the wider policy and sociocultural context (macrosystem) ( 11 ). This perspective helps reveal how national policies influence local practices and how norms and services affect caregiver behavior. Given nutrition’s multisectoral nature spanning health, agriculture, education, and social protection, we explore how intersectoral collaboration is operationalized in Nigeria, identifying barriers and enablers to inform more coordinated system-level responses to child undernutrition. Methods Study Design and Participants We conducted a qualitative case study to explore intersectoral collaboration for complementary feeding in Nigeria. The “case” for this study is defined as the national system of policies and practices surrounding complementary feeding, examined through multiple stakeholder perspectives. This design was chosen to allow an in-depth understanding of contextual processes in a real-world setting, using interviews as the primary data source. Participants were recruited through purposive and snowball sampling to ensure diverse representation across sectors involved in complementary feeding. Inclusion criteria included being an English or Pidgin-speaking Nigerian with relevant experience in nutrition policy or programs. Initial participants were identified via professional networks, with others referred through snowball sampling. Our goal was to conduct approximately 20–30 interviews, guided by the principle of reaching thematic saturation ( 12 ). A total of 20 interviews were conducted, reaching thematic saturation. Participants included national/regional policymakers (n = 7), primary health workers (n = 6), parents of children under two (n = 5), and NGO representatives (n = 2), drawn from across Nigeria’s geopolitical zones. While not formally stratified, most participants were from national (35%) and northern (30%) regions; 60% were female. See Tables 1 and 2 for participant characteristics. Data Collection We developed a semi-structured interview guide informed by literature on multisectoral nutrition coordination and the study’s ecological framework. The guide was reviewed by subject matter experts to validate its relevance and clarity. The guide included open-ended questions on topics such as: participants’ roles in complementary feeding initiatives; perceptions of current complementary feeding practices and challenges in their context; experiences with intersectoral coordination (e.g. collaboration between health services, agriculture/food programs, and community initiatives); barriers to and facilitators of working across sectors; and suggestions for improving policy implementation and service delivery for complementary feeding. This line of questioning often led participants to organically discuss influences across the individual, community, and systemic levels. When these themes did not surface naturally, follow-up probing questions were used to elicit concrete examples of coordination (or lack thereof) among stakeholders at different levels (from national policy down to community outreach). All interviews were conducted in English via Zoom video conferencing. Each interview lasted approximately 45–60 minutes. At the start of each session, the interviewer reviewed the study purpose and confidentiality, then obtained the participant’s verbal informed consent to proceed. Interviews were audio-recorded with permission. The recordings were subsequently transcribed verbatim for analysis. To ensure accuracy, the interviewer cross-checked the transcripts against the audio and corrected any transcription errors. All personal identifiers were removed from transcripts to ensure anonymity. Generic descriptors (e.g., “PolicyMaker_01”) were assigned to differentiate participants in the data. See Supplementary Materials, Annex 1 for the interview guide. Data Analysis We analysed the interview transcripts using a thematic analysis approach to identify patterns and themes related to intersectoral collaboration and complementary feeding. The analysis was primarily inductive, allowing themes to emerge from the data rather than imposing predetermined codes. First, the primary researcher (L.O.) independently read through all transcripts to grasp the content and make initial analytic summaries. Next, L.O. conducted open coding of the transcripts line-by-line, labeling meaningful segments of text (e.g., descriptions of a collaboration effort, mentions of a policy barrier, suggestions for improvement). Coding was facilitated using Microsoft Excel: for each transcript, data excerpts were copied into an Excel sheet and assigned codes in adjacent columns. The use of Excel allowed the team to easily sort and organize excerpts by code and by participant type enabling comparison across different stakeholders. L.O. periodically met and debriefed the team about the coding scheme, resolve any discrepancies in code application, and refine code definitions. Through iterative discussions, similar codes were grouped into themes reflecting the major topics raised by participants. After initial coding, the research team reviewed the assembled themes and supporting quotations. We iteratively refined the thematic map by merging overlapping themes, splitting broad themes into more specific subthemes, and verifying that each theme was grounded in the data. During the later stage of analysis, we incorporated Bronfenbrenner’s ecological systems theory as an interpretive lens to situate these themes within different system levels. For example, we considered which themes related to the microsystem (family and immediate community influences on caregiver feeding practices), which pertained to the mesosystem (coordination between healthcare services, NGOs, and other community structures), and which reflected macrosystem factors (national policies, cultural norms). The theory was applied post hoc to help explain how factors at various levels interact and to ensure our interpretation captured the multi-level nature of the issues. This theoretically informed synthesis allowed us to draw more nuanced conclusions about how strengthening intersectoral collaboration at one level (e.g., policy) might influence outcomes at another level (e.g., household feeding practices). Throughout the analysis process, we maintained an audit trail in the Excel workbooks documenting code decisions and theme development. The credibility of the analysis was reinforced by peer debriefing to confirm that our interpretations resonated with their experiences. Findings Using Bronfenbrenner’s ecological framework, we organized the findings into microsystem, mesosystem, and macrosystem levels. Across these levels, participants described a range of barriers and facilitators affecting intersectoral collaboration for complementary feeding. Key themes are presented by ecological level with illustrative quotes from caregivers, community leaders, healthcare workers, and policymakers. Table 1 Characteristics of Interview Participants (N = 20). All values are number of participants interviewed, with percentages in parentheses. Characteristics Category N (%) Sex Female 14 (60%) Male 6 (40%) Age group (years) 25–34 5 (25%) 35–44 8 (40%) 45–54 4 (20%) 55–65 3 (15%) Role / Sector National policymakers 7 (35%) Primary health care workers 6 (30%) Caregivers of children < 2 5 (25%) NGO representatives 2 (10%) Table 2 Interviewee groups by geography Geography No. of interviewees NGO 2 National 2 Parent 5 East 2 North 1 South 1 West 1 Policymaker 7 National 5 North 1 West 1 Primary health care 6 North 4 West 2 Total 20 Coordination Mechanisms Facilitating Intersectoral Collaboration The nutrition coordination and governance structure in Nigeria has undergone significant transformation in recent years. Historically, nutrition interventions were implemented in vertical silos, led by various government agencies, NGOs, and development partners, often operating independently. This led to hyper-fragmentation across sectors and levels of government, resulting in duplication of efforts and inefficiencies in delivering nutrition services. One federal policymaker noted: Prior to now, partners would come in, do their programs and so there was a lot of hyper-fragmentation, sectorially multi-level... minimized communication across the tiers of government and of course with partners. So this is where the coordination comes in. Recognizing that malnutrition is multifaceted and multisectoral, the federal government identified the need for stronger coordination, profile raising, and prioritization of nutrition. This shift called for moving beyond the traditional health-centric approach, emphasizing collaboration across agriculture, education, Water, Sanitation and Hygiene, health, and social protection. A policymaker emphasized: The issue of malnutrition is multifaceted, is multisectoral... so it's not like just health will sort of provide all the solutions. So there was that need for strong coordination and collaboration around that. In response, decentralized coordination emerged as a key pillar. As part of this reform, the Nutrition 774 initiative was launched in February 2025, with a compact signed by the Minister of Budget and Planning, state governors, and local government representatives. The initiative rests on a tripartite foundation that includes government, development partners, and the private sector, aimed to shift focus away from federal control and bring implementation closer to the grassroots. As a policymaker put it: We wanted to have a breach between the policy and implementation… and ensure that we're focusing not just on States but on the local government areas... constitutionally and practically the closest to the people. The Nutrition 774 initiative also introduced a bottom-up approach, elevating nutrition as a national priority. As participants noted, this commitment translated into concrete institutional reforms. The development of Standard Operating Procedures (SOPs) under the initiative followed a co-creation process involving subnational governments, federal agencies, and development partners. The intent was to promote local ownership and ensure interventions were tailored to the cultural and contextual needs of communities. “Nutrition 774 will bring local ownership to also fit the local context because when you move from Akwa Ibom to Niger States, the context is different. So really having tailored solutions... to fit the needs, cultural needs as well of the people at the grassroots.” [Policymaker, North] Coordination structures were expanded at all levels: the National Committee on Food and Nutrition under the Ministry of Budget and Planning, the Nutrition Technical Working Group under the Ministry of Health, State Committees on Food and Nutrition, and ward-level committees at the local level. In addition, the Nutrition Intervention Fund (NIF) was created to strengthen financing through performance-based mechanisms: “NIF is supposed to help pull or lock financing for nutrition... when ministries implement these nutritional interventions... then they can be rewarded through the NIF to do more.” [Policymaker, Finance]. Despite these advances, challenges persist. Funding shortfalls, weak implementation capacity, and inadequate monitoring and evaluation continue to hinder the full realization of nutrition goals. Nonetheless, the Nutrition 774 initiative offers a promising model for integrated, decentralized, and locally tailored nutrition governance that could significantly enhance both the delivery and sustainability of nutrition interventions in Nigeria. Ecological Analysis of Barriers and Facilitators to Intersectoral Collaboration in Complementary Feeding Microsystem: Household and Caregiver-Level Factors Complementary feeding practices are deeply influenced by the immediate household context, particularly caregiver burden, gender norms, economic pressures, and food perceptions. Primary Caregiver Burden and Isolation At the microsystem level, mothers described the practical and emotional strain of feeding infants and young children. For example, one father explained that “feeding her is a bit stressful… you just buy something quick to give when the child refuses home-prepared food ”, highlighting how stress and time pressure can lead to suboptimal feeding choices. Interviews with primary caregivers (also known to as parents in this study), revealed that caregivers, predominantly mothers, often bear the full responsibility of feeding children with minimal help. One mother shared: Most times I do things myself… other adult family members rarely help. Cultural Norms At the microsystem, traditional family dynamics also constrained mothers’ decision-making. A healthcare worker and agricultural policy reform advocate observed: “Who makes decisions? The husband or maybe the matriach, the grandmother makes the decisions about what to feed the child,” suggesting that patriarchal norms and elders’ influence often dictate feeding decisions rather than the mother’s preferences. A mother’s lack of education was strongly highlighted as a determinant of complementary feeding. Health care workers pointed out: The schooling environment is extremely important…if you are in the north, there is little opportunity for you as a woman to make a decision about your child. Economic Pressure and Infrastructure Gaps Poverty and poor infrastructure often push caregivers toward cheaper, less nutritious foods. One urban mother noted, “Urban poverty has led to terrible nutrition... sweet potatoes are cheaper and more filling, but people prefer processed foods like spaghetti.” This reflects not just economic hardship but also misperceptions about the value of local, nutritious staples. Several participants highlighted that even when healthy foods are available, families may still choose packaged options due to convenience or misinformation. Caregivers also lacked guidance on food preparation and faced hidden costs. One father said, “Even if I know this food is good, I might buy something else if it’s cheaper.” A mother added, “With poor power supply, I store spaghetti more easily than oranges.” These accounts underscore how financial and infrastructural barriers undermine healthy complementary feeding at home. Contextual enablers Despite widespread barriers, some caregivers demonstrate resourcefulness and resilience, drawing