MSc Project Report2021-2022“Ask any of us ‘can you show me thedata?’ We barely have it”: A
qualitative study of research
priorities on infant and young childfeeding in emergencies

Candidate number: 211476
Word count: 9968
Project length: Standard
Submitted in part fulfilment of the requirements for the degree of MSc
Nutrition for Global Health
September 2022

1 Table of Contents
ABSTRACT ...................................................................................................................................................... 5
ACKNOWLEDGEMENTS .................................................................................................................................. 6
STATEMENT OF ACADEMIC CONTRIBUTION ................................................................................................... 7
ABBREVIATIONS AND DEFINITIONS ................................................................................................................ 9
LIST OF FIGURES ........................................................................................................................................... 10
LIST OF TABLES ............................................................................................................................................ 10
1.

INTRODUCTION ................................................................................................................................... 11
1.1.

MORTALITY AND INFANT AND YOUNG CHILD FEEDING ...................................................................................... 11

1.2.

INFANT AND YOUNG CHILD FEEDING IN EMERGENCIES ...................................................................................... 12

1.3.

INTERVENTIONS FOR INFANT AND YOUNG CHILD FEEDING IN EMERGENCIES .......................................................... 13

1.4.

RESEARCH ON INFANT AND YOUNG CHILD FEEDING IN EMERGENCIES ................................................................... 14

1.5.

CRITICAL GAPS BETWEEN UNMET NEED FOR KNOWLEDGE AND EVIDENCE-BASED PRACTICE IN IYCF-E ........................ 16

1.6.

RATIONALE ............................................................................................................................................. 17

2.

AIMS AND OBJECTIVES ........................................................................................................................ 17

3.

METHODS ............................................................................................................................................ 18

4

5

6

3.1.

RESEARCH TEAM AND REFLEXIVITY ............................................................................................................... 18

3.2

STUDY DESIGN ......................................................................................................................................... 18

3.3

DATA ANALYSIS ........................................................................................................................................ 21

3.4

ETHICS ................................................................................................................................................... 22

RESULTS .............................................................................................................................................. 22
4.1.

PARTICIPANT CHARACTERISTICS ................................................................................................................... 22

4.1

VIEWS ON THE LACK OF RESEARCH IN IYCF-E ................................................................................................. 23

4.3

VIEWS ON EACH OF PRUDHON ET AL.’S1 TEN RESEARCH PRIORITIES IN IYCF-E ...................................................... 25

4.4

ADDITIONAL RESEARCH PRIORITIES TO CONSIDER IN IYCF-E .............................................................................. 33

DISCUSSION ......................................................................................................................................... 33
5.1.

VIEWS ON THE LACK OF IYCF-E RESEARCH .................................................................................................... 34

5.2.

VIEWS ON EACH OF PRUDHON ET AL.’S1 TEN RESEARCH PRIORITIES IN IYCF-E ...................................................... 34

5.3.

ADDITIONAL RESEARCH PRIORITIES TO CONSIDER IN IYCF ................................................................................. 38

5.4.

STRENGTHS AND LIMITATIONS .................................................................................................................... 38

CONCLUSION ....................................................................................................................................... 39

3

7

RECOMMENDATIONS .......................................................................................................................... 40

8

REFERENCES ........................................................................................................................................ 41

9APPENDICES ........................................................................................................................................ 48
9.1

ETHICS APPROVAL .................................................................................................................................... 48

9.2

RECRUITMENT EMAIL ................................................................................................................................ 49

9.3

PARTICIPANT INFORMATION SHEET.............................................................................................................. 50

9.4

CONSENT FORM ...................................................................................................................................... 52

9.5

INTERVIEW GUIDE .................................................................................................................................... 53

9.6

CODEBOOK ............................................................................................................................................. 57

9.7

CONSOLIDATED CRITERIA FOR REPORTING QUALITATIVE STUDIES (COREQ): 32-ITEM CHECKLIST 59 ........................ 62

9.8.

CARE FORM ............................................................................................................................................ 64

4

Abstract
Background
Humanitarian emergencies can compromise child feeding practices through forced
displacement, unsolicited provision of breastmilk substitutes, inadequate sanitation, and foodinsecurity. With limited resources and increasing populations affected by emergencies, it isparamount that research on infant and young children in emergencies (IYCF-E) focuses on
the most pressing priorities. This study aims to determine what these are.
Methods
This was a qualitative study. I conducted thirteen semi-structured interviews using an interview
guide via Zoom. In total, twenty-three were invited to participate, four declined and six failed
to respond. Of the thirteen, ten were recruited using purposive and three through snowball
sampling. Questions related to ten previously published research priorities in IYCF-E.
Participants had at least five years of experience in IYCF-E as practitioners, policymakers, or
researchers. I analysed them deductively based on this study’s objectives and inductively toallow for identification of additional themes. This was done using thematic analysis with NVivo
software.
Results
All participants commented on the lack of research on IYCF-E. Specifically, a recurring theme
was the lack of evidence on impact and effectiveness across interventions. Most participants
stated that critical priorities are the effectiveness of complementary feeding interventions andhow to safely provide breastmilk substitutes. There is scanty evidence in the literature on
IYCF-E, and in general, participants perceptions of this evidence on the research prioritiesaligned with the actual availability of evidence. These evidence gaps hinder IYCF-E
programmes and, ultimately, health outcomes.
Conclusions
This study indicates that evidence generation should now be targeted at comparing theeffectiveness of different complementary feeding interventions, and how to safely provide
breastmilk substitutes without compromising breastfeeding. Future research must be focusedon the implementation of IYCF-E interventions to determine their effectiveness, which would
result in routine application and policy changing practices.

5

Acknowledgements
I would like to extend a huge thank you to all my study participants who took the time out of
their busy schedules to share their views with me. Without your valuable insights, this project
would not have been possible. I would also like to thank my supervisors for their ongoingsupport, encouragement, and guidance. I have learnt so much from both of you. Importantly I
would like to extend my most profound appreciation for the Commonwealth Scholarship
Commission, whose funding made this entire master’s degree possible. Lastly, I would like tothank my classmates (particularly my revision buddies), my friends, my family, and my partner
for providing endless encouragement, comic relief, coffee breaks and words of wisdom.

6

Statement of Academic Contribution
Project development
My external supervisor and their Emergency Nutrition Network colleagues generated the
project’s idea. They requested a ‘stock take’ and an update on the research priorities in infant
and young child feeding in emergencies as previously determined by Prudhon et al.1 To
streamline the project and to build my qualitative research skills, I asked for it to purely be aqualitative study, which both supervisors supported.
Contact, input, and support
My internal supervisor provided feedback on my ethics form before submission and suggested
some possible frameworks I could use to guide the project. Although I chose a different
framework, these suggestions helped me to find the framework I eventually decided on. I had
four 20-30 minute meetings with them, in which they provide advice on qualitative researchmethods. My external supervisor gave me a list of potential participants and their contact
details. Once I began writing the project, I had five 20-30 minute meetings in which they
provided general guidance on the development of the project, and I provided feedback on how
it was progressing. In a joint meeting, my internal and external supervisors suggested changes
to my topic guide, which I used to make improvements on it. Following this my internal
supervisor made direct edits on it to improve it further.
Main research work
I collected, analysed, and drew conclusions from the qualitative data on my own. My external
supervisor helped identify infant and young child feeding in emergencies (IYCF-E) researchrepositories, which aided in the identification of relevant literature for the background anddiscussion. My internal supervisor sent me additional studies conducted in refugee camps that
I incorporated into the background and discussion.
Writing-up
I worked alone to write the project. My external supervisor provided general comments on thecontent of my background and then on the final draft of the project to ensure it met theirrequirements. This led me to reframe terminology, add additional key literature that they
provided, and be more explicit in my explanations. My internal supervisor provided comments
on an outline of my background and one draft of the project. This led me to edit the title of the
project, add a few additional pieces of key literature that they provided as well as simplifying
my framework and restructuring my interpretation of the results against the framework. These7

comments from both of my supervisors were used to produce, and ultimately improve the final
submission. I am most grateful for their time.

8Abbreviations and definitions
IYCF: Infant and young child feeding
WHO: World Health Organization
Breastmilk substitutes: Any food/drink represented as a replacement for breastmilk,
whether appropriate for that purpose or not.
Complementary foods: Foods (solid/semi-solid) that are introduced in addition tobreastmilk. Ideally, age-appropriate, adequate, and safe.
Dietary diversity: The number of different foods or food groups consumed over a givenreference period, which serves as a proxy for diet quality.
Exclusive breastfeeding: When an infant receives only breastmilk and no other liquids orsolids, even water, except for vitamin/mineral supplements or medicine for the first six
months of life.
Humanitarian emergencies: An event or series of events that represents a critical threat tothe health, safety, or wellbeing of a population
Infant and young child feeding in emergencies (IYCF-E): Refers to the support andprotection of the nutritional needs of non-breastfed and breastfed infants, young children
from birth until two years, and pregnant and lactating women in humanitarian emergencies.
Wasting: When a child has a low weight-for-height, also known as acute malnutrition. It is anindication of recent and rapid severe weight loss; however, it can continue for a long periodof time.

9

List of Figures
Figure 1: Map of internal displacement of populations because of conflict and natural
disasters in 202078 ............................................................................................................... 12
Figure 2: Evidence gaps in knowledge translation, an adaption of Pearson andJordan’s framework58 .......................................................................................................... 16
Figure 3: Research priorities classified by type of evidence required for knowledgetranslation, an adaption of Pearson and Jordan’s framework58...................................... 33

List of Tables
Table 1: Research priorities in IYCF-E and priority ranking1........................................... 15
Table 2: Participant characteristics ................................................................................... 23

10

1. Introduction
1.1. Mortality and infant and young child feeding
Globally, countries have eight years to meet the Sustainable Development Goal of ending
preventable deaths of newborns and children under five2. Although the United Nations havepledged that no one would get left behind3, the under-five mortality rate (76 deaths per 1000
live births) of children who reside in 38 fragile and conflict-affected countries is triple that ofchildren living in all other countries4. This is partly due to substandard sanitation, limited healthservices, food insecurity, and poor infant and young child feeding (IYCF) practices5,6. IYCF
encompasses how a child is fed from birth until two years.
Infant and young child feeding in emergencies (IYCF-E) refers to the support of the nutritional
needs of non-breastfed and breastfed infants, young children from birth until two years, andpregnant and lactating women in humanitarian emergencies7. Optimal IYCF, generally and in
emergencies, entails exclusive breastfeeding for the first six months of life, followed by theappropriate introduction of nutritious and safe complementary foods, and continued
breastfeeding until two years or older8. Globally, if all children were breastfed, it is estimatedthat 823 000 deaths in children under five years may be avoided, with 13.8% of these being
children under two9. Breastmilk provides antimicrobial and immunological benefits, reduces
inflammation, and impedes infectious microorganisms in infants10; it particularly has aprotective effect against diarrhoea and respiratory illnesses11. Compared to exclusively
breastfed infants between the ages of 0 and 5 months, those not breastfed have a 14-times
higher risk of all-cause mortality and 8.7-times higher risk of infection-related mortality12.
Suboptimal dietary practices such as the inadequate introduction of complementary foods, a
critical aspect of IYCF, are an underlying and immediate cause of child undernutrition13 andconsequent mortality. A diet of poor quality or insufficient quantities and persistent illness canlead to weight loss. A child who has rapidly lost a significant amount of weight has an increased
risk of all-cause mortality and infection-related mortality, particularly from measles, diarrhoea,
and pneumonia14. It is estimated that if proper complementary feeding counselling is provided
to food-secure individuals, and additional appropriate food supplements are provided to foodinsecure individuals, that 221 000 deaths in children under five years may be avoided15.

