Abstract
Background
Infant and Young Child Feeding (IYCF) globally is characterised by a "triple burden" of malnutrition, encompassing undernutrition, micronutrient deficiencies, and overnutrition. Papua New Guinea (PNG) experiences a particularly heavy burden, with nearly half (48%) of children under five years (CU5) affected by stunting, ranking fourth highest globally. Sub-optimal IYCF practices and infant malnutrition remain critical public health challenges in PNG. Addressing these challenges requires context-specific, tailored interventions at key stages of infant growth. However, information on caregivers’ knowledge, attitudes, and practices (KAP) related to infant feeding in PNG is limited. Therefore, this study assessed caregivers’ nutritional KAP and explored key determinants of IYCF to inform the development of context-specific, evidence-based interventions to improve infant nutrition in PNG.
Methods
A mixed-methods design was used, combining interview-assisted questionnaires and a Yumi Tok Stori (YTS) approach. Participants were mothers of infants aged 5-10 months, from Simbu Province and the Eastern Highlands, from March to May of 2025. The quantitative method assessed caregivers' nutritional knowledge, attitudes, and infant feeding practices. Infant and young child feeding (IYCF) dietary adequacy indicators, including Minimum Acceptable Diet (MAD), Minimum Dietary Diversity (MDD), and Minimum Meal Frequency (MMF), were determined based on the World Health Organisation’s guidelines. The qualitative component explored from a caregiver's experience the factors that influenced infant feeding practices. The Yumi Tok Stori discussions were recorded, transcribed and analysed using reflexive thematic analysis. The results from the quantitative and qualitative parts were integrated by summarising important findings aligned with the qualitative themes.
Results
Sixty-six mothers/caregivers completed the interview-assisted questionnaires: infants had a mean (SD) age of 7.8 months (1.3). There was a heterogeneous distribution of knowledge, with areas of strength alongside notable gaps, resulting in a relatively low overall mean (SD) knowledge score of 7.5 (1.9) out of 16. Breastfeeding initiation was nearly universal (97%), yet only 36% of mothers practised exclusive breastfeeding. While 61% of respondents knew that exclusive breastfeeding supports infant growth and survival for the first six months, and 67% correctly identified 6 months as the appropriate age to introduce complementary foods, knowledge of animal-source foods was limited. Only 42% of mothers identified eggs as suitable for infants at 6 months, and fewer than 20% recognised that fish or chicken was appropriate at this age.
Regarding feeding practices, only 35% of infants met the MAD. MDD was achieved by 47%, with a mean (SD) of 4.5 (1.6) food groups consumed, while MMF was met by 70%, with a mean (SD) of 2.4 (1.2) meals per day. Although most mothers (84.9%) were aware that sugar should not be added to infants’ foods and drinks, nearly half (46%) reported that their infant had consumed a sugar-sweetened beverage on the previous day. Awareness of multiple micronutrient powders (MNPs) was very limited: only 4 mothers (6%) had heard of them, and just one reported having used them.
Forty mothers were recruited for 5 Yumi Tok Stori sessions, including 23 who also completed interviewer-assisted questionnaires. Five themes were developed: 1) Cultural Expectations and Gender Roles; 2) Grandmothers' Support and Influence; 3) Natural and Traditional Feeding Practices; 4) Mixed Messages- The Influence of Grandmothers and Health Workers on Infant Feeding; 5) Challenges of Food Accessibility and Affordability. Opportunities for intervention and improvement were also identified through the discussions.
Conclusion
Caregivers demonstrated strong knowledge and positive attitudes toward breastfeeding and complementary feeding, but these did not consistently translate into recommended practices. Although antenatal care attendance was generally adequate, IYCF counselling during pregnancy was inconsistently delivered, representing a missed opportunity to influence early feeding intentions. Infant feeding practices were shaped primarily by sociocultural determinants, including gender roles, caregiving arrangements, and the influence of grandmothers and spouses, rather than maternal choice alone. Postnatal uptake of feeding advice was strongly influenced by trust, power, and communication in interactions with health workers. Finally, structural constraints related to food affordability, accessibility, and programme reach limited dietary diversity and micronutrient intake despite caregiver awareness.
Despite generally good awareness of recommended IYCF practices in the first six months of life, awareness appeared to decline for feeding practices beyond six months. Exclusive breastfeeding, timely introduction of animal-source foods, and minimum acceptable diet attainment remained low, alongside very limited awareness of MNPs. Missed opportunities for antenatal nutritional counselling, reliance on informal advice, postnatal health worker interactions, household dynamics, and economic constraints interacted to widen gaps between recommended and practised feeding behaviours. These findings provide critical evidence to inform coordinated, context-specific interventions across health facility, community, and household levels to strengthen complementary feeding and improve infant nutrition in PNG.