on social support and practical strategies to implement positive complementary feeding practices even in constrained environments. A few caregivers demonstrated resourcefulness and positive practices, often drawing on knowledge from personal networks or experience: “I actually go natural… blend fruits and vegetables well… I buy my fruits in bulk and I've learned how to dry my fruits myself and turn them into fruits powders to make my own baby cereal…This way I don’t rely on power supply. Because I buy in bulk, I don’t worry about the fruits my baby likes, going out of season” said one mother, describing an innovative homemade approach to provide nutrient-rich foods. Another mother cited advice from family members with health expertise: “my mom is a retired nurse and midwife and she taught me about different vitamins found in foods and how I can incorporate them into my food…I also learned from friends and online child nutrition influencers.” These examples highlight how caregivers’ own agency and social support networks (e.g. female relatives, friends) can facilitate good complementary feeding practices even in constrained environments. In summary, at the household level, barriers to effective complementary feeding and engagement with services included caregiver fatigue, limited family support, gender norms, knowledge gaps, and financial hardship, whereas facilitators included caregiver motivation, creativity in using local foods, and advice from trusted sources. These factors influence whether and how families seek or benefit from external cross-sectoral support for nutrition. Mesosystem: Community and Service Delivery Factors Mesosystem factors, the linkages between families and their immediate community and service environments, emerged as critical to enabling or hindering intersectoral collaboration around complementary feeding. Inconsistent Nutritiion Support from Health Services Although frequent encounters with the healthsystem provide crucial touchpoints to influence complementary feeding, this opportunity is often underutilized. Caregivers consistently reported receiving vague or superficial advice during clinic visits. One mother shared: “In the hospital, they just said, give your child whatever you feel you can afford” revealing how missed counseling opportunities left parents with little guidance on diet diversity or managing feeding challenges. This inconsistency is rooted in several persistent structural issues. First, primary healthcare workers are overstretched, tasked with immunization, disease surveillance, antenatal care, and recordkeeping, leaving little bandwidth for in-depth nutrition counseling. As one community health worker explained: Nutrition counseling is just one more thing on a long list and often receives insufficient emphasis. Second, there is a lack of specialized training on child nutrition and behavior change communication. Many health workers are either inadequately prepared or lack confidence in delivering context-sensitive dietary advice. Third, participants noted that even though nutrition is systematically integrated into health performance monitoring, supervision is rarely prioritized or incentivized in routine practice. The absence of clear service delivery benchmarks for complementary feeding within primary health care weakens accountability and de-prioritizes nutrition during clinical interactions. Positive Community Engagement and Informal Support Systems Despite these gaps, caregivers pointed to instances of positive community engagement and informal support that helped improve complementary feeding practices. One mother who delivered in private or better-resourced facilities reported more structured support: During antenatal classes, they taught us recipes and how to combine foods. These experiences, however, were not universal and often dependent on facility-level initiative or NGO support. Informal networks like peer support groups, online platforms, or family advice were crucial in filling service gaps. One father noted: Online baby-led weaning influencers helped a friend’s malnourished child improve. It really works. Still, these examples raise concerns about equity and sustainability. Access to informal resources like online nutrition influencers or structured antenatal classes depends on literacy, digital access, and facility location often leaving rural or marginalized caregivers behind. Moreover, without consistent institutional support, these efforts remain fragile and non-systematic. A nutrition advocate from an NGO summarized the missed opportunity for stronger community-driven intersectoral collaboration: Communities are a reflection of their champions. We need to profile their success stories. This highlights the need for intentional identification and support of local nutrition champions, whose example can legitimize good complementary feeding practices and bridge the trust gap between formal services and families. Participants suggested that primary health centers could routinely refer families to community nutrition champions or host co-led group counseling sessions that include both facility staff and peer educators. Embedding community actors within health system workflows would enhance continuity of care while reducing provider burden. Multi-Sector Collaboration at the Local Level Many caregivers and service providers identified siloed programming and missed opportunities for collaboration across health, agriculture, education, and social protection sectors. While relevant programs exist such as school feeding and agricultural extension programs, these are often poorly coordinated at the community level. One mother observed: “Government policy and subsidized nutrient-rich foods would help us,” but reported no such support locally. The persistence of these gaps reflects both institutional fragmentation and weak decentralization of accountability. Local government areas often lack clear mandates or resources to convene intersectoral forums, and where such structures exist (e.g. ward-level nutrition committees), they tend to be unsustained or inactive donor-funded projects. Even when coordination structures are established, operational silos and poor communication across ministries limit collective action. A rare example of success came from one primary healthcare worker: “A ward-level nutrition committee had been set up, including health, agriculture, and women’s affairs representatives, which helped in pooling resources for community nutrition classes.” Such cross-sector platforms, when functional, enable coordinated interventions (e.g. aligning nutrition education with food distribution), but these remain the exception rather than the norm. Agricultural extension officers often operate separately from primary healthcare teams, leading to fragmented services and mixed messages for families, making nutrition everyone’s job but no one’s responsibility. The mesosystem reveals both structural gaps and missed opportunities for collaboration, driven by limited workforce capacity, weak integration of nutrition into PHC, and poor coordination. Still, community-led innovations, informal networks, and a few effective partnerships show what’s possible. Strengthening local coordination, training frontline workers, and empowering trusted community champions could help turn these fragmented efforts into a cohesive, nutrition-sensitive system. Macrosystem: Policy and Institutional-Level Factors At the macrosystem level, encompassing national policies, governance, and broader socio-economic influences, the data revealed both systemic barriers to intersectoral collaboration and some facilitating factors that have begun to emerge in Nigeria’s nutrition landscape. A dominant theme in policymakers’ interviews was the challenge of siloed sectors and fragmented governance. National level interviewees candidly acknowledged that, historically, ministries and agencies worked in isolation on nutrition-related issues “prior to now, partners would come in, do their programs…there was a lot of fragmentation and minimal communication across the tiers of government” [Policymaker]. Each sector tended to focus narrowly on its mandate, and international NGOs often implemented projects independently, resulting in duplication and inefficiencies. These findings echo documented issues in Nigeria’s nutrition governance: inadequate information-sharing, working in silos, and overlapping efforts have been identified as key bottlenecks in previous assessments​ ( 13 ). Participants in our study described similar role ambiguity and competition among institutions, which undermines the implementation of comprehensive complementary feeding strategies. As a policymaker who was a federal government advisor explained, “ nutrition falls under multiple ministries (health, agriculture, etc.) with no single empowered authority, leading to a lot of talk but little action or actual coordination thereafter in committees.” Another critical macrosystem barrier was the gap between policy formulation and implementation on the ground. Policymakers pointed out that Nigeria has developed robust plans on paper such as a National Food and Nutrition Policy and a multi-sector strategic plan but translating these into action has lagged. “If you look at the multi-sectoral plan of action… the challenge is that only about 20% of it has been implemented” [Policymaker]. This implementation gap was compounded by structural issues such as inadequate maternity protections. Participants highlighted that work obligations and insufficient maternity leave often forced mothers to return to work shortly after childbirth, disrupting exclusive breastfeeding and early nutrition practices. However, a few respondents highlighted promising examples of policy action at the subnational level. In Kwara State, for instance, a recent policy shift mandating six months of paid maternity leave was cited as a critical facilitator of improved breastfeeding and complementary feeding practices. Financing bottlenecks Subnational governments often struggle to implement federal nutrition initiatives due to limited funding and capacity. Respondents cited persistent resource constraints and delays in fund disbursement. As one federal finance policymaker noted, “budget allocation is one thing, release of funds is another.” As a result, policies like counseling, food fortification, and subsidies are often underfunded at delivery points ( 7 ). Heavy reliance on donor funding further undermines sustainability—many interventions stall once external support ends. Moving forward, greater domestic investment and dedicated financing for complementary feeding are urgently needed. Macrosystem Facilitators Despite these challenges, the macrosystem analysis revealed signs of progress. High-level political commitment is growing, with several interviewees citing new coordination bodies and stronger leadership. “The Vice President chairs the National Council on Nutrition,” one advisor noted, highlighting cross-sector engagement. The recent launch of the Nutrition 774 initiative, which assigns nutrition focal persons to all 774 LGAs, was also seen as a key step toward decentralizing and institutionalizing multisectoral action. “We came up with Nutrition 774, a bottom-up approach” , explained a national official, “the five sectors on N774 are agriculture, education, WASH, health, and social protection.” This initiative was described as a promising platform for convergence at local level, aligning with the National Multisectoral Plan of Action for Food and Nutrition 2021–2025.​ Participants felt that such frameworks, if fully executed, facilitate collaboration by clearly defining roles and pooling resources across ministries. One policymaker highlighted the establishment of a Legislative Network on Nutrition in the National Assembly as a best practice, noting that it has spurred lawmakers to champion nutrition and even inspired neighboring countries to consider similar models. Finally, participants discussed broader societal and industry influences that affect complementary feeding and require intersectoral action. A nutrition advocate and health policy advisor pointed out that agricultural policy has prioritized cash crops and staples for mass production: So before when folks were working with locally grown items, indigenous crops that could easily, with minimum resources, withstand the climate within the agronomic characteristics within our own environment can no longer do that..that scenario has been hampered and interjected by the interest of global agricultural players. This highlights a misalignment between agricultural goals and nutrition outcomes—one that nutrition-sensitive agriculture programs could help bridge. Conflict and insecurity were also cited as macrosystem barriers, disrupting food production and access to complementary foods. Overall, Nigeria’s complementary feeding challenges are rooted in broader systems of policy, governance, economy, and culture. Key barriers include sectoral silos, weak implementation, limited funding, and commercial influence. However, growing political will, multisector platforms, and shared recognition of nutrition as a priority offer pathways forward. Aligning these macro-level structures with community and household efforts is essential for lasting impact. Table 3 Summary of barriers and facilitators across ecological system levels. Level Category Barriers Facilitators Microsystem Caregiver Burden & Support Mothers bear responsibility alone; limited help from family Supportive family members; emotionally resilient caregivers Cultural Norms & Gender Roles Patriarchal norms; elders dominate feeding decisions Nutrition advice from healthcare workers and online platforms Economic & Infrastructure Constraints Cost of nutritious food; poor storage and electricity access Use of affordable, local foods; creative food preservation strategies Mesosystem Health Service Delivery Inconsistent nutrition counseling; overburdened staff; lack of training Well-resourced clinics and NGO support; opportunities during antenatal visits Community Engagement Unequal access to informal support; digital and geographic disparities Peer support groups; local nutrition champions; online platforms Cross-sector Coordination Siloed programming; inactive