11

1.2. Infant and young child feeding in emergencies
Humanitarian emergencies impact countries across the globe and can occur because of ‘manmade’ and so-called ‘natural’ causes. ‘Man-made’ causes include conflict and violence, while‘natural’ causes can include flooding, droughts, and earthquakes. It is estimated that 235
million people required humanitarian assistance in 2021, with the expectation that this will
increase to 274 million in 202216. Globally, displaced people make up 1% of the world’s
population, and almost half of these are children16. Figure 1 indicates the countries impacted
by conflict (shown in orange) and natural disasters (blue) in 2020. Conflict and violence
primarily afflict African and Middle Eastern countries, while natural disasters affect populations
worldwide.

Figure 1: Map of internal displacement of populations because of conflict and natural disasters in 202078

Regardless of the location or cause of a humanitarian emergency, it can disproportionallyaffect the health of vulnerable members of the population. Infants and young children areamongst the most vulnerable17. There is a shortage of robust evidence on exclusive
breastfeeding rates in humanitarian emergencies. In war-afflicted Iraq, exclusive
breastfeeding rates at six months have been estimated to be as low as 6%18. Additionally,each one-unit increase in the conflict casualty rate, a proxy for the severity of conflict, wasassociated with an almost three percentage-point decline in the probability of being exclusively
breastfed at six months18. Dietary diversity is a simple proxy for diet quality and nutrient12density. In Somalia, where droughts and conflict are frequent, only 15% of children living ininternally displaced person camps met the recommended minimum dietary diversity19. In
Nigeria, similar findings indicate that conflict and displacement significantly reduced
households’ dietary diversity20. Furthermore, in Algeria’s refugee camps where families rely
on food aid, a high concurring prevalence of obesity in women and undernutrition in womenand children was found21. This illustrates some of the ways emergency settings have beenshown to impact infants, young children, and their caregivers.
Humanitarian emergencies compromise breastfeeding through multiple pathways. It is
common for breastmilk substitutes to be widely distributed, in a solicited or unsolicited andoften harmful manner, in emergency settings22,23. They may be provided without sufficient
instruction on safe usage24, leading to incorrect preparation and infants being over-or underfed. Emergency settings often lack secure areas for women to breastfeed, leaving them feelingunsafe, uncomfortable and that breastfeeding is a burden5,22,24,25. Additionally, there may be alack of health system support. These factors may culminate in women changing feedingpractices and ceasing breastfeeding. Following this, caregivers may be unable to prepare
breastmilk substitutes hygienically, as sanitation is frequently compromised23. These changes
in feeding practices, related to interrupted breastfeeding and increased breastmilk substituteuse, are associated with an increased incidence of diarrhoea, malnutrition, and mortality26–28.
Similarly, humanitarian emergencies can hinder the safe introduction of complementary foods.
Food supplies can be interrupted, reducing dietary intake and quality19. Displaced caregivers
must counter these challenges while meeting the nutritional needs of their children while
travelling. A caregiver’s mental health, an often-neglected aspect, may be negatively impacted
thereby influencing their ability to care for their child29. This suboptimal introduction ofcomplementary foods increases a child’s risk of mortality through the development of
micronutrient deficiencies, acute malnutrition, and increased risk of infections30. To help
counter this, various interventions are employed to support IYCF-E.

1.3. Interventions for infant and young child feeding in emergencies
Examples of interventions for supporting IYCF-E include providing baby-friendly spaces, cashtransfers, and supplementary feeding programmes, and integrating these into other sectors inemergencies, such as sanitation and food security. Due to prior concerns of protecting andsupporting breastfeeding it is only recently that interventions have been expanded to
specifically support non-breastfed infants. Although technical guidance on implementing
IYCF-E interventions is well documented7,23,31–34, there is a lack of empirical evidence on their13effectiveness and impact on IYCF indicators. Other reviews have highlighted this lack ofevidence1,35–39.
For instance, baby-friendly spaces are designed to provide a safe environment for women to
receive psychosocial, breastfeeding, and health education support in emergency settings40.
One evaluation of the intervention in Cameroon found a reduction in observed breastfeeding
difficulties41. However, others did not assess the impact on IYCF outcomes in theirevaluations42,43. In settings where breastmilk substitute use is high and breastfeeding rates
are low, such as Syria, reflections on programming previously indicated a lack of guidance on
how best to support non-breastfed infants44. A recent UNICEF45 publication illustrates how tosafely provide breastmilk substitutes as an intervention to support these infants. However,there lacks evidence on its implementation. Cash transfers aim to help individuals andhouseholds improve their food security and diet quality7. A meta-analysis of non-emergency
settings found that they slightly increased children’s dietary diversity46. While in humanitarian
emergencies, cash transfers have been found to have varying effects on IYCF outcomes. In
Pakistan, they were found to reduce acute malnutrition in children47; whereas in Somalia48,
despite it increasing childhood dietary diversity, and in Niger49, where dietary diversity was notassessed, it was not found to have this effect. Blanket supplementary feeding programmes
are used to counter food insecurity. In an emergency, they have been noted to contain highamounts of starchy foods and limited fruit and vegetables21. This limit in quantity and quality
may not meet the dietary needs of children under two years50 and, as stated earlier,populations who are heavily reliant on them present with both obesity and undernutrition,
further indicating their unsuitability21. In addition to these prescribed interventions, recent
guidelines emphasise the importance of integrating IYCF, generally and in emergencies, into
other sectors51,52. For these interventions to have the intended impact, substantive evidence
and cooperation between sectors supporting humanitarian emergencies is needed.

1.4. Research on infant and young child feeding in emergencies
Humanitarian emergencies are complex and unpredictable, affecting the quantity and qualityof available research. Affected populations often have, or are at risk of, poor health and residein substandard living conditions making it unethical to withhold treatment in order to study acontrol group39,53. Additionally, multiple interventions are often implemented simultaneously,
making it challenging to attribute outcome changes to one aspect, outside of experimental
conditions54. These challenges are compounded further by funding limitations and competingstakeholder interests55. This provides some clarity as to why there is a lack of robust, empiricalevidence on IYCF-E. Yet it is imperative that programmes and interventions dealing with14

vulnerable groups, such as women and children, particularly in volatile settings, be evidencebased56. For these reasons, research in IYCF-E must be targeted at the most pressing
matters.
In 2016, Prudhon et al. acknowledged this lack of evidence in IYCF-E and conferred withvarious experts, identifying ten research priorities on the subject (Table 1)1.
Table 1: Research priorities in IYCF-E and priority ranking1

It has been six years since it was published, humanitarian emergencies have continued toincrease57. The COVID-19 pandemic, mounting effects of climate change, and continued
political conflicts pose the most significant challenges to the sector57, and therefore its ability15

to generate evidence. The pandemic reversed progress by limiting people's access tohealthcare and placing additional strain on healthcare services. In areas serviced by thehumanitarian sector, antenatal care visits have decreased by 43%16. Currently, up to 43
countries experience famine-like conditions16, which continued climate change is likely to
exacerbate, pushing more people into food insecurity. Protracted conflicts across the Middle
East and North, West and Central Africa continue, increasing the burden on the sector andrequiring organisations to enter areas that are unsafe to access16. Wherever there are adults
experiencing crises, there are infants and young children being affected too. Evidently, there
are challenges both in researching and implementing interventions in IYCF-E.

1.5.

Critical gaps between unmet need for knowledge and evidence-based

practice in IYCF-E
Although various published guidelines7,23,31–34 on IYCF-E exist, there remains a lack ofevidence behind the prescribed interventions. Yet, as highlighted, it is critical that interventions
involving infants and young children are evidence-based. Pearson and Jordan58 developed aframework illustrating the gaps, and in doing so the different types of evidence needed, in theprocess of evidence generation and translation of health-related research into implementation.
These include the gap between an unmet need for knowledge and discovery, which relates to
descriptive or epidemiological studies that describe the extent and severity of the problem(gap one). Following this, it speaks to the gap between discovery and evaluation, which relates
to evidence on what programmes work (gap two). Lastly, the gap between evaluation andimplementation or policy action, which relates to evidence on how to increase uptake of anintervention already known to be effective and translated into policy (gap three). Figure 2
shows an adapted version of this framework58. Pearson and Jordan58 assert that the presenceof these gaps, or lack of evidence, can hinder the process of evidence-based practice, andconsequently, health outcomes. Framing the lack of evidence in IYCF-E in this regard canhelp to organise and clarify where research should be targeted going forward.

Figure 2: Evidence gaps in knowledge translation, an adaption of Pearson and Jordan’s framework58

16

1.6. Rationale
Given the continual paucity of research conducted in IYCF-E and the changes in context,
particularly the COVID-19 pandemic and climate change, that have taken place since Prudhon
et al.’s1 list of priorities was published; it is now necessary to provide an update on the current,
most relevant research priorities. Qualitative methods will allow this study to identify which ofthese priorities remain unanswered and, additionally, which have been addressed, but
practitioners and policymakers do not perceive this to be the case due to a lack of evidencetranslation. In doing so, these researchers, policymakers, and practitioners’ perceptions will
help determine where the gaps lie in translating evidence into practice and the possible
reasons for it. To the best of my knowledge, no qualitative study has investigated this in IYCFE before. Additionally, this study will further add to the body of evidence on how Jordan andPearson’s58 critical gaps can be applied to evidence-based practice, specifically in a global
health matter such as IYCF-E. Its findings will provide researchers with insight into what
research priorities in IYCF-E are relevant and essential to practitioners. It will also provide abasis for advocacy for practitioners and organisations working in IYCF-E to ensure that
research is conducted on the most critical topics.

