Socioeconomic Inequality in Exclusive Breastfeeding Behavior and Ideation Factors for Social Behavioral Change in Three North-western Nigerian States: A Cross-sectional Study

"Socioeconomic inequalities exist in exclusive breastfeeding behaviors and in associated ideation factors in the three states but are mostly avoidable. Messaging for SBC communication interventions to improve breastfeeding practices could be more effective by targeting the mitigation of these inequalities."

Factors such as knowledge, attitudes, and social norms and conventions influence individuals' and communities' health states, including healthcare-seeking behaviours. Social and behavioural change (SBC) programmes to foster positive breastfeeding behaviours typically focus on modulating psychosocial influences, or ideations, as intermediate determinants of health behaviours. Since 2017, the United States Agency for International Development (USAID) Nigeria has invested in implementing SBC intervention programmes through the Breakthrough ACTION Nigeria (BA-N) consortium. Conducted in BA-N programme areas, this study explores the empirical evidence of inequalities in the practice of exclusive breastfeeding (EBF) and associated ideational dimensions and domains.

BA-N aims to increase 17 priority health behaviours by improving individual and social determinants of health, facilitating SBC coordination and collaboration among partners, and strengthening the SBC capacity of national and sub-national public sector entities. The BA-N SBC intervention programme consists of three core components: (i) advocacy outreach to opinion leaders and community influencers at state and local government area (LGA) levels; (ii) direct engagement of community members through household visits and community dialogues, with referrals for services as needed; and (iii) complementary integrated SBC messaging through mass, mid-media, and mobile phones. The thrust of BA-N programming and interventions is based on the ideation model of strategic communication and behaviour change.

This exploration is based on the household data from a Breakthrough RESEARCH Nigeria (BR-N) Behavioral Sentinel Surveillance (BSS) baseline survey wave conducted between September and October 2019. The BSS data were obtained through a representative two-stage cluster-sample, a cross-sectional population survey of 3,007 women with a child under two years in wards from Kebbi, Sokoto, and Zamfara states. The researchers estimated the concentration indexes (CIxs) of EBF behaviour, ranked by household wealth index. Inequality was decomposed to associated ideational factors and sociodemographic determinants. "Avoidable inequalities" (those that are amenable to intervention) and the proportion of linear redistribution to achieve zero inequality were estimated.

Women from wealthier households were more likely to practice EBF (CIx = 0.1236, p-value = 0.00). Attendance of at least four antenatal clinic visits (ANC 4+) was the most significant contributor to the inequality, contributing CIx = 0.0307 (p-value = 0.00) to the estimated inequality in EBF practice. The elasticity estimates showed that a percentage change in the ideation factors of partners influencing the decision to breastfeed and ANC 4+ during the last pregnancy could significantly result in a 0.15% (p-value = 0.00) and 0.08% (p-value = 0.00) change in EBF behaviour, respectively. Inequality in regular attendance at community meetings (CIx = 0.1887, p-value =0.00); ANC 4+ (CIx = 0.3722, p-value = 0.00); and maternal age (CIx = 0.0161, p-value = 0.00) were pro-rich. A 10.7% redistribution of EBF behaviour from the wealthier half to the economically poorer half of the population could eliminate the inequality (line of zero inequality). Inequalities were mainly in the cognitive and social norms dimension and were all pro-poor.

In other words, women in the wealthiest households were more likely to exclusively breastfeed than those in the lower socioeconomic (poorer) households. Regular antenatal (at least 4) visits during pregnancy contributed significantly to breastfeeding practices' inequality. The findings showed that changes in the population distribution of women who had ANC 4+ during pregnancy, women whose partners influenced their decision to breastfeed the child exclusively, and those knew the benefits of EBF significantly changed the practice of exclusive breastfeeding. The results could reflect the fact that better-off individuals might have better access to the antenatal clinic during pregnancy, where EBF is a regular topic during health education sessions and is commonly a part of advocacy messages.

Per the researchers, these results have implications for SBC programming in northern Nigeria, where socioeconomically disadvantaged groups are consistently disadvantaged in their access to health care. For instance, SBC interventions often employ multichannel approaches, including the use of broadcasting mass communication approaches (using mass media) for behaviour change, as is the case in the three north-western states of Nigeria. An implicit assumption in such intervention strategy and the expected impact is that all population groups are uniformly exposed to the intervention and impacted is assumed to be uniform across all strata. Non-uniform (unequal) exposure to population-based SBC interventions could generate a skewed, non-uniform response across population sub-groups. This inequality can potentially minimise the intensity of programme impact in disadvantaged groups, favouring advantaged groups in the population and ultimately resulting in suboptimal programme impact.

Instead, one could hone in on the elasticity of spousal communication, for example, The study highlights the importance of male partners' role in influencing the decision to breastfeed the child and suggests that programmatic enhancement of this role could be effective in improving population breastfeeding behaviour. Further exploration into the role of men in SBC communication and in the decision to exclusively breastfeed the child is necessary for informing future interventions.

In conclusion: "The findings suggest that improving and expanding ANC coverage through pro-poor intervention could improve breastfeeding practices among the socioeconomically disadvantaged group of the population. The results showed that inequality in exclusive breastfeeding practice is totally (100%) amenable and could be mitigated through targeted interventions. Sociodemographic factors, which are unmodifiable (constants) were not significant contributors to the inequality in exclusive breastfeeding. Programmatically achieving a reduction in the inequality in exclusive breastfeeding behavior by 10% could eliminate the inequality (zero inequality) in the population distribution of positive exclusive breastfeeding behavior."