or unsustained coordination platforms Ward-level committees with multisector reps (e.g., health, agri, WASH) Macrosystem Policy & Institutional Reform Work obligations and insufficient maternity leave creating urgency for mothers to return to work after delivery Policy shift enabling six-month paid maternity leave in Kwara State to support exclusive breastfeeding and early nutrition Policy Implementation Strong policies on paper but weak local execution and accountability National Food and Nutrition Policy; Nutrition 774 framework Funding & Governance Delayed fund disbursement; dependency on donor funding Nutrition budget lines; pooled fund models under discussion Political Commitment Historical sectoral fragmentation; weak enforcement of roles Vice President-led Council; Legislative Network on Nutrition Discussion We examined how multilevel factors influence intersectoral collaboration to improve complementary feeding in Nigeria, using an ecological systems perspective. Drawing on the voices of policymakers, parents, and healthcare workers, we highlight dynamics across the micro, meso, and macro systems that shape nutrition policies and practices. While Nigeria has made meaningful progress, including high-level political commitment and multisector policy frameworks, our findings reveal persistent challenges in translating these advances into coordinated, context-sensitive actions that reach caregivers. Microsystem Dynamics: Household Realities and Caregiver Constraints Our data reveal that decision-making around child feeding is often influenced by male partners or elders, reinforcing power imbalances that restrict women’s autonomy. These findings align with other research showing that traditional beliefs can override evidence-based practices ( 13 ). Tackling these dynamics requires culturally appropriate strategies that engage fathers, grandmothers, and community elders, not just mothers, in complementary feeding education and behavior change efforts. Encouragingly, a few caregivers in our study reported success when they received actionable guidance through antenatal classes or support from knowledgeable relatives. This supports global evidence that context-tailored and family-inclusive counseling can significantly improve complementary feeding outcomes ( 14 ). For example, in Peru, the use of sheltered conveners who can coordinate others without being hampered by institutional conflicts emerged as a critical determinant of the country’s success in improving child nutrition outcomes ( 8 ). Enhancing intersectoral collaboration at the microsystem level involves aligning the work of the health, education, and social sectors to deliver consistent messaging through clinics, community groups, and media platforms. Mesosystem Dynamics: Community-Level Gaps and Coordination Opportunities At the mesosystem level, the interface between caregivers and frontline services emerged as a critical but often weak link between policy and household action. Participants described health facilities that overlooked nutrition due to workforce shortages, limited training, and lack of institutional support. This reflects Ene-Obong et al.'s ( 15 )concept of “first contact failure,” where routine visits miss opportunities to promote complementary feeding. Addressing this requires service-level collaboration for example, embedding nutrition in PHC protocols and equipping agricultural extension workers to share feeding messages during community visits. Frontline workers also noted poor coordination across sectors at the local level. While health, agriculture, and social protection often run parallel programs, most LGAs lack operational coordination platforms, leading to duplication and inefficiencies. Revitalizing ward and LGA-level nutrition committees, backed by performance-based incentives (e.g., mandatory reporting or conditional funding), could improve alignment. The Nutrition 774 initiative deploying nutrition focal points in every LGA was cited as a promising step, especially when focal points are empowered to convene multisectoral actors. A comparable model in Tanzania showed success through district-level committees with strong leadership and oversight roles, supporting implementation of its National Multisectoral Nutrition Action Plan ( 16 ). Macrosystem Dynamics: Translating Political Will into Practice Nigeria’s national nutrition architecture reflects substantial high-level momentum, but implementation bottlenecks persist. Our findings affirm the literature’s description of a “commitment-implementation gap” ( 13 ) where national plans exist but subnational execution falters due to institutional capacity, and poor accountability. Tensions between ministries, especially over who leads coordination, further weaken intersectoral collaboration. Stakeholders agreed that housing nutrition leadership within a neutral, high-level entity, such as the Ministry of Budget and Planning under the Vice President’s office, clarifies roles for nutrition going forward. Accountability was another recurring issue. State-level compliance with national directives remains voluntary and often unenforced. Participants stressed that without mechanisms to reward performance or sanction neglect, nutrition remains deprioritized. Tools such as public progress scorecards, performance-based disbursement through the Nutrition Intervention Fund, and civil society monitoring, already in use through scaling up nutrition platforms, can strengthen accountability structures (17). Financing for nutrition Resource flow remains a major constraint. Even with dedicated nutrition budgets, delayed disbursements and poor fund utilization hinder implementation. Addressing this requires protecting allocations, streamlining release processes, and incentivizing states through matching grants. Public-private partnerships can also bolster support for families during the complementary feeding phase. Broader political economy challenges such as weak enforcement of breast-milk substitute regulations ( 18 ), misaligned agricultural priorities, and poor intersectoral coordination further limit progress. Tackling these requires engaging sectors like trade, media, and consumer protection, and reorienting agriculture to promote nutrient-dense foods. National platforms like the National Council on Nutrition can help align strategies across sectors. Strategies to Strengthen Intersectoral Collaboration for Complementary Feeding Intersectoral collaboration is inherently complex and labor-intensive, requiring ongoing coordination across sectors and systems. Yet, the benefits, better child nutrition, health equity, and development outcomes justify the investment. Drawing on our findings, we propose six strategies to improve coordination for complementary feeding in Nigeria: Establish Clear Coordination Mechanisms Across all Levels Formal coordination structures are needed at national, state, and local levels. While the National Council on Nutrition offers oversight, state and local committees must be empowered with clear roles and accountability mechanisms. National guidelines should define ministry responsibilities and set expectations for regular coordination and progress tracking. Build Capacity and Incentivize Frontline Workers Frontline workers need updated training on complementary feeding. Cross-sector training for agricultural, education, and social workers can reinforce messages. Incentives, such as performance awards or additional funds, can motivate local actors and promote accountability. Engage Communities and Promote Social Behavior Change Community involvement is critical. Strengthening mother groups, father forums, and local influencers can support information-sharing (19). Highlighting “nutrition champions” and linking community groups with health centers and mass media campaigns can drive behavior change and ensure message consistency. Improve Policy Implementation and Financing Operationalizing national plans through costed local workplans with clear targets is key. Dedicated nutrition budget lines and timely fund release e.g., via quarterly disbursements can improve execution. Innovative financing like results-based funding and pooled resources should be explored, along with better public financial tracking. Strengthen Monitoring, Evaluation, and Learning Systems A unified M&E framework should track both nutrition-specific and nutrition-sensitive indicators. Data must be reviewed regularly to inform adjustments. Tools like dashboards and scorecards can enhance transparency and accountability. Promising innovations should be evaluated and scaled through partnerships with academic institutions. Navigate the Political Economy and Institutionalize Support Addressing institutional resistance requires a phased, politically informed approach. Strengthening existing platforms, advocating through legislative channels, and aligning nutrition with broader development goals can secure long-term support. Demonstrating the wider benefits of child nutrition will help build sustained political will. Study Limitations A potential limitation is selection bias, as the lead researcher (L.O.) recruited participants through her professional network, possibly skewing responses toward more engaged or system-aware individuals. This may have limited the diversity of perspectives, particularly regarding intersectoral collaboration. Although purposive sampling ensured sectoral representation, generalizability is limited due to the qualitative design. Not all geopolitical zones were equally represented, and virtual interviews may have excluded more digitally marginalized parents. Nonetheless, the study provides rich, context-specific insights into the systemic and multilevel factors influencing complementary feeding in Nigeria, with relevance for similar LMICs aiming to strengthen nutrition outcomes through intersectoral collaboration. Conclusion This study highlights the complex, multilevel factors influencing intersectoral collaboration for complementary feeding in Nigeria. While national policies and coordination have advanced, major gaps remain in implementation, local alignment, and frontline capacity particularly for vulnerable caregivers. Strengthening collaboration requires action across all levels: equipping frontline workers, engaging communities, and improving coordination and accountability. Promising efforts like the Nutrition 774 initiative and lessons from countries like Tanzania show potential, but progress depends on sustained investment and local ownership. The strategies proposed offer pragmatic, phased steps to improve outcomes through collective leadership and multisectoral partnerships that center families. Advancing complementary feeding will not only boost nutrition but also support Nigeria’s broader development goals. Declarations Positionality Statement As a mother of two young daughters, my lived experience deeply informs my research on complementary feeding. This personal journey shapes my understanding of the challenges caregivers face and fuels my commitment to finding practical, context-specific solutions. As a public health professional, I approach this work not only with academic interest but with a deep sense of empathy and urgency to improve systems that support families especially those navigating these decisions in resource-limited settings. My dual lens as both a researcher and a parent, ground this study in lived reality. I acknowledge that this positionality may have also influenced how I interpreted participants’ perspectives, particularly in recognizing emotional and practical challenges that might otherwise be overlooked. Ethics approval and consent to participate This study was approved by the Institutional Review Board of Loma Linda University (#5250146) and Nigeria Health Research Ethics Committee. All procedures complied with ethical standards for research involving human subjects. The study’s reliance on experienced adult stakeholders (ages 25 and above) and the non-sensitive nature of topics (policy/program discussions) minimized risk to participants. Nonetheless, the research was careful to uphold ethical principles of respect, beneficence, and justice throughout the process. Consent to Participate and Publish Because interviews were conducted remotely, verbal informed consent was obtained from each participant prior to starting the recording. The interviewer explained the study aims, what participation entailed, and assured participants of confidentiality. Participants were informed that their involvement was voluntary and that they could decline to answer any question or end the interview at any time. Permission to record the interview and publish final results was explicitly sought. Verbal consent (for both participation and recording) was documented at the beginning of each audio recording. To protect confidentiality, no real names or personal identifiers appear in the transcripts or analysis; each participant was assigned a unique code, and any potentially identifying details mentioned during interviews (such as specific workplaces or locations) were generalized or removed in the transcripts. Audio recordings and transcript files were stored securely on a password-protected Loma Linda University One Drive folder accessible only to the research team. Availability of data and materials missing Audio recordings and transcript files were stored securely on a password-protected Loma Linda University One Drive folder accessible only to the research team. Funding No funding was received for this research. Also, participants did not receive monetary compensation. Clinical trial number: not applicable References Pérez-Escamilla R S-PS, Lott M, et al. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Healthy Eating Research. 2017. Unicef. Young children’s diets show no improvement in last decade, ‘could get much worse’ under COVID-19 2021. Available from: https://www.unicef.org/nigeria/press-releases/young-childrens-diets-show-no-improvement-last-decade-could-get-much-worse-under#:~:text=half%20of%20children%20aged%206,groups%20they%20need%20to%20thrive. National Population Commission - NPC, ICF. Nigeria Demographic and Health Survey 2018 - Final Report. Abuja, Nigeria: NPC and ICF, 2019. Na M KS, Murray-Kolb, LE. . Regional Landscape Analysis of Trends and Factors of Young Children's Diet in UNICEF's West and Central Africa Region (WCAR UNICEF). 