2. Aims and objectives
Aim:
This study aims to determine the extent to which the ten research priorities, as
proposed by Prudhon et al.1, of infant and young child feeding in humanitarian
emergencies have been realised.

Objectives:
1. Using Prudhon et al.’s1 ten research priorities, explore the perceptions of those working
in IYCF-E on current research and gaps in knowledge on the topic and compare thisagainst the current state of the evidence
2. Explore and contrast the perceptions of different stakeholders working in IYCF-E on
why some research priorities may have been answered while others remainunanswered
3. Determine the perceptions of the relevance of Prudhon et al.’s1 ten research priorities
and whether there are additional priorities to consider

17

3. Methods
3.1. Research team and reflexivity
3.1.1 Personal characteristics
I, the author and investigator, am the only researcher of this study. I am a registered dietitian,studying Master of Science (MSc) in Nutrition for Global Health at the London School ofHygiene and Tropical Medicine (LSHTM). I have limited experience in qualitative
methodologies. However, through my work, I have counselled many individuals, providing mewith the skills, such as engaged listening, to explore participants’ experiences andperspectives. I managed a child health organisation in an informal settlement where much of
my work involved supporting IYCF in an emergency-like setting. I reviewed the qualitative
methodologies module at LSHTM and received advice from my internal supervisor.
3.1.2

Relationship with participants

All interaction with participants was limited to recruitment-related correspondence. No priorrelationships influenced the participants’ responses and my interpretation of them. I notified
participants that this was in fulfilment of my MSc and my prior work had driven my interest on
the topic. Since I have programmatic experience in a similar field, I remained cognisant of how
this may influence the responses of the participants and my analysis of the results andmaintained a study journal to monitor my decision-making process.

3.2 Study design
This study makes use of a qualitative design. This provided the means for an in-depth
exploration of stakeholders’ perspectives and experiences. Reporting was guided by theConsolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Appendix 7)59.

3.2.1 Theoretical frameworks
Pearson and Jordan’s58 framework (Figure 2) highlighting the types of evidence required inknowledge translation helped guide the study’s aim, objectives, topic guide, and theinterpretation and presentation of the results. I used thematic content analysis60,61 to provide
structure to the organisation of the data and to underpin the methodology in identifying themes.

18

3.2.2 Participant selection
Sampling and method of approach
I recruited participants through three pathways by means of purposive (ten participants) andsnowball sampling (three participants). Firstly, through their position at the Emergency
Nutrition Network, the researcher’s external supervisor identified potential participants andshared their details; nine were recruited this way. Secondly, I searched LinkedIn for others
working in IYCF-E, which resulted in an additional participant. Thirdly, to use the existing
participants' networks, I selected the remaining three through snowball sampling. A purposive
sampling method allowed for the selection of participants based on what would best informthe study’s objectives62, in this case with heterogenous work and research experience in IYCFE. A snowball sampling approach meant that participants could suggest any other experts intheir field. All participants had to speak English and have over five years of work experiencein IYCF-E. I invited participants to participate via email (Appendix 2) with an attachedinformation sheet (Appendix 3) and consent form (Appendix 4). Participants confirmed their
willingness to participate by returning the signed consent. Following this, I sent possible
interview times to them along with Prudhon et al.’s1 research priorities. This allowed theparticipants to familiarise themselves with them.
Sample size
It is suggested that thematic saturation in qualitative research, where interviews generate no
new ideas or themes, may be reached by 12 participants63. I transcribed the interviews andcoded them shortly after they took place to monitor this. Through this process, I determinedthat a sample size of 13 allowed for thematic saturation while still being small enough to ensure
a detailed analysis of each interview within the time constraints.
Non-participation
Four people who were invited to participate refused, reason being they were unavailable
during the interviews’ time frame. Another six did not respond to the invitation. No participants
dropped out.

19

3.2.3 Setting
Setting of data collection and presence of non-participants
To allow for the inclusion of participants living in different countries, interviews were carriedout on the video conferencing software, Zoom (v5.10.4), from my residence in London, United
Kingdom. Participants were able to interview in their chosen venue, which may have helped
them feel more comfortable. I conducted the interviews according to the participants’schedules. During the interviews, no one was present apart from myself and the participants.
Description of sample
I interviewed 13 participants of varying ages and genders from a mix of research, policy, andprogrammatic backgrounds in IYCF-E. To best fulfil its aim and objectives, this study requireda variety of stakeholders working in IYCF-E. Participants needed to have a minimum of five
years’ work experience to help ensure they would be equipped to speak on the research
priorities.

3.2.4 Data collection
Interview guide, repeat interviews, audio/visual recording, and field notes
Before commencement, I designed an interview guide (Appendix 5) and used it for a pilot
interview with two peers from LSHTM. Due to time constraints, no follow-up interviews wereconducted. The interviews’ audio was recorded and transcribed verbatim by Zoom software.
Following the interview, I checked the transcript for accuracy. I maintained field notes during
and after each interview and referred to them during analysis.
Duration, data saturation and returning of transcripts
Data collection took place between 11 July and 5 August 2022, with each interview lasting
between 45 and 60 minutes. Data saturation was reached as no new information was gained
from new participants. Transcripts were returned to participants for validation; however, none
were returned with corrections.
Data collection process
Before each interview, I ensured adequate internet connection to avoid interruption. At thestart, I greeted the participant and reminded of the study’s aim and objectives. I explicitly statedthat any information shared would be kept anonymous and that the interview would berecorded, but that it would be deleted once transcribed. The participant was allowed to ask
questions, after which the recording was initiated. The interview guide structured the20interviews, but the semi-structured nature allowed me and the participants to deviate, allowing
the conversation to flow more naturally.

3.3 Data analysis
Number of data coders, software, coding tree, participant checking
I, the sole coder, coded the data using NVivo 12 (v12.7.0) software. I did not present the codesin the form of a coding tree; however, the codebook (Appendix 6) provides clarity on the codesused. Due to the limited time frame, I did not ask the participants for feedback on the findings.
Analysis method
Thematic analysis has five stages, as detailed by Clarke and Braun60:
1. Familiarisation and transcription
The researcher read through the transcripts twice before starting with coding. The firsttime was done while listening to the audio recording to correct errors in the transcript.
The second was to become more familiar with the data. After reading each transcript,
brief notes of possible significant findings were made for later reference.
2.

Generating initial codes
The researcher imported the interviews into NVivo 12 for analysis. Considering thespecific nature of this study's aim and objectives, most codes were generated
deductively per Prudhon et al.’s1 priorities. However, the semi-structured interview
format meant that some data was coded inductively. Data was initially coded with someof the surrounding data to retain the context. Some data was coded more than onceas they related to multiple topics.

3. Searching for themes
Once all the data had initial codes, they were organised into potential themes. In Nvivo,
the researcher classified overarching themes as ‘top-nodes’ and collated all the initialcodes under the relevant theme. These themes were then disaggregated into subthemes. Notes made during the familiarisation stage helped identify these sub-themes.
4.

Reviewing themes
Once themes and sub-themes were identified, they were refined. This was an iterative
process; the researcher first reviewed and refined the codes ensuring the extracts
followed a coherent pattern.

21

5. Defining and naming themes
In the last stage, the themes were given a final name. The themes and sub-themes
were reviewed for the last time with the whole data set, ensuring they accurately
portrayed the findings.

3.4 Ethics
Before proceeding with the recruitment of participants, I applied for ethical approval (Appendix
8). I obtained this from LSHTM Ethics Office (Ref: 26757) on 6 July 2022 (Appendix 1).
Interview recordings were kept on a password-encrypted device that only I could access. Once
I had checked the interview transcription for errors, the audio and video recording werepermanently deleted. Each participant was allocated a number between 1 and 13, and I
removed all identifying information from the transcripts. Once the study was completed, I
permanently deleted all data from my device. My internal supervisor stored a copy of the NVivo
data file on LSHTM Compass.

4
4.1.

Results
Participant characteristics

Thirteen participants were recruited for the study. As per the intended sample, all participants
had extensive experience in IYCF-E, with the majority having a background in programmingand policy and fewer in research. Four participants reported that they had a mix of experiencein IYCF-E. All but two had some programmatic experience, and most were women. Participantcharacteristics are summarised in Table 2.

22

Table 2: Participant characteristics
Participant (P)SexExperience (years)

Experience within IYCF-E

1

Male

13

Programmatic

2

Female15

Programmatic and research3

Female12

Programmatic and policy

4

Female13

Programmatic

5

Female6

Policy6

Female22

Programmatic

7

Female8

Programmatic

8

Female12

Programmatic, policy and research

9

Female16

Research

10

Female20

Programmatic

11

Female25

Programmatic and research

12

Male

19

Programmatic

13

Female15

Programmatic

As per the thematic analysis, the results are organised by overarching themes:
1. General views on the lack of IYCF-E research
2. Views on each of Prudhon et al.’s1 ten research priorities in IYCF-E
3. Additional priorities in IYCF-E to consider
A codebook was produced using NVivo (Appendix 6).