2020. Aivalli P, Gilmore B, Srinivas PN, De Brún A. Navigating intersectoral collaboration in nutrition programming: implementors' perspectives from Assam, India. Arch Public Health. 2024;82(1):82. Epub 20240607. doi: 10.1186/s13690-024-01312-6. PubMed PMID: 38849925; PubMed Central PMCID: PMC11157891. Ogbo FA, Page A, Idoko J, Claudio F, Agho KE. Have policy responses in Nigeria resulted in improvements in infant and young child feeding practices in Nigeria? International Breastfeeding Journal. 2017;12(1):9. doi: 10.1186/s13006-017-0101-5. Opara A. Improving Nutrition Outcomes in Nigeria through Strengthened Multisectoral Coordination Nigeria: Nigeria Health Watch; 2024 [cited 2024]. Available from: https://nigeriahealthwatch.medium.com/improving-nutrition-outcomes-in-nigeria-through-strengthened-multisectoral-coordination-87fe6cc2a79d. ExemplarsinGlobalHealth. Peru’s Unique Nutrition Journey. 2016. Kim SS, Avula R, Ved R, Kohli N, Singh K, van den Bold M, et al. Understanding the role of intersectoral convergence in the delivery of essential maternal and child nutrition interventions in Odisha, India: a qualitative study. BMC Public Health. 2017;17(1):161. doi: 10.1186/s12889-017-4088-z. Yunitasari E, Al Faisal AH, Efendi F, Kusumaningrum T, Yunita FC, Chong MC. Factors associated with complementary feeding practices among children aged 6-23 months in Indonesia. BMC Pediatr. 2022;22(1):727. Epub 20221221. doi: 10.1186/s12887-022-03728-x. PubMed PMID: 36539759; PubMed Central PMCID: PMC9769005. Adeomi AA, Fatusi A, Klipstein-Grobusch K. Individual and contextual factors associated with under- and over-nutrition among school-aged children and adolescents in two Nigerian states: a multi-level analysis. Public Health Nutr. 2022;25(8):2339-51. Epub 20220124. doi: 10.1017/s1368980022000258. PubMed PMID: 35067272; PubMed Central PMCID: PMC9991795. Vasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Medical Research Methodology. 2018;18(1):148. doi: 10.1186/s12874-018-0594-7. Adeyemi O, van den Bold M, Nisbett N, Covic N. Changes in Nigeria’s enabling environment for nutrition from 2008 to 2019 and challenges for reducing malnutrition. Food Security. 2023;15(2):343-61. doi: 10.1007/s12571-022-01328-2. Olatona FA, Adenihun JO, Aderibigbe SA, Adeniyi OF. Complementary Feeding Knowledge, Practices, and Dietary Diversity among Mothers of Under-Five Children in an Urban Community in Lagos State, Nigeria. Int J MCH AIDS. 2017;6(1):46-59. doi: 10.21106/ijma.203. PubMed PMID: 28798893; PubMed Central PMCID: PMC5547225. Ene-Obong H, Onuoha N, Eme P. Gender roles, family relationships, and household food and nutrition security in Ohafia matrilineal society in Nigeria. Maternal & Child Nutrition. 2017;13:e12506. doi: 10.1111/mcn.12506. Klemm GC, Kayanda R, Kazoba A, McCann J, Nnally LP, Dickin KL. Translating Multisectoral Nutrition Policy into Community Practice: Participation of Nutrition Officers in Tanzania Fosters Effective Collaborative Strategies to Improve Child Nutrition. Curr Dev Nutr. 2022;6(4):nzac030. Epub 20220228. doi: 10.1093/cdn/nzac030. PubMed PMID: 35415387; PubMed Central PMCID: PMC8992576. USAID. Multisectoral Nutrition Global Evidence Update 2025. Available from: https://nutritionnigeria.org/multisectoral-nutrition-global-evidence-update/#:~:text=Multisectoral%20Nutrition%20Global%20Evidence%20Update,being. USAID. The Community Infant and Young Child Feeding Counselling Package in Kaduna State, Nigeria. 2018. Billings L, Pradeilles R, Gillespie S, Vanderkooy A, Diatta D, Toure M, et al. Coherence for nutrition: insights from nutrition-relevant policies and programmes in Burkina Faso and Nigeria. Health Policy and Planning. 2021;36(10):1574-92. doi: 10.1093/heapol/czab108. Subandoro AWO, Yuko; Mehta,Michelle Ashwin; Wang,Huihui; Ahluwalia,Naina; Finkel,Elyssa; Bulungu, Andrea L.S.; Dinsa,Girmaye Deye; Okara,Latifat Agharese; Wilson,Shelby Elena. Positioning Nutrition within Universal Health Coverage : Optimizing Health Financing Levers. Health, Nutrition, and Population (HNP) discussion paper Washington, DC : World Bank Group. 2022. Additional Declarations No competing interests reported. Supplementary Files FINALInterviewguideImprovingcomplementaryfeedinginNigeriaPGC.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 11 Aug, 2025 Reviews received at journal 03 Aug, 2025 Reviewers agreed at journal 01 Aug, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviewers invited by journal 21 Jul, 2025 Editor invited by journal 20 Jun, 2025 Editor assigned by journal 19 Jun, 2025 Submission checks completed at journal 19 Jun, 2025 First submitted to journal 10 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6863002","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489240905,"identity":"8f43e8d5-c830-4212-b20b-9beb27bda61b","order_by":0,"name":"Latifat Okara","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBACPiA+UAEkJEC8D0DMxk5ACxsDM8OBMwwGYC2MM0AizERoYYBpYeYBCRHUwn7+4IEDNX/kJNvPPvxs82ubPB8zA+OHjzl4tPAkMxw4cMzAWJon3Vg6t++2YRszA7PkzG34HJbMcPgDm0HiPIY0BuncntuMQC1szLz4tPA/BtryD6iF/xnzb8ue2/aEtUgAHXawzSBxtkQamzTDj9uJRGh5bHDgYJ+xseSMZ2yWvQ23k9uYGZvx+oWfP/HxhwPf5OQkzqcx3/jx57bt/Pbmgx8+4tGCChjbwGQDsepB4A8pikfBKBgFo2CkAAANN026q86PwgAAAABJRU5ErkJggg==","orcid":"","institution":"Loma Linda University","correspondingAuthor":true,"prefix":"","firstName":"Latifat","middleName":"","lastName":"Okara","suffix":""},{"id":489240908,"identity":"53ddc7f7-56af-425b-8882-5c497c635a09","order_by":1,"name":"Jisoo Oh","email":"","orcid":"","institution":"Loma Linda University","correspondingAuthor":false,"prefix":"","firstName":"Jisoo","middleName":"","lastName":"Oh","suffix":""},{"id":489240909,"identity":"5c139f85-ee2c-45ef-8f0f-65aa176065c1","order_by":2,"name":"Seth Wiafe","email":"","orcid":"","institution":"Loma Linda University","correspondingAuthor":false,"prefix":"","firstName":"Seth","middleName":"","lastName":"Wiafe","suffix":""},{"id":489240910,"identity":"8a12ec81-2f56-4049-b705-4d7dc80c83e9","order_by":3,"name":"Ronald Mataya","email":"","orcid":"","institution":"Loma Linda University","correspondingAuthor":false,"prefix":"","firstName":"Ronald","middleName":"","lastName":"Mataya","suffix":""}],"badges":[],"createdAt":"2025-06-10 12:23:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6863002/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6863002/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87401809,"identity":"1b6290e9-dfb4-4b5a-91fe-f17faa9b329d","added_by":"auto","created_at":"2025-07-23 11:58:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1130910,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6863002/v1/e75ca96b-adaf-4b9e-9ae6-c705d45632f9.pdf"},{"id":87400499,"identity":"323f1134-cd35-4639-adc9-12b9d0a1cee7","added_by":"auto","created_at":"2025-07-23 11:42:45","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":5426197,"visible":true,"origin":"","legend":"","description":"","filename":"FINALInterviewguideImprovingcomplementaryfeedinginNigeriaPGC.docx","url":"https://assets-eu.researchsquare.com/files/rs-6863002/v1/e4701cdc352772c9fceb4d92.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eStrengthening Intersectoral Collaboration to Improve Complementary Feeding Policies and Practices in Nigeria: An Ecological Systems Perspective\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eComplementary feeding, as defined by the World Health Organization, is the practice of providing children with solid or semi-solid foods in addition to breast milk or formula when breast milk alone is no longer nutritionally sufficient (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This typically starts around 6 months of age. Globally, nutritional outcomes during this critical period remain suboptimal: about one in three children aged 6\u0026ndash;23 months receives a minimally diverse diet, a key indicator of appropriate complementary feeding practices (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In Nigeria, nutrition indicators remain particularly poor. According to the 2024 Nigeria Demographic and Health Survey, only 12% of children aged 6\u0026ndash;23 months meet the minimum dietary diversity standard\u0026ndash;consuming at least 5 out of 8 food groups daily, and only 42% receive meals with adequate frequency (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These deficiencies contribute to persistently high rates of undernutrition with one-third of Nigerian children under five stunted, and 7% of children are acutely wasted (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Inadequate complementary feeding has lifelong consequences, including impaired cognitive development, weakened immunity, and increased mortality (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile interventions for improving complementary feeding are well established, less attention has been paid to how coordinated action across sectors can support their effective implementation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003ePolicy landscape\u003c/h3\u003e\n\u003cp\u003eOver the past three decades, Nigeria has launched several initiatives to improve child nutrition, including the Baby-Friendly Hospital Initiative (1992), National Breastfeeding Policy (1998), and Infant and Young Child Feeding Policy (2005) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). More recent efforts include revising the National Food and Nutrition Policy, establishing a national nutrition budget line in 2016, and launching the National Multisectoral Plan of Action for Food and Nutrition (NMPFAN) in 2021. This plan outlines roles for key ministries and promotes pooled \u0026ldquo;basket funding\u0026rdquo; to support coordinated action.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese efforts reflect growing recognition of malnutrition as a multisectoral issue. Yet, progress is limited by fragmented coordination, siloed implementation, and weak cross-sector collaboration (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This is not unique to Nigeria. Similar challenges have been observed in India, where weak convergence across sectors and limited local-level accountability have impeded the implementation of nutrition programs, including those focused on complementary feeding (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In contrast, Peru\u0026rsquo;s CRECER (\u0026ldquo;to grow\u0026rdquo; in spanish) strategy, grounded in clear roles, shared goals and political will led to significant reductions in child stunting (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo improve complementary feeding at scale, sectors must work together to deliver diverse diets, education, and integrated services. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This study examines how such collaboration functions in Nigeria and where it can be strengthened. Understanding the barriers to implementation requires a systems lens to capture the layered complexity on the ground.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eConceptual Framework\u003c/h2\u003e\u003cp\u003eThis study uses Bronfenbrenner\u0026rsquo;s ecological systems theory to examine how complementary feeding is shaped by interconnected factors from caregivers and communities (microsystem) to health and food systems (mesosystem), and the wider policy and sociocultural context (macrosystem) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This perspective helps reveal how national policies influence local practices and how norms and services affect caregiver behavior.\u003c/p\u003e\u003cp\u003eGiven nutrition\u0026rsquo;s multisectoral nature spanning health, agriculture, education, and social protection, we explore how intersectoral collaboration is operationalized in Nigeria, identifying barriers and enablers to inform more coordinated system-level responses to child undernutrition.\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Participants\u003c/h2\u003e\u003cp\u003eWe conducted a qualitative case study to explore intersectoral collaboration for complementary feeding in Nigeria. The “case” for this study is defined as the national system of policies and practices surrounding complementary feeding, examined through multiple stakeholder perspectives. This design was chosen to allow an in-depth understanding of contextual processes in a real-world setting, using interviews as the primary data source.\u003c/p\u003e\u003cp\u003e Participants were recruited through purposive and snowball sampling to ensure diverse representation across sectors involved in complementary feeding. Inclusion criteria included being an English or Pidgin-speaking Nigerian with relevant experience in nutrition policy or programs. Initial participants were identified via professional networks, with others referred through snowball sampling.\u003c/p\u003e\u003cp\u003eOur goal was to conduct approximately 20–30 interviews, guided by the principle of reaching thematic saturation (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A total of 20 interviews were conducted, reaching thematic saturation. Participants included national/regional policymakers (n = 7), primary health workers (n = 6), parents of children under two (n = 5), and NGO representatives (n = 2), drawn from across Nigeria’s geopolitical zones. While not formally stratified, most participants were from national (35%) and northern (30%) regions; 60% were female. See Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for participant characteristics.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eWe developed a semi-structured interview guide informed by literature on multisectoral nutrition coordination and the study’s ecological framework. The guide was reviewed by subject matter experts to validate its relevance and clarity. The guide included open-ended questions on topics such as: participants’ roles in complementary feeding initiatives; perceptions of current complementary feeding practices and challenges in their context; experiences with intersectoral coordination (e.g. collaboration between health services, agriculture/food programs, and community initiatives); barriers to and facilitators of working across sectors; and suggestions for improving policy implementation and service delivery for complementary feeding. This line of questioning often led participants to organically discuss influences across the individual, community, and systemic levels. When these themes did not surface naturally, follow-up probing questions were used to elicit concrete examples of coordination (or lack thereof) among stakeholders at different levels (from national policy down to community outreach).\u003c/p\u003e\u003cp\u003eAll interviews were conducted in English via Zoom video conferencing. Each interview lasted approximately 45–60 minutes. At the start of each session, the interviewer reviewed the study purpose and confidentiality, then obtained the participant’s verbal informed consent to proceed. Interviews were audio-recorded with permission. The recordings were subsequently transcribed verbatim for analysis. To ensure accuracy, the interviewer cross-checked the transcripts against the audio and corrected any transcription errors. All personal identifiers were removed from transcripts to ensure anonymity. Generic descriptors (e.g., “PolicyMaker_01”) were assigned to differentiate participants in the data. See Supplementary Materials, Annex 1 for the interview guide.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eWe analysed the interview transcripts using a thematic analysis approach to identify patterns and themes related to intersectoral collaboration and complementary feeding. The analysis was primarily inductive, allowing themes to emerge from the data rather than imposing predetermined codes. First, the primary researcher (L.O.) independently read through all transcripts to grasp the content and make initial analytic summaries. Next, L.O. conducted open coding of the transcripts line-by-line, labeling meaningful segments of text (e.g., descriptions of a collaboration effort, mentions of a policy barrier, suggestions for improvement). Coding was facilitated using Microsoft Excel: for each transcript, data excerpts were copied into an Excel sheet and assigned codes in adjacent columns. The use of Excel allowed the team to easily sort and organize excerpts by code and by participant type enabling comparison across different stakeholders. L.O. periodically met and debriefed the team about the coding scheme, resolve any discrepancies in code application, and refine code definitions. Through iterative discussions, similar codes were grouped into themes reflecting the major topics raised by participants.\u003c/p\u003e\u003cp\u003eAfter initial coding, the research team reviewed the assembled themes and supporting quotations. We iteratively refined the thematic map by merging overlapping themes, splitting broad themes into more specific subthemes, and verifying that each theme was grounded in the data. During the later stage of analysis, we incorporated Bronfenbrenner’s ecological systems theory as an interpretive lens to situate these themes within different system levels. For example, we considered which themes related to the microsystem (family and immediate community influences on caregiver feeding practices), which pertained to the mesosystem (coordination between healthcare services, NGOs, and other community structures), and which reflected macrosystem factors (national policies, cultural norms). The theory was applied post hoc to help explain how factors at various levels interact and to ensure our interpretation captured the multi-level nature of the issues. This theoretically informed synthesis allowed us to draw more nuanced conclusions about how strengthening intersectoral collaboration at one level (e.g., policy) might influence outcomes at another level (e.g., household feeding practices). Throughout the analysis process, we maintained an audit trail in the Excel workbooks documenting code decisions and theme development. The credibility of the analysis was reinforced by peer debriefing to confirm that our interpretations resonated with their experiences.\u003c/p\u003e\u003c/div\u003e"},{"header":"Findings","content":"\u003cp\u003eUsing Bronfenbrenner’s ecological framework, we organized the findings into microsystem, mesosystem, and macrosystem levels. Across these levels, participants described a range of barriers and facilitators affecting intersectoral collaboration for complementary feeding. Key themes are presented by ecological level with illustrative quotes from caregivers, community leaders, healthcare workers, and policymakers.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eCharacteristics of Interview Participants (N = 20).\u003c/b\u003e All values are number of participants interviewed, with percentages in parentheses.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (60%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (40%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge group (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25–34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35–44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (40%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45–54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55–65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRole / Sector\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNational policymakers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (35%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary health care workers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (30%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaregivers of children \u0026lt;\u0026nbsp;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNGO representatives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInterviewee groups by geography\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeography\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo. of interviewees\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNGO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNational\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEast\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNorth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSouth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePolicymaker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNational\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNorth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary health care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNorth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003ch3\u003eCoordination Mechanisms Facilitating Intersectoral Collaboration\u003c/h3\u003e\u003cp\u003eThe nutrition coordination and governance structure in Nigeria has undergone significant transformation in recent years. Historically, nutrition interventions were implemented in vertical silos, led by various government agencies, NGOs, and development partners, often operating independently. This led to hyper-fragmentation across sectors and levels of government, resulting in duplication of efforts and inefficiencies in delivering nutrition services. One federal policymaker noted:\u003c/p\u003e\u003cp\u003ePrior to now, partners would come in, do their programs and so there was a lot of hyper-fragmentation, sectorially multi-level... minimized communication across the tiers of government and of course with partners. So this is where the coordination comes in.\u003c/p\u003e\u003cp\u003eRecognizing that malnutrition is multifaceted and multisectoral, the federal government identified the need for stronger coordination, profile raising, and prioritization of nutrition. This shift called for moving beyond the traditional health-centric approach, emphasizing collaboration across agriculture, education, Water, Sanitation and Hygiene, health, and social protection. A policymaker emphasized:\u003c/p\u003e\u003cp\u003eThe issue of malnutrition is multifaceted, is multisectoral... so it's not like just health will sort of provide all the solutions. So there was that need for strong coordination and collaboration around that.\u003c/p\u003e\u003cp\u003eIn response, decentralized coordination emerged as a key pillar. As part of this reform, the Nutrition 774 initiative was launched in February 2025, with a compact signed by the Minister of Budget and Planning, state governors, and local government representatives. The initiative rests on a tripartite foundation that includes government, development partners, and the private sector, aimed to shift focus away from federal control and bring implementation closer to the grassroots. As a policymaker put it:\u003c/p\u003e\u003cp\u003eWe wanted to have a breach between the policy and implementation… and ensure that we're focusing not just on States but on the local government areas... constitutionally and practically the closest to the people.\u003c/p\u003e\u003cp\u003eThe Nutrition 774 initiative also introduced a bottom-up approach, elevating nutrition as a national priority. As participants noted, this commitment translated into concrete institutional reforms. The development of Standard Operating Procedures (SOPs) under the initiative followed a co-creation process involving subnational governments, federal agencies, and development partners. The intent was to promote local ownership and ensure interventions were tailored to the cultural and contextual needs of communities.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Nutrition 774 will bring local ownership to also fit the local context because when you move from Akwa Ibom to Niger States, the context is different. So really having tailored solutions... to fit the needs, cultural needs as well of the people at the grassroots.” [Policymaker, North]\u003c/em\u003e\u003c/p\u003e\u003cp\u003e Coordination structures were expanded at all levels: the National Committee on Food and Nutrition under the Ministry of Budget and Planning, the Nutrition Technical Working Group under the Ministry of Health, State Committees on Food and Nutrition, and ward-level committees at the local level. In addition, the Nutrition Intervention Fund (NIF) was created to strengthen financing through performance-based mechanisms:\u003c/p\u003e\u003cp\u003e\u003cem\u003e“NIF is supposed to help pull or lock financing for nutrition... when ministries implement these nutritional interventions... then they can be rewarded through the NIF to do more.” [Policymaker, Finance].\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDespite these advances, challenges persist. Funding shortfalls, weak implementation capacity, and inadequate monitoring and evaluation continue to hinder the full realization of nutrition goals. Nonetheless, the Nutrition 774 initiative offers a promising model for integrated, decentralized, and locally tailored nutrition governance that could significantly enhance both the delivery and sustainability of nutrition interventions in Nigeria.\u003c/p\u003e\u003ch3\u003eEcological Analysis of Barriers and Facilitators to Intersectoral Collaboration in Complementary Feeding\u003c/h3\u003e\u003ch2\u003eMicrosystem: Household and Caregiver-Level Factors\u003c/h2\u003e\u003cp\u003eComplementary feeding practices are deeply influenced by the immediate household context, particularly caregiver burden, gender norms, economic pressures, and food perceptions.\u003c/p\u003e\u003ch2\u003ePrimary Caregiver Burden and Isolation\u003c/h2\u003e\u003cp\u003eAt the microsystem level, mothers described the practical and emotional strain of feeding infants and young children. For example, one father explained that \u003cem\u003e“feeding her is a bit stressful… you just buy something quick to give when the child refuses home-prepared food\u003c/em\u003e”, highlighting how stress and time pressure can lead to suboptimal feeding choices. Interviews with primary caregivers (also known to as parents in this study), revealed that caregivers, predominantly mothers, often bear the full responsibility of feeding children with minimal help. One mother shared:\u003c/p\u003e\u003cp\u003eMost times I do things myself… other adult family members rarely help.\u003c/p\u003e\u003ch2\u003eCultural Norms\u003c/h2\u003e\u003cp\u003eAt the microsystem, traditional family dynamics also constrained mothers’ decision-making. A healthcare worker and agricultural policy reform advocate observed: \u003cem\u003e“Who makes decisions? The husband or maybe the matriach, the grandmother makes the decisions about what to feed the child,”\u003c/em\u003e suggesting that patriarchal norms and elders’ influence often dictate feeding decisions rather than the mother’s preferences. A mother’s lack of education was strongly highlighted as a determinant of complementary feeding. Health care workers pointed out:\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe schooling environment is extremely important…if you are in the north, there is little opportunity for you as a woman to make a decision about your child.\u003c/em\u003e\u003c/p\u003e\u003ch2\u003eEconomic Pressure and Infrastructure Gaps\u003c/h2\u003e\u003cp\u003ePoverty and poor infrastructure often push caregivers toward cheaper, less nutritious foods. One urban mother noted, \u003cem\u003e“Urban poverty has led to terrible nutrition... sweet potatoes are cheaper and more filling, but people prefer processed foods like spaghetti.”\u003c/em\u003e This reflects not just economic hardship but also misperceptions about the value of local, nutritious staples. Several participants highlighted that even when healthy foods are available, families may still choose packaged options due to convenience or misinformation.\u003c/p\u003e\u003cp\u003eCaregivers also lacked guidance on food preparation and faced hidden costs. One father said, \u003cem\u003e“Even if I know this food is good, I might buy something else if it’s cheaper.”\u003c/em\u003e A mother added, \u003cem\u003e“With poor power supply, I store spaghetti more easily than oranges.”\u003c/em\u003e These accounts underscore how financial and infrastructural barriers undermine healthy complementary feeding at home.