4.1 Views on the lack of research in IYCF-E
4.1.1 Irregular, sparse, and poor-quality evidence
Participants spoke of the lack of research in IYCF-E and how infrequently it gets published.
Some participants expressed concern over continually needing to cite literature publisheddecades ago and how even recent studies were based on historic emergencies.
“When I'm writing papers now, I'm still citing research that's from the 80s and … 90s.
… I guess the fundamental bit of research on why it [IYCF-E] matters … is, fromflooding that happened in Botswana in 2005 or 6, …, I've just been writing apresentation the last couple of days … And I'm aware that I'm citing research,sometimes that’s 20 years old.” – P923

Two participants commented that the IYCF-E operational guidance was based on consensus
instead of being evidence-based. Although they felt confident in using the operational
guidance, they thought it did not aid in building confidence in IYCF-E interventions among
those not working in the sector.
“And again, … it's an easy way out to justify what we're doing, consensus. But whenanyone, if you ask any one of us ‘can you show me the data?’, even the programmaticdata, not just not the evidence … We barely have it. And I'm not doubting what we're
doing works. But we don't have, it we really don't.” – P1
Participants postulated that this lack of good quality evidence then negatively influenced theimportance that other people placed on IYCF-E and how much money was invested in it.
“We don't have evidence to show that these interventions have the outcomes that wesay they do. And that really hampers us in advocacy, like it really, really, really hampersus.”- P9
Almost half of the participants specifically mentioned the lack of impact evaluations in IYCF-E
and that this represented a substantial gap in the evidence. These participants were not limited
to a particular background and included those in research, programming, and policy.
“I just find there's not enough impact evaluations, and there are so many paths thatlead to the impact and so much is focused on input, output, and outcome, not impact.
And I think that's a huge gap.” – P3

4.1.2 Lack of funding and the willingness to use available data
When asked why they thought there was such a limited evidence base for IYCF-E, a quarterof the participants noted a lack of funding available to conduct research in the humanitarian
sector.
“But the bottom line is always the bottom line. … It's hard to mobilise resources
dedicated to research in humanitarian context.”- P1
In addition to the lack of resources available for IYCF-E research, participants mentioned that
there are challenges in capturing data in emergency settings and that there is a lack ofmotivation to build capacity in the monitoring and evaluating of IYCF-E data.

24

“I don't think the monitoring and evaluation portfolio for IYCF-E is straightforward. I
think many find that challenging … I find that also compared to other areas of response,
WASH [water, sanitation and hygiene], food security, protection, education, building
capacity for IYCF-E monitoring and evaluation is really important. And it's not thatwidespread.”- P4
In contrast, another participant, a researcher, suggested that the data needed for IYCF-E
research may be being collected, however, it was not being used to generate research. It wasnoted that this could be due to time constraints or a lack of willingness.
“But … there's not great investment into it. I mean, I think, we have difficulty that a lotof organisations actually do a lot of data collection as part of their work. But it doesn't
necessarily make its way into the peer-reviewed literature.”- P9

4.1.3 Greater interest in acute malnutrition
Some participants drew comparisons between investment and research in acute malnutrition
and IYCF-E. They highlighted that acute malnutrition has received greater interest in the pastand that this has limited the funding available for IYCF-E interventions and its research.
“And it tends to be quite often that you'll only get nutrition funding, if there's wasting[acute malnutrition] … But it's still a battle to get people to see that this is still an
important life intervention.”- P7
One participant noted that this may be due to innovation in the design of the treatment of acutemalnutrition and that this was drawing interest into that work. However, they also noted that
this is lacking in the IYCF-E field.

4.3 Views on each of Prudhon et al.’s1 ten research priorities in IYCF-E
The research priorities have been listed in order of priority according to the responses of theparticipants of this study and the research priorities’ titles have been paraphrased.

4.3.1 The effectiveness and cost-effectiveness of complementary feeding interventions
Out of all ten priorities, this was one of the two most spoken about as a main priority. This wasconsistent across participants from research, policy, and practitioner background. Most
participants felt that this research priority had been partly answered, owing to the fact that it
encompasses multiple interventions. However, they felt that there was still a lack of evidence25looking at the various interventions comparatively and IYCF-E outcomes. No participants
explicitly stated that this was no longer a priority or that it had been answered entirely.
“I think this one is a huge priority, honestly, in terms of what works, what doesn't work,
what is the package of interventions to support complementary feeding inemergencies… I think we're not there yet, in terms of what works best, what is the
package, and in which context to use it.”- P8
More than half of the participants who spoke about this priority expressed how complementary
feeding interventions had been previously neglected in IYCF-E research compared tobreastfeeding. However, most of these participants said this was changing, and there wasgreater interest in it now.
“I know that I push a lot now, … on complementary feeding, because I think that's beena neglected part of infant and young child feeding or nutrition in emergency contexts,
especially. There's… a strong focus,… people who are primarily focused onbreastfeeding.”-P3“So I think complementary feeding has been quite marginalised in the IYCF-E space…
I think the focus really was on breastfeeding and formula feeding because it was so
obviously urgent.”- P9
One participant from a research background indicated that a reason for this shift could be, inpart, that there is more evidence available on breastfeeding now. Hence, it allows for a greater
focus to be placed on research in complementary feeding. Other participants, both with
programmatic experience, felt that despite this shift, there remained challenges in researchingcomplementary feeding interventions in emergency settings because it falls under multiple
sectors.
“So really, … we need different … sectors to be coming together to agree like the areaof complementary feeding, which obviously deals with food, but also deals withnutrition also deals with behaviour change that those … people need to come together
and agree that we want to do research on this area.”- P6
There were heterogeneous answers about in which context this research would be mosthelpful. One participant stated that the focus should be on areas with less acute malnutrition
since this had been prioritised previously; however, another said that areas with high rates of26

stunting or wasting should be prioritised. Two participants expressed that although low-income
settings are important, research in middle- and high-income countries should not be neglected.
“Like, obviously, low- and middle-income countries. Yes. We need more evidence forthere too. But …I think … high- [and] middle-income is also a big gap. And it's probably
emerged, maybe since this review was published, … as an even greater priority.”- P6

4.3.2 Safe supply of breastmilk substitutes
Of the ten participants who reported being knowledgeable about this priority, seven stated thatit remains one of the most critical priorities on the list. These participants were from policy,
programmatic and research backgrounds. Most of these participants felt that this priority wasat least partly answered, however, more research is required.
“I think the ones related to the breastmilk substitutes … whether it was the cashtransfer, the timeliness, the distribution, although we have a lot, but we need to look at
different contexts and what works where.”- P4
Six participants mentioned what they perceived the reasons for this lack of evidence to be.
One felt that it was due to the difficultly in gaining ethical approval for research to be conducted.
Another two thought it was due to a lack of opportunity and appropriate setting to study it.
Three felt that there might be hesitancy in implementing and researching breastmilk
substitutes interventions because it has not been done regularly before.
“I think people have been scared of breastmilk substitutes, and … it's difficult to do,breastmilk substitute programming is hard. And people have tended to shy away from
it. And not wanted to. Yeah, they just wanted to shy away from it.”- P9Interestingly, four participants stated that they felt the Ukraine crisis might offer an opportunity
to study this further as it is a setting where breastfeeding rates are low, and the use ofbreastmilk substitutes is high.
“I think that with the new kinds of emergencies that have emerged and the context
where you have … a number of non-breastfed infants or infants dependent on infant
formula has triggered, you know, … and Ukraine for example, … a trigger in itself.”P827

4.3.3 The extent that cash transfers are used to purchase breastmilk substitutes
Of the ten participants who reported being knowledgeable on this topic, none reported it assufficiently answered. Despite this, some of these participants felt the priority as it currently
stands, would not provide useful information.
“So that one, what’s the relevance to that? How is that information going to be
used?… I think that needs to be more of a wider research priority”- P3
All ten participants from a range of experience in IYCF-E stated that it remained a priority.
However, all but two said that it could be made more meaningful if combined with research
priority four on breastmilk substitutes.
“I don't think it should be by itself, I think that it should be combined with the artificial
feeding support interventions or supporting the non-breastfed. Yeah, so I feel thatneeds to be combined with artificial feeding.”- P8
Two participants expressed their thoughts on the reason for the lack of evidence. One
suggested that the data may already be being collected during post-distribution of cashtransfers, however, no one had put it into research. Another suggested that there could behesitancy or fear over the repercussions if cash transfers were used for breastmilk substitutes;
therefore, it was not being done or studied.

4.3.4 The design, effectiveness, and cost-effectiveness of re-lactation interventions
Five of the nine participants who spoke about this research priority felt that there is likely
practical knowledge and guidance available, however, some mentioned that it is not easy tosource, and there remains a lack of evidence on the impact and effectiveness of theinterventions“I think that there's a growing group of practitioners with knowledge around designing
re-lactation …I don't think that we actually have a sense of what that means and what
it looks like around the globe in an emergency context. If I want to go look to see… inthe last 10 years what are the major re-lactation interventions or programmatic or
projects that have taken place around the globe. Like, there's no place for me to findthat I have to really dig and look for it. And yet, and yet, I know it happens.”- P5

28

All nine participants said that it remains a research priority in IYCF-E. Some said that having
more evidence in this research priority would help to build confidence in its use in emergency
settings.
“I think there's still a great deal of lack of confidence in re-lactation. And so there's notvery many places, not very many instances where there's any sort of systematic kindof programming around re-lactation. So, yeah, we definitely need more research tohelp people to be confident.”- P9

4.3.5 Provision of effective psychological support to caretakers
Nine participants mentioned they were knowledgeable or experienced on this topic. Eight ofthese agreed that this remained a priority, citing that a caregiver’s psychological state can
influence their ability to care for their child and could impact their choice of breastfeeding or
using breastmilk substitutes.
“I think, particularly how to support those mothers and caregivers, who are distressed,
who feel that they need infant formula. But in fact … they're not eligible or … really
what they're needing is breastfeeding support, how to best support them, I think isdifficult. And we don't really have a lot of evidence around it.” -P 9
The one participant who stated it was no longer a priority did not dispute the importance ofproviding psychological support to caregivers but reasoned that there was sufficient guidanceon how to provide it. This echoed many participants' sentiments that there was a lot of
operational guidance on providing this care, however, there was little evidence supporting
what is most effective.
“There’s been a lot done on this, but it doesn't feel systematic. From a researchstandpoint, there's a lot of learning. And there are a lot of case studies, and there area lot of tools. But I don't know that there's been any study to my knowledge that's reallylooked at comparing two different approaches to see what's more effective. .... It's sucha detriment when it comes to feeding practices. And so I really see that as being …
more of a priority to me.” – P2

4.3.6 The long-term effect of IYCF-E interventions on IYCF practices
Eight of the ten participants that spoke of this topic said that studying the long-term effects of
IYCF-E interventions was not a priority. They all mentioned that it is more important to study

29the impact of these interventions in the acute or short-term and that we are not yet at the stageof studying the long-term impact.
“We absolutely are in desperate need of evidence that the interventions that we havein the operational guidance are effective and helpful. So rather, right now, as opposed
to looking to the long term just yet.”- P9
Three of these participants spoke to the challenges of monitoring IYCF outcomes inemergencies in the long term. Two mentioned that there was never funding available after an
emergency to conduct such research, and another noted that only particular crises would lendthemselves to this as displaced people may move, making it difficult to follow up with themover time.