\u003c/p\u003e\u003ch2\u003eContextual enablers\u003c/h2\u003e\u003cp\u003eDespite widespread barriers, some caregivers demonstrate resourcefulness and resilience, drawing on social support and practical strategies to implement positive complementary feeding practices even in constrained environments. A few caregivers demonstrated resourcefulness and positive practices, often drawing on knowledge from personal networks or experience:\u003c/p\u003e\u003cp\u003e\u003cem\u003e“I actually go natural… blend fruits and vegetables well… I buy my fruits in bulk and I've learned how to dry my fruits myself and turn them into fruits powders to make my own baby cereal…This way I don’t rely on power supply. Because I buy in bulk, I don’t worry about the fruits my baby likes, going out of season”\u003c/em\u003e said one mother, describing an innovative homemade approach to provide nutrient-rich foods. Another mother cited advice from family members with health expertise: \u003cem\u003e“my mom is a retired nurse and midwife and she taught me about different vitamins found in foods and how I can incorporate them into my food…I also learned from friends and online child nutrition influencers.”\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThese examples highlight how caregivers’ own agency and social support networks (e.g. female relatives, friends) can facilitate good complementary feeding practices even in constrained environments. In summary, at the household level, barriers to effective complementary feeding and engagement with services included caregiver fatigue, limited family support, gender norms, knowledge gaps, and financial hardship, whereas facilitators included caregiver motivation, creativity in using local foods, and advice from trusted sources. These factors influence whether and how families seek or benefit from external cross-sectoral support for nutrition.\u003c/p\u003e\u003ch2\u003eMesosystem: Community and Service Delivery Factors\u003c/h2\u003e\u003cp\u003eMesosystem factors, the linkages between families and their immediate community and service environments, emerged as critical to enabling or hindering intersectoral collaboration around complementary feeding.\u003c/p\u003e\u003ch2\u003eInconsistent Nutritiion Support from Health Services\u003c/h2\u003e\u003cp\u003eAlthough frequent encounters with the healthsystem provide crucial touchpoints to influence complementary feeding, this opportunity is often underutilized. Caregivers consistently reported receiving vague or superficial advice during clinic visits. One mother shared:\u003c/p\u003e\u003cp\u003e\u003cem\u003e“In the hospital, they just said, give your child whatever you feel you can afford”\u003c/em\u003e revealing how missed counseling opportunities left parents with little guidance on diet diversity or managing feeding challenges.\u003c/p\u003e\u003cp\u003eThis inconsistency is rooted in several persistent structural issues. First, primary healthcare workers are overstretched, tasked with immunization, disease surveillance, antenatal care, and recordkeeping, leaving little bandwidth for in-depth nutrition counseling. As one community health worker explained:\u003c/p\u003e\u003cp\u003eNutrition counseling is just one more thing on a long list and often receives insufficient emphasis.\u003c/p\u003e\u003cp\u003eSecond, there is a lack of specialized training on child nutrition and behavior change communication. Many health workers are either inadequately prepared or lack confidence in delivering context-sensitive dietary advice. Third, participants noted that even though nutrition is systematically integrated into health performance monitoring, supervision is rarely prioritized or incentivized in routine practice. The absence of clear service delivery benchmarks for complementary feeding within primary health care weakens accountability and de-prioritizes nutrition during clinical interactions.\u003c/p\u003e\u003ch2\u003ePositive Community Engagement and Informal Support Systems\u003c/h2\u003e\u003cp\u003eDespite these gaps, caregivers pointed to instances of positive community engagement and informal support that helped improve complementary feeding practices. One mother who delivered in private or better-resourced facilities reported more structured support:\u003c/p\u003e\u003cp\u003eDuring antenatal classes, they taught us recipes and how to combine foods.\u003c/p\u003e\u003cp\u003eThese experiences, however, were not universal and often dependent on facility-level initiative or NGO support. Informal networks like peer support groups, online platforms, or family advice were crucial in filling service gaps. One father noted:\u003c/p\u003e\u003cp\u003eOnline baby-led weaning influencers helped a friend’s malnourished child improve. It really works.\u003c/p\u003e\u003cp\u003eStill, these examples raise concerns about equity and sustainability. Access to informal resources like online nutrition influencers or structured antenatal classes depends on literacy, digital access, and facility location often leaving rural or marginalized caregivers behind. Moreover, without consistent institutional support, these efforts remain fragile and non-systematic. A nutrition advocate from an NGO summarized the missed opportunity for stronger community-driven intersectoral collaboration:\u003c/p\u003e\u003cp\u003eCommunities are a reflection of their champions. We need to profile their success stories.\u003c/p\u003e\u003cp\u003eThis highlights the need for intentional identification and support of local nutrition champions, whose example can legitimize good complementary feeding practices and bridge the trust gap between formal services and families. Participants suggested that primary health centers could routinely refer families to community nutrition champions or host co-led group counseling sessions that include both facility staff and peer educators. Embedding community actors within health system workflows would enhance continuity of care while reducing provider burden.\u003c/p\u003e\u003ch2\u003eMulti-Sector Collaboration at the Local Level\u003c/h2\u003e\u003cp\u003eMany caregivers and service providers identified siloed programming and missed opportunities for collaboration across health, agriculture, education, and social protection sectors. While relevant programs exist such as school feeding and agricultural extension programs, these are often poorly coordinated at the community level. One mother observed:\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Government policy and subsidized nutrient-rich foods would help us,” but reported no such support locally.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe persistence of these gaps reflects both institutional fragmentation and weak decentralization of accountability. Local government areas often lack clear mandates or resources to convene intersectoral forums, and where such structures exist (e.g. ward-level nutrition committees), they tend to be unsustained or inactive donor-funded projects.\u003c/p\u003e\u003cp\u003eEven when coordination structures are established, operational silos and poor communication across ministries limit collective action. A rare example of success came from one primary healthcare worker:\u003c/p\u003e\u003cp\u003e\u003cem\u003e“A ward-level nutrition committee had been set up, including health, agriculture, and women’s affairs representatives, which helped in pooling resources for community nutrition classes.”\u003c/em\u003e Such cross-sector platforms, when functional, enable coordinated interventions (e.g. aligning nutrition education with food distribution), but these remain the exception rather than the norm.\u003c/p\u003e\u003cp\u003eAgricultural extension officers often operate separately from primary healthcare teams, leading to fragmented services and mixed messages for families, making nutrition everyone’s job but no one’s responsibility. The mesosystem reveals both structural gaps and missed opportunities for collaboration, driven by limited workforce capacity, weak integration of nutrition into PHC, and poor coordination. Still, community-led innovations, informal networks, and a few effective partnerships show what’s possible. Strengthening local coordination, training frontline workers, and empowering trusted community champions could help turn these fragmented efforts into a cohesive, nutrition-sensitive system.\u003c/p\u003e\u003ch2\u003eMacrosystem: Policy and Institutional-Level Factors\u003c/h2\u003e\u003cp\u003eAt the macrosystem level, encompassing national policies, governance, and broader socio-economic influences, the data revealed both systemic barriers to intersectoral collaboration and some facilitating factors that have begun to emerge in Nigeria’s nutrition landscape. A dominant theme in policymakers’ interviews was the challenge of siloed sectors and fragmented governance. National level interviewees candidly acknowledged that, historically, ministries and agencies worked in isolation on nutrition-related issues \u003cem\u003e“prior to now, partners would come in, do their programs…there was a lot of fragmentation and minimal communication across the tiers of government” [Policymaker].\u003c/em\u003e Each sector tended to focus narrowly on its mandate, and international NGOs often implemented projects independently, resulting in duplication and inefficiencies. These findings echo documented issues in Nigeria’s nutrition governance: inadequate information-sharing, working in silos, and overlapping efforts have been identified as key bottlenecks in previous assessments​ (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Participants in our study described similar role ambiguity and competition among institutions, which undermines the implementation of comprehensive complementary feeding strategies. As a policymaker who was a federal government advisor explained, “\u003cem\u003enutrition falls under multiple ministries (health, agriculture, etc.) with no single empowered authority, leading to a lot of talk but little action or actual coordination thereafter in committees.”\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother critical macrosystem barrier was the gap between policy formulation and implementation on the ground. Policymakers pointed out that Nigeria has developed robust plans on paper such as a National Food and Nutrition Policy and a multi-sector strategic plan but translating these into action has lagged. \u003cem\u003e“If you look at the multi-sectoral plan of action… the challenge is that only about 20% of it has been implemented” [Policymaker].\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis implementation gap was compounded by structural issues such as inadequate maternity protections. Participants highlighted that work obligations and insufficient maternity leave often forced mothers to return to work shortly after childbirth, disrupting exclusive breastfeeding and early nutrition practices. However, a few respondents highlighted promising examples of policy action at the subnational level. In Kwara State, for instance, a recent policy shift mandating six months of paid maternity leave was cited as a critical facilitator of improved breastfeeding and complementary feeding practices.\u003c/p\u003e\u003ch2\u003eFinancing bottlenecks\u003c/h2\u003e\u003cp\u003eSubnational governments often struggle to implement federal nutrition initiatives due to limited funding and capacity. Respondents cited persistent resource constraints and delays in fund disbursement. As one federal finance policymaker noted, \u003cem\u003e“budget allocation is one thing, release of funds is another.”\u003c/em\u003e As a result, policies like counseling, food fortification, and subsidies are often underfunded at delivery points (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Heavy reliance on donor funding further undermines sustainability—many interventions stall once external support ends. Moving forward, greater domestic investment and dedicated financing for complementary feeding are urgently needed.\u003c/p\u003e\u003ch2\u003eMacrosystem Facilitators\u003c/h2\u003e\u003cp\u003eDespite these challenges, the macrosystem analysis revealed signs of progress. High-level political commitment is growing, with several interviewees citing new coordination bodies and stronger leadership. \u003cem\u003e“The Vice President chairs the National Council on Nutrition,”\u003c/em\u003e one advisor noted, highlighting cross-sector engagement. The recent launch of the Nutrition 774 initiative, which assigns nutrition focal persons to all 774 LGAs, was also seen as a key step toward decentralizing and institutionalizing multisectoral action.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“We came up with Nutrition 774, a bottom-up approach”\u003c/em\u003e, explained a national official, \u003cem\u003e“the five sectors on N774 are agriculture, education, WASH, health, and social protection.”\u003c/em\u003e This initiative was described as a promising platform for convergence at local level, aligning with the National Multisectoral Plan of Action for Food and Nutrition 2021–2025.​ Participants felt that such frameworks, if fully executed, facilitate collaboration by clearly defining roles and pooling resources across ministries. One policymaker highlighted the establishment of a Legislative Network on Nutrition in the National Assembly as a best practice, noting that it has spurred lawmakers to champion nutrition and even inspired neighboring countries to consider similar models.\u003c/p\u003e\u003cp\u003eFinally, participants discussed broader societal and industry influences that affect complementary feeding and require intersectoral action. A nutrition advocate and health policy advisor pointed out that agricultural policy has prioritized cash crops and staples for mass production:\u003c/p\u003e\u003cp\u003eSo before when folks were working with locally grown items, indigenous crops that could easily, with minimum resources, withstand the climate within the agronomic characteristics within our own environment can no longer do that..that scenario has been hampered and interjected by the interest of global agricultural players.\u003c/p\u003e\u003cp\u003eThis highlights a misalignment between agricultural goals and nutrition outcomes—one that nutrition-sensitive agriculture programs could help bridge. Conflict and insecurity were also cited as macrosystem barriers, disrupting food production and access to complementary foods. Overall, Nigeria’s complementary feeding challenges are rooted in broader systems of policy, governance, economy, and culture. Key barriers include sectoral silos, weak implementation, limited funding, and commercial influence. However, growing political will, multisector platforms, and shared recognition of nutrition as a priority offer pathways forward. Aligning these macro-level structures with community and household efforts is essential for lasting impact.