4.3.7 Determining the number beneficiaries and coverage of IYCF-E programmes
Of the nine participants who shared their thoughts on this priority, all felt that there were tools
or methods available to calculate this and that it was no longer a research priority.
“But I think that again … we did have a suggested, sort of, how to and who to prioritise …
so I’d say we are more or less there.”- P8

4.3.8 Ready-to-use versus powdered infant formula
Eight of the eleven participants who spoke of this topic stated that this topic is not a current
priority. Most participants said that there is information available, particularly on the pros andcons, of using ready-to-use versus powdered infant formula, however, the decision of which
to use would be context-specific and driven by what was available at the time. Therefore, theyfelt that this topic did not require further research.
“We know a lot of the safety and time and the cost-effectiveness, ultimately, we knowthat ready-to-use infant formula is prohibitively expensive so … that's more contextdictated as opposed to … some kind of trial... Even if the evidence shows you that, we
can always use powdered breastmilk substitutes … or powdered infant formula. You
never know what's going to happen. Like there could be a natural disaster thatcompromises the water system. So … I don't know that that's something that we needmore.”- P2

30

4.3.9 Calculating the impact of specific IYCF-E programmes
Although this was the least mentioned priority, all four participants, from a mix of research andprogrammatic backgrounds, said that it was still a priority. They felt that it provides vital
information for advocacy, particularly when approaching donors.
“It's important in terms of the evidence around the importance of our IYCF-E
programmes, because we need it for the advocacy, we need to continue raising the
profile of IYCF-E programmes and investment”.- P8

4.3.10 Effectively link and mainstream IYCF-E interventions with other sectors
Ten participants spoke about this topic; all affirmed that it remains a research priority in IYCFE. Many participants felt that progress had been made since the list of priorities had been
published and that there were multiple sources of guidance on how to go about it. However,as with the priority of providing psychological support to caregivers, participants noted a lackof evidence on its impact.
“We have the UNHCR framework, I think it is a great framework to tell us what to do. I
don't think we've necessarily researched it to say… is this effective? Like, have wedone this effectively? … I know there's some of the grey literature out there … casestudies …. But I think there's definitely more to be done for sure.” -P6
Participants highlighted the challenges in researching this. These included the complexity ofthe topic as it would require multiple sectors in the emergency response to participate. Anotherchallenge that was noted was the difficulty in finding a genuinely integrated IYCF-E
intervention to study.
“I think intersectoral work in general is very difficult. It's under-resourced. … We still
are dependent on siloed funding opportunities. And so … it takes real intentionality.
And even to find a programme. So often your research dollars are separate from yourprogrammatic dollars so sometimes you have research money, and you're looking fora programme that would allow you to look at this question…I think finding good
examples of IYCF-E interventions integrated well is a challenge, and then to be able
to construct a study around that...”- P6

31

4.3.11 Summary of findings in relation to Pearson and Jordan’s58 critical gaps in evidence
In general, participants repeatedly mentioned the lack of evidence showing impact andeffectiveness of IYCF-E interventions. There were no priorities that participants’ opinions
resulted in an inconclusive interpretation; either all or a clear majority of participants agreed. I
mapped the research priorities that participants perceive to still be a priority onto theframework in Figure 3 below. The priorities deemed to be irrelevant were the long-term effects
of IYCF-E interventions, ready-to-use versus powdered infant formula, and determining thenumber of beneficiaries and coverage of IYCF-E programmes. The remaining priorities wereconsidered unanswered yet still relevant and requiring further evidence by most participants.
Discovery
The priorities related to the extent that cash transfers are used to purchase breastmilk
substitutes and how to calculate the impact of IYCF-E programmes can be classified asproviding evidence, if answered, for gap one. Evidence generated for these research priorities
will aid in describing the extent or severity of the specified problems.
Evaluation
The priorities related to the effectiveness and cost-effectiveness of complementary feeding
interventions, the effectiveness of re-lactation interventions, providing effective psychologicalsupport, calculating the impact of IYCF-E programmes, and linking IYCF-E with other sectors
can be classified as providing evidence for gap two. Evidence generated for these research
priorities aid in identifying what interventions work and in which settings.
Implementation science of routine programmes and policy
The priorities related to the effectiveness and cost-effectiveness of complementary feeding
interventions and safe mechanisms for supplying breastmilk substitutes can be classified asproviding evidence for gap three. Evidence generated for these research priorities will assist
in determining how these interventions can be best implemented and therefore translated into
routine practice and policy.
Mapping the research priorities onto Pearson and Jordan’s framework58 gives a visualindication of what participants viewed as still a priority. The presence of these potential
evidence gaps, as mentioned earlier, could be limiting evidence-based implementation ofinterventions, and consequent health outcomes in infants and young children in emergencies.

32

Figure 3: Research priorities classified by type of evidence required for knowledge translation, an adaption of Pearson
and Jordan's framework58

4.4

Additional research priorities to consider in IYCF-E

Participants made various suggestions for additional research priorities that should beconsidered. These were heterogeneous. Two participants spoke of the role that gender norms
play in IYCF-E; one felt that men’s involvement in IYCF-E should be researched, while anothersuggested women’s empowerment and its impact on IYCF-E practices. Another twoparticipants mentioned that IYCF-E interventions should be looked at together with otheraspects of child health, such as developmental milestones and child play. While others spokeof investigating the feasibility of integrating IYCF-E interventions into existing health systems
and exploring the best time points for providing IYCF counselling.

5

Discussion

Despite the role that poor feeding practices play in increasing mortality and morbidity risk ininfants and young children in emergencies, there remains a dearth of evidence on the subject.
To counter this, Prudhon et al.1 published a list of research priorities in IYCF-E. Now, this study
set out to explore the perceptions of experts in IYCF-E as to which of these research priorities
remain relevant and unanswered. Additionally, to determine whether there is alignment
between the state of the evidence on IYCF-E and the perceived state of the evidence toconclude whether gaps exist within the evidence itself or in the translation of that evidence
into practice.

33

Participants commonly referenced the lack of evidence in IYCF-E, noting reasons such as alack of funding, challenges in data collection, a greater interest in acute malnutrition over IYCFE research, and ethical concerns in researching breastmilk substitutes for risk ofcompromising breastfeeding. In accordance with this and since only six years have passed
since Prudhon et al.1 published their list, participants generally deemed that most of theresearch priorities remain unanswered. The priorities concerning the effectiveness ofcomplementary feeding interventions, and concerning safe mechanisms of supplying
breastmilk substitutes, were regarded as the most pressing. Only those relating to long-term
effects of IYCF-E interventions, calculating the coverage of programmes, and ready-to-use
versus powdered infant formula were considered as no longer relevant. In general, there were
no notable differences in opinion between participants with research, programmatic or policy
experience in IYCF-E.

5.1.

Views on the lack of IYCF-E researchParticipants from all backgrounds consistently mentioned the lack of evidence available on
IYCF-E. Although there seems to be no other qualitative literature exploring experts'
perceptions on this subject, apart from Prudhon et al.1, this lack has been highlighted in various
systematic and scoping reviews35,36,38,39. Notably, the most recent Humanitarian Health
Evidence Review38 identified only four articles focusing on IYCF-E published between 2013
and 2021, while 13 were on wasting. This comparison shows agreement with participants’views that acute malnutrition has received greater interest previously. Participants commonly
spoke of the need for evidence on the effectiveness across the scope of interventions in IYCFE, an evidence map of reviews drew similar conclusions36. Although the authors of this review
drew their conclusions from examining the available evidence, this qualitative study provides
valuable confirmation of this need by speaking to experts in IYCF-E who generate and use
this research. This similarity indicates alignment between the state of the evidence and theparticipants’ perceptions of the evidence. The challenges the participants identified in
conducting research in humanitarian emergencies, specifically the lack of funding andwillingness to use available data to generate peer-reviewed literature, are consistent withthose identified in other reviews55,64. It is apparent that these difficulties persist across thesector.

5.2.

Views on each of Prudhon et al.’s1 ten research priorities in IYCF-E

The perceptions of unanswered priorities noted in this study are very similar to the evidence
gaps identified in the most recent Humanitarian Health Evidence Review38. Again, indicatingalignment between perceptions of evidence and the state of the evidence. This may be, in34

part, due to the presence of clear communication channels in IYCF-E when evidence ispublished, but also partly because there is such little evidence published on the topic that it isquickly learned about.
The exception to the similarities between this review’s38 findings and this study was that thereview highlighted gaps in interventions for breastfeeding and nutrition education, which were
not specifically on Prudhon et al.’s1 list, nor were they identified by participants as otherpriorities to consider. In contrast to the review’s38 conclusions on the gap in breastfeeding
evidence, participants explicitly stated that research into complementary feeding interventions
required greater focus because they felt that breastfeeding in IYCF-E had been prioritised
previously. The review38 was conducted systematically, however it focused solely onhumanitarian emergencies in low- and middle-income settings and did not include any grey
literature or any studies published prior to 2013. Since much of the evidence in IYCF-E that isreferenced in peer-reviewed articles is dated26,27,65 or is only published in grey literature, theparticipants of this qualitative study may have been considering grey literature or evidence
published prior to 2013, indicating why this qualitative study found different results. Although
the Infant Feeding in Emergencies operational guidance indicates the different options forsupporting complementary feeding7, there remains a lack of evidence comparing theinterventions’ effectiveness and impact on IYCF practices. Although, ultimately, the decisionof which intervention to choose in an emergency setting will be context-specific and dependent
on the availability of resources and the capacity of the organisation supplying them. The
participants in this study emphasised the necessity of having the evidence to make thisdecision.
In addition to complementary feeding, the priority on designing safe breastmilk substitutes
interventions in settings where breastmilk substitutes use is high and breastfeeding rates are
low was consistently mentioned as a priority above the others. None of the previously
mentioned reviews highlighted this gap or the need for evidence, nor did they specify any
literature relating to this topic. This may be because this need has only become recognised
as a need more recently, indicating alignment between the state of the evidence, or lackthereof, and perceptions of participants on the evidence. It has been noted that breastmilk
substitutes have been extensively distributed in a harmful and unsolicited manner5,22,23,66 inemergencies in the past. Therefore, practitioners’ focus had been on preventing this and notnecessarily on how to safely provide breastmilk substitutes. UNICEF recently released
guidance on the supply of breastmilk substitutes in emergencies45. Although this goes someway in providing practitioners with guidance, participants highlighted the growing concern that
more situations may arise where this is needed and that they would like to see further evidence35

on how this has been done in different contexts. This extensive gap relates specifically to how
best to implement the safe provision of breastmilk substitutes without compromisingbreastfeeding, with an expressed need of evidence in middle- and high-income countries.
Most participants noted that the priority on the extent that cash transfers are used to purchasebreastmilk substitutes remains relevant and is unanswered. Since Prudhon et al.1 published,
there has been studies evaluating cash transfers to improve nutritional status and dietary
diversity, and reduce the risk of acute malnutrition47–49. However, none of these referred tobreastmilk substitutes. This may be due, as participants noted, to hesitancy to appearing tosupport breastmilk substitutes. Although participants did not view this as one of the mostpressing priorities, future evaluations of cash transfer programmes may want to consider
including this as an outcome, particularly as more emergencies occur in different contexts
where there may be high breastmilk substitute use and low breastfeeding rates.
Participants felt that the priority on the design and effectiveness of re-lactation interventions,remains an unanswered priority. They emphasised that there may be growing institutional
knowledge whereby some practitioners working in IYCF-E know how to support re-lactation,
however, there was a lack of “formal” or peer-reviewed evidence on the effectiveness of suchinterventions. Again, re-lactation was not discussed in any of the reviews. In accordance withthis study’s findings, a recent scoping review on re-lactation methods and facilitators
acknowledged this lack of evidence as its authors were required to rely on case studies and alimited evidence base67. However, none of the articles included in this review were conductedin emergencies, which hinders the external validity of these results to such settings. Further
evidence of the effectiveness of the various prescribed re-lactation interventions inemergencies may provide greater confidence and use of the techniques.
Participants regarded the priority concerning providing effective psychological support tocaregivers, as having been partly answered since Prudhon et al.1 was published. Specifically,
they identified that there was operational guidance on providing psychological care but a lackof evidence on the efficacy of this care in practice. Indeed, various guidelines31,68,69 have been
published on this since 2016 that specifically reference the needs of children’s caregivers. In
agreement with the participants’ views, an evidence map concluded that no reviews evaluating
the evidence of providing effective support to caregivers had been published between 2000
and 201636. A literature search found that this is still the case. In general, evidence of theefficacy of providing psychological care to adults in emergencies, whether caregivers or not,is limited. A systematic review and a meta-analysis showed results in favour of mental healthand psychosocial support programmes in adults in humanitarian emergencies70,71, however,36

they did not specifically refer to adults in the role of caregivers or the resulting impacts on IYCF
outcomes. Caregivers of children may face additional or different burdens therefore, similar
evidence specific to caregivers would aid in answering this priority.
The priority concerning calculating impact of IYCF-E programmes was spoken of the least.
Those that did speak of it noted the importance of having it answered and prioritised so thatthe evidence generated by these methods could be used to advocate for IYCF-E. Most
participants were practitioners, and this priority relates to the means to calculate impact, which
may be why so few felt experienced enough to talk about it. This has not been emphasised inprevious reviews, as they have been focused on gaps in the evidence and not on
methodologies in creating the evidence. Two tools that relate to this priority that have beencreated since Prudhon et al.1 published include The Cost of Not Breastfeeding tool72, allowing
for the determination of economic losses related to not breastfeeding, and the Humanitarian
Lives Saved Approach73, a methodology to determine which interventions are most effective
in humanitarian settings. This discrepancy between the existence of tools and perceptions ofparticipants indicates that there could be poor translation of evidence on this priority,
highlighting that this priority has been addressed and that it is not the lack of evidence that
presents a problem, but rather the communication of it.
Participants felt the priority relating to effectively integrating IYCF-E interventions into othersectors remains a priority. Since the research priorities were published in 2016, Save theChildren and UNHCR have released a multi-sectoral framework detailing the linkage of IYCFE with other sectors52. Although participants acknowledged the progress this served, they feltthat more evidence could be generated on the effectiveness of applying this framework. Briefcase studies are noted in the roll-out guide74. However, these do not acknowledge the barriers
associated with multisectoral work and how to overcome them, arguably a key component of
successful implementation. Another set of case studies noted the challenges associated with
implementation such as the lack of staff interest in multi-sectoral work, lack of supportive
policies, and a lack of specific reporting systems for the integrated activities75. Other studies
on different multisectoral health interventions have noted additional potential barriers such asa lack of funding76,77, ineffective mechanisms to share learnings across sectors76, poortransdisciplinary awareness of activities76, lack of staff motivation77, and unclear staff
responsibilities 77. It is possible that these may influence the integration of IYCF-E into othersectors too. Further detailed evaluations on the implementation of this framework acrossdifferent contexts are required.

37

Pearson and Jordan’s58 framework aids in outlining the different types of evidence that exist
and are needed in IYCF-E (Figure 3). What is apparent is the clear lack of evidence, acrossmost of Prudhon et al.’s1 research priorities, showing the impact and effectiveness of IYCF-E
interventions. Participants repeatedly expressed this, placing the greatest emphasis on theneed for such evidence on complementary feeding interventions and safe mechanisms ofsupplying breastmilk substitutes without compromising breastfeeding. This indicates that
research in IYCF-E should be focusing on the final part of the cycle (Figure 3) - theimplementation science of getting interventions into routine programmes and policy. Evidence
in this area would provide greater understanding into the most effective modes and contexts
in which interventions should be implemented, the methods of implementing these effective
interventions at scale within emergency contexts and the methods required to increase policy
interest and stakeholder investment.

5.3.

Additional research priorities to consider in IYCF

Participants’ suggestions of additional priorities in IYCF-E were heterogeneous. However,some common themes were identified relating to the role of gender norms in shaping IYCF-E
practices, how best to integrate IYCF-E into an existing health system, and the influence ofmaternal nutritional status on IYCF-E outcomes, amongst others. These gaps were not
identified in previous reviews, however, they could provide areas for further research in the
future.

5.4.

Strengths and limitations

Strengths of this study include that it used qualitative methodology to determine the current
priorities, which provided depth and understanding as to which topics remain a research
priority and why the gaps exist in the evidence. Using semi-structured interviews and a
combination of deductive and inductive coding allowed for themes outside the objectives tobe identified. A study like this has not been done before, allowing it to generate novel findings
in identifying reasons for gaps in the evidence. Participants had extensive experience in IYCFE and came from a mix of backgrounds, giving authority to their answers and allowing for
greater confidence in the findings. Conducting interviews on Zoom permitted the inclusion ofparticipants working in different settings, allowing for a more diverse selection of participants.
Most participants’ answers agreed across the full breadth of topics discussed, allowing greater
confidence in the interpretation of the results.
Limitations of the study include that participants self-reported areas of IYCF-E they are more
knowledgeable. Due to social desirability bias, they may have reported on more or fewer areas38

than they are familiar, which would influence the interpretation of whether participants’
perception of the evidence matches the available evidence. The researcher tried to prevent
this by allowing introductions before the recording started so that the participant would feel
more comfortable sharing opinions. Whilst qualitative methods provided benefit, adding acomponent of ranking the research priorities as was done in Prudhon et al.’s1 initial paper may
have added additional value. No one else critically evaluated the coding; however, theresearcher kept a study journal to ensure consistency in coding and interpreting the results.
Further work could involve including another analyst or by sharing the findings with participants
to ensure that they agree with the interpretation. There is the risk of selection bias as someparticipants were selected via snowball sampling, therefore their opinions may be like those
who recommended them. To counter this, the researcher recruited participants via multiple
pathways. Due to the limited sample size, the results of this study may not be generalisable
to represent the views of all researchers, policymakers, and practitioners in IYCF-E. To
mitigate this risk, the researcher continued to collect data until saturation was reached torepresent better those working in the sector. Participants rarely had just one type of experiencein IYCF-E, making it a challenge to contrast perceptions between them. However, this is likely
unavoidable. Despite these limitations, the fact that data saturation was reached and thatparticipants had extensive experience indicates high internal validity.

6

Conclusion

IYCF-E remains concerningly under-researched, with current priorities being the effectivenessof different complementary feeding interventions and mechanisms for safely supplying
breastmilk substitutes while still protecting, promoting, and supporting breastfeeding. Of theten research priorities, participants consistently found seven to still be relevant, and apart frommethods for calculating the impact of IYCF-E interventions, which has been addressed, theirperceptions of the evidence aligned with the state of the evidence. However, this is likely
because there is so little evidence available. Reasons for the gaps are clear: emergency
settings provide considerable challenges in conducting research ethically and is majorly
underfunded. Case studies, grey literature and other operational research provide essential
sources of guidance in IYCF-E; however, this study indicates how research now needs to befocussed on how to effectively implement the different prescribed interventions, to result in an
uptake in routine programming, policy and stakeholder interest, and consequently better
health outcomes for infant and young children in emergency settings.

39

7

Recommendations
1. Research should be focused on the effectiveness and implementation of different
complementary feeding interventions and how to safely distribute breastmilk
substitutes without compromising breastfeeding.
2. Following this, research should be focused on the effectiveness of re-lactationinterventions and provision of psychological support for caregivers, and the integrationof IYCF-E into other sectors.
3. Evidence, regardless of whether it is operational or academic, should be consolidated
and made accessible among the IYCF-E community.