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of barriers and facilitators across ecological system levels.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBarriers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFacilitators\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMicrosystem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaregiver Burden \u0026amp; Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMothers bear responsibility alone; limited help from family\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSupportive family members; emotionally resilient caregivers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCultural Norms \u0026amp; Gender Roles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatriarchal norms; elders dominate feeding decisions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNutrition advice from healthcare workers and online platforms\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEconomic \u0026amp; Infrastructure Constraints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCost of nutritious food; poor storage and electricity access\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUse of affordable, local foods; creative food preservation strategies\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMesosystem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth Service Delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInconsistent nutrition counseling; overburdened staff; lack of training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWell-resourced clinics and NGO support; opportunities during antenatal visits\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunity Engagement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnequal access to informal support; digital and geographic disparities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePeer support groups; local nutrition champions; online platforms\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCross-sector Coordination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSiloed programming; inactive or unsustained coordination platforms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWard-level committees with multisector reps (e.g., health, agri, WASH)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMacrosystem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePolicy \u0026amp; Institutional Reform\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWork obligations and insufficient maternity leave creating urgency for mothers to return to work after delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePolicy shift enabling six-month paid maternity leave in Kwara State to support exclusive breastfeeding and early nutrition\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePolicy Implementation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStrong policies on paper but weak local execution and accountability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNational Food and Nutrition Policy; Nutrition 774 framework\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFunding \u0026amp; Governance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDelayed fund disbursement; dependency on donor funding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNutrition budget lines; pooled fund models under discussion\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePolitical Commitment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHistorical sectoral fragmentation; weak enforcement of roles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eVice President-led Council; Legislative Network on Nutrition\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe examined how multilevel factors influence intersectoral collaboration to improve complementary feeding in Nigeria, using an ecological systems perspective. Drawing on the voices of policymakers, parents, and healthcare workers, we highlight dynamics across the micro, meso, and macro systems that shape nutrition policies and practices. While Nigeria has made meaningful progress, including high-level political commitment and multisector policy frameworks, our findings reveal persistent challenges in translating these advances into coordinated, context-sensitive actions that reach caregivers.\u003c/p\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eMicrosystem Dynamics: Household Realities and Caregiver Constraints\u003c/h2\u003e\u003cp\u003eOur data reveal that decision-making around child feeding is often influenced by male partners or elders, reinforcing power imbalances that restrict women\u0026rsquo;s autonomy. These findings align with other research showing that traditional beliefs can override evidence-based practices (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Tackling these dynamics requires culturally appropriate strategies that engage fathers, grandmothers, and community elders, not just mothers, in complementary feeding education and behavior change efforts. Encouragingly, a few caregivers in our study reported success when they received actionable guidance through antenatal classes or support from knowledgeable relatives.\u003c/p\u003e\u003cp\u003eThis supports global evidence that context-tailored and family-inclusive counseling can significantly improve complementary feeding outcomes (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). For example, in Peru, the use of sheltered conveners who can coordinate others without being hampered by institutional conflicts emerged as a critical determinant of the country\u0026rsquo;s success in improving child nutrition outcomes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Enhancing intersectoral collaboration at the microsystem level involves aligning the work of the health, education, and social sectors to deliver consistent messaging through clinics, community groups, and media platforms.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eMesosystem Dynamics: Community-Level Gaps and Coordination Opportunities\u003c/h2\u003e\u003cp\u003eAt the mesosystem level, the interface between caregivers and frontline services emerged as a critical but often weak link between policy and household action. Participants described health facilities that overlooked nutrition due to workforce shortages, limited training, and lack of institutional support. This reflects Ene-Obong et al.'s (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)concept of \u0026ldquo;first contact failure,\u0026rdquo; where routine visits miss opportunities to promote complementary feeding. Addressing this requires service-level collaboration for example, embedding nutrition in PHC protocols and equipping agricultural extension workers to share feeding messages during community visits.\u003c/p\u003e\u003cp\u003eFrontline workers also noted poor coordination across sectors at the local level. While health, agriculture, and social protection often run parallel programs, most LGAs lack operational coordination platforms, leading to duplication and inefficiencies. Revitalizing ward and LGA-level nutrition committees, backed by performance-based incentives (e.g., mandatory reporting or conditional funding), could improve alignment.\u003c/p\u003e\u003cp\u003eThe Nutrition 774 initiative deploying nutrition focal points in every LGA was cited as a promising step, especially when focal points are empowered to convene multisectoral actors. A comparable model in Tanzania showed success through district-level committees with strong leadership and oversight roles, supporting implementation of its National Multisectoral Nutrition Action Plan (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eMacrosystem Dynamics: Translating Political Will into Practice\u003c/h2\u003e\u003cp\u003eNigeria\u0026rsquo;s national nutrition architecture reflects substantial high-level momentum, but implementation bottlenecks persist. Our findings affirm the literature\u0026rsquo;s description of a \u0026ldquo;commitment-implementation gap\u0026rdquo; (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) where national plans exist but subnational execution falters due to institutional capacity, and poor accountability.\u003c/p\u003e\u003cp\u003eTensions between ministries, especially over who leads coordination, further weaken intersectoral collaboration. Stakeholders agreed that housing nutrition leadership within a neutral, high-level entity, such as the Ministry of Budget and Planning under the Vice President\u0026rsquo;s office, clarifies roles for nutrition going forward.\u003c/p\u003e\u003cp\u003eAccountability was another recurring issue. State-level compliance with national directives remains voluntary and often unenforced. Participants stressed that without mechanisms to reward performance or sanction neglect, nutrition remains deprioritized. Tools such as public progress scorecards, performance-based disbursement through the Nutrition Intervention Fund, and civil society monitoring, already in use through scaling up nutrition platforms, can strengthen accountability structures (17).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eFinancing for nutrition\u003c/h2\u003e\u003cp\u003eResource flow remains a major constraint. Even with dedicated nutrition budgets, delayed disbursements and poor fund utilization hinder implementation. Addressing this requires protecting allocations, streamlining release processes, and incentivizing states through matching grants. Public-private partnerships can also bolster support for families during the complementary feeding phase.\u003c/p\u003e\u003cp\u003eBroader political economy challenges such as weak enforcement of breast-milk substitute regulations (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), misaligned agricultural priorities, and poor intersectoral coordination further limit progress. Tackling these requires engaging sectors like trade, media, and consumer protection, and reorienting agriculture to promote nutrient-dense foods. National platforms like the National Council on Nutrition can help align strategies across sectors.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cp\u003eStrategies to Strengthen Intersectoral Collaboration for Complementary Feeding\u003c/p\u003e\n\u003cp\u003eIntersectoral collaboration is inherently complex and labor-intensive, requiring ongoing coordination across sectors and systems. Yet, the benefits, better child nutrition, health equity, and development outcomes justify the investment. Drawing on our findings, we propose six strategies to improve coordination for complementary feeding in Nigeria:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eEstablish Clear Coordination Mechanisms Across all Levels\u003cbr\u003e\u0026nbsp;Formal coordination structures are needed at national, state, and local levels. While the National Council on Nutrition offers oversight, state and local committees must be empowered with clear roles and accountability mechanisms. National guidelines should define ministry responsibilities and set expectations for regular coordination and progress tracking.\u003c/li\u003e\n \u003cli\u003eBuild Capacity and Incentivize Frontline Workers\u003cbr\u003e\u0026nbsp;Frontline workers need updated training on complementary feeding. Cross-sector training for agricultural, education, and social workers can reinforce messages. Incentives, such as performance awards or additional funds, can motivate local actors and promote accountability.\u003c/li\u003e\n \u003cli\u003eEngage Communities and Promote Social Behavior Change\u003cbr\u003e\u0026nbsp;Community involvement is critical. Strengthening mother groups, father forums, and local influencers can support information-sharing (19). Highlighting \u0026ldquo;nutrition champions\u0026rdquo; and linking community groups with health centers and mass media campaigns can drive behavior change and ensure message consistency.\u003c/li\u003e\n \u003cli\u003eImprove Policy Implementation and Financing\u0026nbsp;\u003cbr\u003eOperationalizing national plans through costed local workplans with clear targets is key. Dedicated nutrition budget lines and timely fund release e.g., via quarterly disbursements can improve execution. Innovative financing like results-based funding and pooled resources should be explored, along with better public financial tracking.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003eStrengthen Monitoring, Evaluation, and Learning Systems\u003cbr\u003eA unified M\u0026amp;E framework should track both nutrition-specific and nutrition-sensitive indicators. Data must be reviewed regularly to inform adjustments. Tools like dashboards and scorecards can enhance transparency and accountability. Promising innovations should be evaluated and scaled through partnerships with academic institutions.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"6\"\u003e\n \u003cli\u003eNavigate the Political Economy and Institutionalize Support\u003cbr\u003eAddressing institutional resistance requires a phased, politically informed approach. Strengthening existing platforms, advocating through legislative channels, and aligning nutrition with broader development goals can secure long-term support. Demonstrating the wider benefits of child nutrition will help build sustained political will.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eStudy Limitations\u003c/p\u003e\n\u003cp\u003eA potential limitation is selection bias, as the lead researcher (L.O.) recruited participants through her professional network, possibly skewing responses toward more engaged or system-aware individuals. This may have limited the diversity of perspectives, particularly regarding intersectoral collaboration. Although purposive sampling ensured sectoral representation, generalizability is limited due to the qualitative design. Not all geopolitical zones were equally represented, and virtual interviews may have excluded more digitally marginalized parents.