40

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9

Appendices
9.1 Ethics Approval

MSc Research Ethics Committee
XXXXXXXXXXXXXMSc Student
MSc Nutrition for Global Health
LSHTM
6 July 2022
Dear XXXXXXXXXXXXX
Study Title: An update on the research priorities of infant and young child feeding in emergency settings: A qualitative study
LSHTM MSc Ethics Ref: 26757
Thank you for responding to the MSc Committee’s request for further information on the above research and submitting revised documentation.
The further information has been considered by the RGIO on behalf of the committee.
Confirmation of ethical opinion
On behalf of the Committee, I am pleased to confirm a favourable ethical opinion for the above research on the basis described in the application(CARE) form and supporting documentation as revised, subject to the conditions specified below.
Conditions of the favourable opinion
Approval is contingent on local ethical approval having been received, where relevant. It is the responsibility of the student and their supervisor
to ensure appropriate local ethical approval is in place before a study commences (ie if you indicated this in the local approval section of theform). Please forward confirmation of local ethics approval as soon as it is received.
Approved documents
The final list of documents reviewed and approved by the Committee is as follows:
Document Type

File Name

Date

VersionInvestigator CV

Curriculum Vitae_ XXXXXXXXXXXXX

29/03/2022

1

Other

Research_Ethics_online_training_certificate

29/03/2022

1

Information Sheet

Consent form for participant and representative

31/03/2022

1

Advertisements

Recruitment e-mail31/03/2022

1

Information Sheet

Participant Information Sheet_Final

06/04/2022

1

Information Sheet

Topic guide_Final

06/04/2022

1

Protocol / Proposal

Topic guide_Final

21/04/2022

1

Covering Letter

Letter of clarification_ XXXXXXXXXXXXX

04/07/2022

1

Covering Letter

Letter of support - ENN_ XXXXXXXXXXXXX

04/07/2022

1

Information Sheet

Letter of support - ENN_ XXXXXXXXXXXXX

04/07/2022

1

After ethical review
Any subsequent changes to the application must be submitted to the Committee via an Amendment form on the ethics online applications website.
Ethics online applications website link: http://leo.lshtm.ac.uk
Yours sincerely,

Professor Paul Milligan
Chair9.2 Recruitment Email
Subject: Participation in an MSc study on updating the research priorities in infant andyoung child feeding in emergency settings
Dear XXX,
My name is XXXXXXXXXXXXX, and I am a Master of Science student studying Nutrition for Global
Health at the London School of Hygiene and Tropical Medicine (LSHTM).
I’d like to invite you to take part in my research study entitled: An update on the research
priorities in infant and young child feeding in emergency settings: A qualitative study.
You have been identified, with the assistance of

XXXXXXXXXXXXX

at Emergency Nutrition

Network, as a possible participant because of your work in infant and young child feeding inemergencies. Joining the study is completely up to you, before you decide I would like you tounderstand why the research is being done and what it would involve for you. I haveattached an information sheet, which details the purpose of the study, and a consent form.
Participation will entail one single interview, lasting 45 to 60 minutes, in English via Zoom. I
will provide you with a list of 10 research priorities in IYCF-E as determined in prior research.
I will ask that you read through them briefly before the interview.
Should you agree to participate, I ask that you sign the consent form and return it to me atyour earliest convenience. After this, I will forward you a Calendly link with available timeslots to schedule the interview. I am flexible with dates and times, so if you would prefer atime that is not available on the link then please do not hesitate to contact me.
If you have any further questions, please contact me via email. I look forward to hearing
back from you.
Many thanks and best wishes,XXXXXXXXXXXXXMSc Nutrition for Global Health candidate499.3 Participant Information Sheet
Participant Information Sheet
Title of Project: A update on research priorities in infant and young child feeding in emergencies: A
qualitative study
Introduction
I am a Master of Science student currently studying Nutrition for Global Health at the London School ofHygiene and Tropical Medicine (LSHTM). I would like to invite you to take part in a research study. Joining
the study is entirely up to you. Before you decide, you need to understand why the research is being done andwhat it would involve. I will be available to answer any questions you may have. Ask questions if anything
you read is not clear or if you would like more information. Please feel free to talk to others about the study if
you wish. Take time to decide whether or not to take part.
What is the purpose of the study?
I am conducting this study to determine what the current research priorities are in infant and young childfeeding in emergencies (IYCF-E). This is in the completion of my degree. I want to understand what different
peoples’ perceptions are of the current priorities and gaps in research in IYCF-E, using a predetermined listof 10 research priorities as set out by Prudhon et al (2016). I would also like to determine whether any
progress has been made on previously published research priorities, whether these are still relevant, andwhether there are any more that need to be added to the list. I will be contrasting the perceptions ofresearchers and practitioners in IYCF-E, to determine the reasons for any gaps in the evidence base.
Why have I been asked to take part?
You have been invited because you have been identified as someone who works, or who has worked, in thefield of IYCF-E.
Do I have to take part?
No. It is up to you to decide to take part. If you don’t want to take part, that’s ok. If you agree to take part, I
will ask that you sign the attached consent form and return it to me via email at your earliest convenience.
We will discuss the study briefly before the interview and you will be given an opportunity to ask any
clarifying questions. You may email me before the interview if you would like further information before
signing the consent form.
What will happen to me if I take part?
You will complete one interview of 45 to 60 minutes from your home/work with the primary researcher(XXXXXXXXXXXXX) via Zoom. This interview will be recorded and transcribed so that it can be analysed. After
which, the recording will be permanently deleted.
What will I have to do?
I will ask you to read over a list of ten research priorities in IYCF-E that have been identified in a previous
research paper by Prudhon et al (2016). I will then ask you to answer a set of pre-prepared questions in avideo interview with me on Zoom, which is a free to use conferencing software. This can be done from any
private space with internet connection and should take no longer than one hour. If you are taking part,please download and familiarise yourself with Zoom if you have not done so already. Feel free to contact meshould you require further information on the software.
What are the possible risks and disadvantages?
The interview questions are not expected to cause you any discomfort. However, if they do we can stop theinterview at any point.
What are the possible benefits?
I cannot promise the study will help you but the information that I get from the study will help in building
the knowledge and understanding of research priorities in IYCF-E. This piece of work will be used by the
Emergency Nutrition Network to advocate for further research in IYCF-E.

What if something goes wrong? If you have a concern about any aspect of this study, you may email me,
the main researcher, XXXXXXXXXXXXX@student.lshtm.ac.uk.
Can I change my mind about taking part?
Yes. You can withdraw from the study at any time. During the interview, you can also choose to skip aquestion or end the interview at any time. If you withdraw from the study after I have collected the data, I
will destroy all your recorded interviews. However, if you withdraw consent once the data has been
anonymised, I will be unable to identify your data so will need to use the data collected up to yourwithdrawal.
What will happen to the information collected about me?
All information collected about you will be kept private. Identifiable information will include your name,email address and occupation (place of work and job title). Only the study staff and authorities who checkthat the study is being carried out properly will be allowed to look at information about you. I will keep all
information about you safe on secure data servers. At the end of the project, the raw files (notes, recordingsetc.) will be permanently deleted. An anonymised data file (without any of your identifiable information) will
be stored on LSHTM Compass.
What are your choices about how your information is used?
You can stop being part of the study at any time, without giving a reason, but as mentioned above if the data
has been anonymised, I will keep information about you that I already have.
I need to manage your records in specific ways for the research to be reliable. This means I won’t be able to
let you see or change the data I hold about you. However, once the interview is complete I will send you thetranscript, should there be any corrections you wish to make I ask that you contact me as soon as possible. If
I do not hear back from you within 48 hours I will assume you are satisfied with the transcript and do notwish to make any corrections.
Where can you find out more about how your information is used?
You can find out more about how we use your information• At https://www.lshtm.ac.uk/files/research-participant-privacy-notice.pdf• by emailing me on XXXXXXXXXXXXX@student.lshtm.ac.uk•

by sending an email to DPO@lshtm.ac.uk

What will happen to the results of this study?
They will form part of a summer project dissertation, which I will share with you for your information once it
has been marked. You are welcome to feedback on this document. I also intend to submit for publication to apeer reviewed journal.
Who is organising and funding this study?
London School of Hygiene & Tropical Medicine is the sponsor for the research and they have full
responsibility for the project including the collection, storage and analysis of your data, and will act as theData Controller for the study. This means that they are responsible for looking after your information andusing it properly.
Who has reviewed this study?
All research involving human participants is looked at by an independent group of people, called a Research
Ethics Committee, to protect your interests. This study has been reviewed and given favourable opinion by
The London School of Hygiene and Tropical Medicine Research Ethics Committee (ref: 26757).
Further information and contact details
Thank you for taking the time to read this information sheet. If you think you will take part in the study
please read and sign the consent form.
If you would like any further information, please contact me who can answer any questions you may haveabout the study.

51

9.4 Consent Form
Title of Project: An update on research priorities in infant and young child feeding in emergencies: A qualitative
study
Name of researcher responsible for project: XXXXXXXXXXXXXStatement

PleaseinitialI confirm that I have read and understood the information sheet dated 12 September 2019 (version 2)
for the above-named study. I have had the opportunity to consider the information, ask questions andhave these answered satisfactorily.
I understand that my consent is voluntary and that I am free to withdraw this consent at any time
without giving any reason and without my/the participant’s medical care or legal rights being
affected.
I understand that data about/from me/the participant may be shared via a public data repository or
by sharing directly with other researchers, and that I will not be identifiable from this information
I agree to take part in the above-named study.

Printed name of participant

Printed name of person obtaining consent

Signature of participantSignature of person obtaining consent

Date

Date

52

9.5 Interview Guide
Note: This guide is not intended to be followed verbatim. It is designed as a guide to structure the interview
and ensure consistency while allowing for flexibility to explore additional topics as they arise. Questions are
subject to change depending on the specific circumstances.

Pre-interview•

Send a reminder to the participant the day before•

Ensure the participant has signed and returned the consent form.

•

Ensure the internet connection is stable.

•

Ensure video recording is functional by running a pilot recording just before the interview.

•

Ensure a notebook is ready and dated for this interview.

Underlined and italics represents reminders to the interviewer, not to be read out to participants

BEGINNING THE INTERVIEW

How are you? Thank you for taking the time for this interview.
My name is, and I am an MSc student at LSHTM currently studying Nutrition for Global Health.

I am a registered dietitian from. Before coming to the MSc, I worked as a

Did you have a chance to read through the 10 research priorities that I sent via email?
As a reminder: The project aims to determine the extent to which the ten research priorities, as proposed by
Prudhon et al. (2016), of infant and young child feeding in humanitarian emergencies (IYCF-E) have beenrealised.
In doing so I am interested in finding out where you feel there are important gaps in research in IYCF-E. This
information will be used to guide researchers on what evidence is needed to usefully inform current practice.
I am also interested in understanding the extent to which current research is communicated to practitioners
and if or how it shapes current practice. I would like to know where you feel there are gaps in knowledge ofcurrent research (by yourself, your colleague/ organisation, or in general practice), and what can then be done
to bridge those gaps.

Once we start the recording, I will ask you to introduce yourself. During the interview, I will be taking notes so
if I pause or look down you know what I am doing.
Before we do that, do you have any questions regarding the information sheet or consent form? I just want toreiterate that everything you say will be kept anonymous. Your quotes from this interview may be used in the
final study, but they will be anonymised. Once the transcript is complete, I will email it to you in case you haveany corrections.
If at any point you would like to stop the interview, we can do so. Do you mind if I start the recording?
Start recording

INTRODUCTION

1.

Where are you currently working?
• What is your position there?
• And for how long have you been in that role?

2.

What is your educational background?

3.

How long have you worked with infant and young child feeding in emergencies (IYCF-E)?
• Do you mind expanding a little about your experience?
Note the topics the participant works on using the list of 10 research priorities

4.

Are you currently working on research on IYCF-E, or have you done so in the past?
• If yes – is that more operational or academic research?

OBJECTIVE 1:
Using Prudhon et al.’s ten research priorities, explore the perceptions of those working in IYCF-E on
current research and gaps in knowledge on the topic
OBJECTIVE 2:
Explore and contrast the perceptions of researchers and practitioners in IYCF-E, on why someresearch priorities may have been answered while others remain unanswered

Continual probe: Do you think this is a general issue in IYCF or specific to IYCF-E
The focus of the following few questions will be on Prudhon et al.’s list of 10 research priorities.

54

1.

Let’s first chat about the topics that you are most experienced in or knowledgeable about, which you
mentioned as XXX [insert topics mentioned during the introduction – if did not mention then ask: whichof these are you most experienced in or have more knowledge about]1.1. Which of these do you think have been sufficiently answered, or answered in part? [Make note of]
For each topic: Let us start with XX• Why do you think this topic has been so well researched? What are the enabling factors?
• To what extent do you think others in the IYCF-E community know about this research? Why do you
think that is?
• How has this evidence been used to inform policy or practice, if at all?
• Are there any remaining gaps on this topic? Or, given what we now know, what is the next step ofresearch in this area? What else do we need to know?
1.2. Which of these has not been well answered? [Make note of]• Do you think this is a problem? Do you think it should be more of a priority? Why do you think so?
• Why do you think there has been less work on this topic?
• Are there any specifics that you would like to see in these under-researched topics? For example,
countries or contexts where you feel this research would be particularly helpful?
2. Now I would like to chat about the topics for which you have less experience or knowledge, which would be
those remaining, namely XX [insert remaining topics]. Is this correct?
• Do you think that your lack of experience on this topic reflects the lack of priority given to this topic
within the ICYF-E community as a whole? Or is it something you know others work on, but you don’t
personally work on much?
Let’s just review what we have discussed. You feel that out of the 10 research priorities, the following havebeen answered XXX [List the priorities that the participant specified as being answered]. And the following areremaining to be answered XXX [List the priorities that the participant specified as being unanswered].

OBJECTIVE 3:
Determine the perceptions on the relevance of Prudhon et al.’s ten research priorities and whether there are
additional priorities to consider

1. Considering all the things we have discussed so far, of the research priorities that you have identified as
being unanswered, what do you think should be prioritised now?
• Why do you say so?
2.

Do you think any of these unanswered priorities are not relevant anymore?

55

• Would you like to elaborate on why you say so?
3.

Do you think there are research priorities that are not listed there that should be?

Lastly, is there anyone with relevant experience that you would suggest I interview for the study?
Thank you for your time. I will forward you this transcript once it is completed. If you have any corrections,then please let me know. If you are interested, I can forward you the completed project once it has beenreturned from marking.

56

9.6 Codebook

Name

Description

Files

References

10

25

1

1

1

1

Requires rewording or combining Participants need to express that thepriority as it currently stands is notwith breastmilk substitutes
meaningful and/or needs to be combined
priority
with priority 4

7

12Unanswered priority

Participant must explicitly state that they
feel that there is insufficient evidence on theextent that cash transfers are used topurchase breastmilk substitutes

89

Why we don't have the researchParticipants’ thoughts on reasons for thelack of evidence

2

3

1

1

1

1

2- Complementary feeding

11

37

Aspects answered but still

9

13

4

4

Fragile1

1

Middle- and high-income

2

2

1

1

2

2

1

1

1- Cash transfer breastmilk
substitutes
Miscellaneous
Contradictions in policy

Fear over what may
happenHave the data but it's notcompiled

insufficient evidenceContexts where it's needed

countries need evidence
too
Where acute malnutrition is
not an issue
Miscellaneous
IYCF-E research morenecessary than IYCF

57

Name

Description

Files

References1

1

One of the most important of the Participants must specify that is is a“main”/“important”/“top”/“high” etc. priority
priorities

6

7

Previously neglected

68

Why we don't have the research

33Complementary feeding

2

2

1

1

10

17

A priority

2

2

Acute is more of a priority

8

10

Challenges in researching

3

5

1

1

2

2

No funding for long term

22

4- Effectively design IYCF-E
programmes where breastmilk
substitute use is high

10

27

7

10

6

6

1

3

More funding for research incommercial complementary
foodsParticipants must state that complementary
feeding has been neglected in the pastcompared to another aspect of IYCF

sits under multiple sectors
No commercial gain insome of them
3- Long term effects IYCF
interventions

Difficulty follow up longterm
Monitoring and evaluation
challenges

One of the most important of thepriorities
Part answers, but more to be
done
Rewording or combination
required

58

Name

Description

Files

References

Why we don't have the research

68Different opinions within

11

Ethical challenges

1

1

Hesitancy

3

3

It's only becoming more of

2

3

4

5

5- Re-lactation interventions

9

15

Have operational guidance or

5

5

9

10

9

22

6

7

2

4

Not a priority

1

1

Split into lactation support and

1

1

8

9

7- Potential beneficiaries andcoverage99Tools available so less of a

9

9

11

15

organisations on how tomanagea priority now
Ukraine may offer
opportunity to study

grey literature
Lack of evidence but still apriority
6- Effective psychologicalsupportHave operational guidance orgrey literature
Lack of evidence on
effectiveness or impact

trauma counselling
Still a priority

priority
8- RTU vs powdered

59

Name

Description

Files

References

3

3

Not a priority, aspects are known

8

8

Still a priority

3

3

Why we don't have the research

11Industry lobbied against

1

1

Lack of will and funding2

2

Not yet at the point of RTU vs1

1

9- Calculate impact IYCF-E
programme

55Important for advocacy

5510 - Effectively link andmainstream

10

18

4

4

4

4

Still a priority

10

10

Why we don't have the research00Complex1

1

Lack of motivation from

1

1

Silos

3

3

Additional priorities

6

11

2

2

1

1

1

1

Have operational or grey
literature

powdered

Have operational or grey
literature
Lack of evidence on
effectiveness or impact

other sectors

Gender
Women’s empowerment
impact on IYCF practices
Male involvement in IYCF-E

60

Name

Description

Files

References

2

2

1

1

1

1

2

2

2

2

ECD

1

1

Integration with play

1

1

1

1

Wet nursing

11

Lactating women in

1

1

1

1

8

29

5

9

Lacking impact evaluations

6

7

Limited resources and data

69More interest in acute3

4

Health systems related
Acceptability and feasibilityof IYCF-E within existing
health systems
Best time points to target
IYCF-E counselling
Maternal nutrition status role in
IYCF nutrition status inemergencies
Other child health topics

Miscellaneous

infectious disease research
Funding into humanresources (lactation
consultants or breastmilk
substitutes)
The general lack of research in
IYCF-E
Irregular, sparse and poor-

Participants must mention that there is alack or highlight reasons for the lack ofevidence

quality evidence

malnutrition

619.7 Consolidated Criteria for Reporting Qualitative Studies (COREQ): 32Item Checklist 59
No

Item

Guide questions/description

Domain 1: Research team and reflexivity
Personal characteristics
1.
Interviewer/facilitator
Which author/s conducted the interview or focus group?
2.
Credentials
What were the researcher’s credentials? e.g. PhD, MD
3.
Occupation
What was their occupation at the time of the study?
4.
GenderWas the researcher male or female?
5.
Experience and training
What experience or training did the researcher have?
Relationship with participants
6.
Relationship established Was a relationship established prior to study commencement?
7.
Participant knowledge of What did the participants know about the researcher? e.g.
the interviewer
personal goals, reasons for doing the research
8.
Interviewer
What characteristics were reported about thecharacteristics
interviewer/facilitator? e.g. Bias, assumptions, reasons andinterests in the research topic
Domain 2: Study design
Theoretical framework
9.
Methodological
What methodological orientation was stated to underpin theorientation and Theory
study? e.g. grounded theory, discourse analysis, ethnography,
phenomenology, content analysis
Participant selection
10. Sampling
How were participants selected? e.g. purposive, convenience,
consecutive, snowball
11. Method of approach
How were participants approached? e.g. face-to-face,telephone, mail, email
12. Sample size
How many participants were in the study?
13. Non-participation
How many people refused to participate or dropped out?
Reasons?
Setting
14. Setting of data collection Where was the data collected? e.g. home, clinic, workplace
15. Presence of nonWas anyone else present besides the participants andparticipants
researchers?
16
Description of sample
What are the important characteristics of the sample? e.g.
demographic data, date
Data collection
17. Interview guide
Were questions, prompts, guides provided by the authors?
Was it pilot tested?
18.
19.

Repeat interviews
Audio/visual recording

20.

Field notes

21.
22.

Duration
Data saturation

23.

Transcripts returned

Were repeat interviews carried out? If yes, how many?
Did the research use audio or visual recording to collect thedata?
Were field notes made during and/or after the interview or
focus group?
What was the duration of the interviews or focus group?
Was data saturation discussed?

Were transcripts returned to participants for comment and/or
correction?
Domain 3: analysis and findings

Sectionreported(pag e)3.1.1 (18)3.1.1 (18)3.1.1 (18)3.1.1 (18)3.1.1 (18)3.1.2 (18)3.1.2 (18)3.1.2 (18)3.2.1 (18)3.2.2 (19)3.2.2 (19)3.2.2 (19)3.2.2 (19)3.2.3 (20)3.2.3 (20)3.2.3 (20)3.2.4 (20)Appendix 6(57)
3.2.4 (20)3.2.4 (20)3.2.4 (20)3.2.4 (20)3.2.2 (19)3.2.4 (20)3.2.4 (20)62Data analysis
24. Number of data coders
25. Description of thecoding tree
26. Derivation of themes
27. Software
28. Participant checking
Reporting
29. Quotations presented
30.
31.
32.

Data and findings
consistent
Clarity of major themes
Clarity of minor themes

How many data coders coded the data?
Did authors provide a description of the coding tree?

3.3 (21)
3.3 (21)

Were themes identified in advance or derived from the data?
What software, if applicable, was used to manage the data?
Did participants provide feedback on the findings?

3.3 (21)
3.3 (21)
3.3 (21)

Were participant quotations presented to illustrate the themes /findings? Was each quotation identified? e.g. participant
numberWas there consistency between the data presented and thefindings?
Were major themes clearly presented in the findings?
Is there a description of diverse cases or discussion of minor
themes?

4 (22-33)
4 (22-33)
4 (22-33)
4 (22-33)

63

9.8.

Care Form

64

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