\u003c/p\u003e\n\u003cp\u003eNonetheless, the study provides rich, context-specific insights into the systemic and multilevel factors influencing complementary feeding in Nigeria, with relevance for similar LMICs aiming to strengthen nutrition outcomes through intersectoral collaboration.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the complex, multilevel factors influencing intersectoral collaboration for complementary feeding in Nigeria. While national policies and coordination have advanced, major gaps remain in implementation, local alignment, and frontline capacity particularly for vulnerable caregivers. Strengthening collaboration requires action across all levels: equipping frontline workers, engaging communities, and improving coordination and accountability. Promising efforts like the Nutrition 774 initiative and lessons from countries like Tanzania show potential, but progress depends on sustained investment and local ownership. The strategies proposed offer pragmatic, phased steps to improve outcomes through collective leadership and multisectoral partnerships that center families. Advancing complementary feeding will not only boost nutrition but also support Nigeria\u0026rsquo;s broader development goals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ePositionality Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs a mother of two young daughters, my lived experience deeply informs my research on complementary feeding. This personal journey shapes my understanding of the challenges caregivers face and fuels my commitment to finding practical, context-specific solutions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs a public health professional, I approach this work not only with academic interest but with a deep sense of empathy and urgency to improve systems that support families especially those navigating these decisions in resource-limited settings. My dual lens as both a researcher and a parent, ground this study in lived reality. I acknowledge that this positionality may have also influenced how I interpreted participants\u0026rsquo; perspectives, particularly in recognizing emotional and practical challenges that might otherwise be overlooked.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Loma Linda University (#5250146) and Nigeria Health Research Ethics Committee. All procedures complied with ethical standards for research involving human subjects. The study\u0026rsquo;s reliance on experienced adult stakeholders (ages 25 and above) and the non-sensitive nature of topics (policy/program discussions) minimized risk to participants. Nonetheless, the research was careful to uphold ethical principles of respect, beneficence, and justice throughout the process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate and Publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBecause interviews were conducted remotely, verbal informed consent was obtained from each participant prior to starting the recording. The interviewer explained the study aims, what participation entailed, and assured participants of confidentiality. Participants were informed that their involvement was voluntary and that they could decline to answer any question or end the interview at any time. Permission to record the interview and publish final results was explicitly sought. Verbal consent (for both participation and recording) was documented at the beginning of each audio recording.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo protect confidentiality, no real names or personal identifiers appear in the transcripts or analysis; each participant was assigned a unique code, and any potentially identifying details mentioned during interviews (such as specific workplaces or locations) were generalized or removed in the transcripts. Audio recordings and transcript files were stored securely on a password-protected Loma Linda University One Drive folder accessible only to the research team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials missing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAudio recordings and transcript files were stored securely on a password-protected Loma Linda University One Drive folder accessible only to the research team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this research. Also, participants did not receive monetary compensation.\u0026nbsp;\u003c/p\u003e\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eP\u0026eacute;rez-Escamilla R S-PS, Lott M, et al. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Healthy Eating Research. 2017.\u003c/li\u003e\n\u003cli\u003eUnicef. Young children\u0026rsquo;s diets show no improvement in last decade, \u0026lsquo;could get much worse\u0026rsquo; under COVID-19 2021. Available from: https://www.unicef.org/nigeria/press-releases/young-childrens-diets-show-no-improvement-last-decade-could-get-much-worse-under#:~:text=half%20of%20children%20aged%206,groups%20they%20need%20to%20thrive.\u003c/li\u003e\n\u003cli\u003eNational Population Commission - NPC, ICF. Nigeria Demographic and Health Survey 2018 - Final Report. Abuja, Nigeria: NPC and ICF, 2019.\u003c/li\u003e\n\u003cli\u003eNa M KS, Murray-Kolb, LE. . Regional Landscape Analysis of Trends and Factors of Young Children\u0026apos;s Diet in UNICEF\u0026apos;s West and Central Africa Region (WCAR UNICEF). 2020.\u003c/li\u003e\n\u003cli\u003eAivalli P, Gilmore B, Srinivas PN, De Br\u0026uacute;n A. Navigating intersectoral collaboration in nutrition programming: implementors\u0026apos; perspectives from Assam, India. Arch Public Health. 2024;82(1):82. Epub 20240607. doi: 10.1186/s13690-024-01312-6. PubMed PMID: 38849925; PubMed Central PMCID: PMC11157891.\u003c/li\u003e\n\u003cli\u003eOgbo FA, Page A, Idoko J, Claudio F, Agho KE. Have policy responses in Nigeria resulted in improvements in infant and young child feeding practices in Nigeria? International Breastfeeding Journal. 2017;12(1):9. doi: 10.1186/s13006-017-0101-5.\u003c/li\u003e\n\u003cli\u003eOpara A. Improving Nutrition Outcomes in Nigeria through Strengthened Multisectoral Coordination Nigeria: Nigeria Health Watch; 2024 [cited 2024]. Available from: https://nigeriahealthwatch.medium.com/improving-nutrition-outcomes-in-nigeria-through-strengthened-multisectoral-coordination-87fe6cc2a79d.\u003c/li\u003e\n\u003cli\u003eExemplarsinGlobalHealth. Peru\u0026rsquo;s Unique Nutrition Journey. 2016.\u003c/li\u003e\n\u003cli\u003eKim SS, Avula R, Ved R, Kohli N, Singh K, van den Bold M, et al. Understanding the role of intersectoral convergence in the delivery of essential maternal and child nutrition interventions in Odisha, India: a qualitative study. BMC Public Health. 2017;17(1):161. doi: 10.1186/s12889-017-4088-z.\u003c/li\u003e\n\u003cli\u003eYunitasari E, Al Faisal AH, Efendi F, Kusumaningrum T, Yunita FC, Chong MC. Factors associated with complementary feeding practices among children aged 6-23 months in Indonesia. BMC Pediatr. 2022;22(1):727. Epub 20221221. doi: 10.1186/s12887-022-03728-x. PubMed PMID: 36539759; PubMed Central PMCID: PMC9769005.\u003c/li\u003e\n\u003cli\u003eAdeomi AA, Fatusi A, Klipstein-Grobusch K. Individual and contextual factors associated with under- and over-nutrition among school-aged children and adolescents in two Nigerian states: a multi-level analysis. Public Health Nutr. 2022;25(8):2339-51. Epub 20220124. doi: 10.1017/s1368980022000258. PubMed PMID: 35067272; PubMed Central PMCID: PMC9991795.\u003c/li\u003e\n\u003cli\u003eVasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Medical Research Methodology. 2018;18(1):148. doi: 10.1186/s12874-018-0594-7.\u003c/li\u003e\n\u003cli\u003eAdeyemi O, van den Bold M, Nisbett N, Covic N. Changes in Nigeria\u0026rsquo;s enabling environment for nutrition from 2008 to 2019 and challenges for reducing malnutrition. Food Security. 2023;15(2):343-61. doi: 10.1007/s12571-022-01328-2.\u003c/li\u003e\n\u003cli\u003eOlatona FA, Adenihun JO, Aderibigbe SA, Adeniyi OF. Complementary Feeding Knowledge, Practices, and Dietary Diversity among Mothers of Under-Five Children in an Urban Community in Lagos State, Nigeria. Int J MCH AIDS. 2017;6(1):46-59. doi: 10.21106/ijma.203. PubMed PMID: 28798893; PubMed Central PMCID: PMC5547225.\u003c/li\u003e\n\u003cli\u003eEne-Obong H, Onuoha N, Eme P. Gender roles, family relationships, and household food and nutrition security in Ohafia matrilineal society in Nigeria. Maternal \u0026amp; Child Nutrition. 2017;13:e12506. doi: 10.1111/mcn.12506.\u003c/li\u003e\n\u003cli\u003eKlemm GC, Kayanda R, Kazoba A, McCann J, Nnally LP, Dickin KL. Translating Multisectoral Nutrition Policy into Community Practice: Participation of Nutrition Officers in Tanzania Fosters Effective Collaborative Strategies to Improve Child Nutrition. Curr Dev Nutr. 2022;6(4):nzac030. Epub 20220228. doi: 10.1093/cdn/nzac030. PubMed PMID: 35415387; PubMed Central PMCID: PMC8992576.\u003c/li\u003e\n\u003cli\u003eUSAID. Multisectoral Nutrition Global Evidence Update 2025. Available from: https://nutritionnigeria.org/multisectoral-nutrition-global-evidence-update/#:~:text=Multisectoral%20Nutrition%20Global%20Evidence%20Update,being.\u003c/li\u003e\n\u003cli\u003eUSAID. The Community Infant and Young Child Feeding Counselling Package in Kaduna State, Nigeria. 2018.\u003c/li\u003e\n\u003cli\u003eBillings L, Pradeilles R, Gillespie S, Vanderkooy A, Diatta D, Toure M, et al. Coherence for nutrition: insights from nutrition-relevant policies and programmes in Burkina Faso and Nigeria. Health Policy and Planning. 2021;36(10):1574-92. doi: 10.1093/heapol/czab108.\u003c/li\u003e\n\u003cli\u003eSubandoro AWO, Yuko; Mehta,Michelle Ashwin; Wang,Huihui; Ahluwalia,Naina; Finkel,Elyssa; Bulungu, Andrea L.S.; Dinsa,Girmaye Deye; Okara,Latifat Agharese; Wilson,Shelby Elena. Positioning Nutrition within Universal Health Coverage : Optimizing Health Financing Levers. Health, Nutrition, and Population (HNP) discussion paper Washington, DC : World Bank Group. 2022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Complementary Feeding, Intersectoral Collaboration, Ecological Systems Theory, Child Nutrition, Health Policy, Nigeria","lastPublishedDoi":"10.21203/rs.3.rs-6863002/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6863002/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComplementary feeding is critical to reducing child malnutrition and promoting long-term health. While Nigeria has introduced several national policies promoting intersectoral collaboration, implementation challenges remain, and key indicators continue to lag. Although existing literature recognizes the multisectoral drivers of complementary feeding, there is limited insight into how policymakers and stakeholders can effectively harness intersectoral collaboration to strengthen policy implementation and practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aims to explore how intersectoral collaboration can be operationalized to strengthen the implementation of complementary feeding policies and practices by examining stakeholder perspectives on key challenges and enablers, mapping collaboration across sectors and levels of government, and understanding how systemic, community, and household-level factors shape feeding outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe employed a qualitative case study design, informed by Bronfenbrenner’s Ecological Systems Theory, to explore the multilevel influences on complementary feeding practices in Nigeria. Semi-structured interviews (n=20) were conducted with purposively selected stakeholders, including policymakers, primary health workers, caregivers, and representatives from non-governmental organizations, to ensure sectoral diversity. Thematic analysis was conducted, with findings organized across the micro-, meso-, and macro-levels of the ecological framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the microsystem level, caregivers described cultural norms, limited support networks, and financial barriers shaping feeding practices. The mesosystem level revealed fragmented service delivery and inconsistent community engagement. At the macrosystem level, challenges included limited funding and weak policy enforcement. However, participants also identified emerging political will evidenced by the Vice President’s leadership of the National Council on Nutrition and initiatives such as Nutrition 774, national coordination platforms, and grassroots innovations, as potential facilitators of improved intersectoral collaboration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImproving complementary feeding in Nigeria requires coordinated action across household, community, and policy levels. Empowering frontline workers, strengthening feedback loops, and clarifying sector roles can close the gap between policy and practice. Sustained progress hinges on dedicated funding, shared accountability, and leadership that rewards collaboration.\u003c/p\u003e","manuscriptTitle":"Strengthening Intersectoral Collaboration to Improve Complementary Feeding Policies and Practices in Nigeria: An Ecological Systems Perspective","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 11:42:40","doi":"10.21203/rs.3.rs-6863002/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-11T13:30:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-03T14:26:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31992086078036545334468026028142948430","date":"2025-08-01T10:30:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97275972089302923642155345034945428771","date":"2025-07-28T08:54:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-21T12:42:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-20T08:29:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-20T03:55:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-20T03:53:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-06-10T12:10:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3e77f755-e570-4d07-952d-09ae849f6408","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-23T11:42:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-23 11:42:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6863002","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6863002","identity":"rs-6863002","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}