Practitioner Perspectives on Child Feeding in Uganda: Community Engagement through the Global Agenda

This collaborative research study arose in response to the United Nations Sustainable Development Goals 2 and 3, which have amongst their targets an aim to eradicate preventable deaths in children under five years old. The research is founded on the aims of the Global Agenda for Social Work and Social Development which aims at strengthening the social work profession through linkages between global challenges and local responses. To address these issues through nutritious child feeding, it was essential to understand the views and experiences of SW and social development practitioners involved with child feeding practices. Through an online qualitative survey and reflexive thematic analysis, we explored the views and experiences of practitioners working with the Uganda Red Cross Society. Three themes were developed from analysis of the data: Lifestyle Choices & Restrictions; Limited Resources & Facilities; and Knowledge & Education. A reflection on the challenges encountered and advancing international social work through engagement with the Global Agenda are also presented.


Introduction
Despite global progress towards a reduction in mortality amongst children under the age of five years, rates in Sub-Saharan Africa remain a cause for concern with one in 13 children in this region dying before their fifth birthday (World Health Organisation 2020).With malnourishment putting children at greater risk of death from common childhood illnesses such as diarrhoea, it has been argued that adequate nutrition could provide a relatively simple but effective intervention in the prevention of deaths in children under five years old (World Health Organisation 2020).However, Sub-Saharan Africa is currently facing a so-called double-burden of undernutrition and overweight/obesity across all ages due to a greater reliance on calorie-dense, nutrient poor foods (Reardon et al. 2021).While 'child nutrition' is linked to outcomes relating to food insecurity (such as stunting, and wasting), we use the term 'child feeding' to bring focus to the practices of ensuring nutrition, while also allowing exploration of the understandings, beliefs and attitudes underlying those practices.
This collaborative research study arose in response to the United Nations (UN) Sustainable Development Goal (SDG) 2 -The Alleviation of Hunger and SDG 3 -Good Health and Wellbeing, which have amongst their targets an aim to eradicate preventable deaths in children under five years old.The study was also founded on the aims of the Global Agenda for Social Work and Social Development (GA) which aims at strengthening the social work (SW) profession by building linkages between global challenges and local responses.The GA particularly aims at a re-positioning of SW by strengthening its profile and visibility, developing new partnerships, boosting the confidence of SW practitioners and enabling them to make a stronger contribution to policy development (Jones and Truell 2012).
To address SDG2 and SDG3 through nutritious child feeding interventions, it is essential to understand the views and experiences of SW and social development practitioners involved with child feeding practices.To investigate this, our study drew on the views and experiences of practitioners working with the Uganda Red Cross Society (URCS).The study highlights the knowledge and attitudes towards child feeding and nutrition in Uganda, with an emphasis on the GA in the SW discourse and where solutions can be developed within the SW community.A reflection on the challenges encountered, lessons learnt from the global south, and suggestions for better integrating the GA as we move forward are also presented.

Food Insecurity in Uganda
Uganda is classed as one of the least developed countries on the Development Assistance Committee (DAC) List of the Organisation for Economic Co-operation and Development (OECD) recipients and with high numbers of refugees, and the continued impacts of COVID-19, it faces uniquely cross-cutting challenges that align with increases in food insecurity (Kansiime et al. 2021;Manirambona, Wilkins, and Lucero-Prisno 2021).Food insecurity is more pronounced in northern and eastern Uganda (e.g.Acholi and Karamoja) where long-standing issues related to conflict, displacement and drought have limited food production, availability and access (Tusiime, Renard, and Smets 2013;World Food Programme 2022).The quality of children's diets remains a particular cause for concern in Uganda with service cuts limiting support that could enhance nutrition and health during an important developmental period (World Food Programme 2022;Stein et al. 2022).Furthermore, COVID-19 related restrictions such as school closures and physical distancing have resulted in nutritious food being harder to obtain, leading to calls for urgent action to be taken to address nutrition as part of the COVID-19 response (Fore et al. 2020).A rapid assessment showed a 44% increase in those reporting food insecurity in Uganda during the pandemic, and during this time the consumption of nutritionally rich foods decreased (Kansiime et al. 2021).Understanding the challenges and tensions surrounding child feeding in Uganda is pivotal to the development of adequate assistance by SW and other practitioners to support SDG-2 and SDG-3 in countries facing crisis.
Operationalising SDGs 2 and 3, the Uganda Nutrition Action Plan (UNAP, 2011-2016) recognized the multidimensional nature of malnutrition and emphasized the need for multisectoral coordination in addressing this (Government of Uganda 2011).More recently, the Uganda Ministry of Health published their Maternal, Infant, Young Child and Adolescent Nutrition (MIYCAN) Strategy noting that 'nutrition has been a comparatively neglected aspect' of health for these groups (2021: 4).Furthermore, the strategy reiterated the Ministry's commitment to prioritize nutrition within the health system overall.Other entities, including humanitarian and development agencies, buttress government efforts to address gaps in relation to nutrition and ensuring food security; URCS amplifies these efforts with interventions aimed at increasing household food security especially in northern Uganda, in Moyo, Obongi, Yumbe and Karamoja sub-region through food security initiatives and community resilience programming.Implementation of disaster preparedness initiatives aimed at early warning, early action framework for mitigating climate induced disasters-flood and drought indirectly also contribute to bridging nutrition gaps (URCS, 2021).However, food insecurity remains a cause for concern.
With food and food cultures embedded in traditional practices (Trefry, Parkins, and Cundill 2014), we sought to engage practitioners who worked directly with communities where food insecurity occurs to ensure any resultant interventions are appropriate to the cultural context.This approach also aligned with the GA to engage with communities in meaningful knowledge co-production.

Social Work and the Global Agenda in Uganda
Poverty reduction and social development are central to SW practice in Uganda, however debate has cast doubt the over the ability of the profession to successfully deal with these issues at the local level in the African context (Dhemba 2014).In Uganda the SW profession has faced a number of challenges not least that it emerged from and in many ways remains entangled with the colonial project (Twikirize 2014) though new ways of working are appearing to challenge the dominance of western models (Gray, Coates, and Bird 2008;Luwangula et al. 2019).In addition, a lack of regulation and protection for the profession has characterised SW in Uganda, for example, while the majority of SW practitioners in Uganda are employed by NGOs, these 'may not be very strict on the discipline-specific credentials of the person who is recruited as a social worker' (Twikirize et al. 2014: 191) and in a 2014 study, almost a third of those employed in SW roles had no SW background (Twikirize et al. 2014).Despite this, many social development practitioners' work involves meeting the same agenda of social change and these professionals can meaningfully contribute to the discussion and practice of the GA.Indeed, as Luwangula et al. 2019: 138 have argued, the indigenous and innovative models present in Uganda 'directly relate to the main themes of the Global Agenda for Social Work and Social Development'.Three themes have been identified by Wamara et al. (2022) which inform an understanding of indigenised social work practice in Uganda, these centre around ubuntu and include: (1) collective action and mutuality, (2) communal welfare and respect for life and (3) liberation and restoration.They relate directly to the GA by empowering the practitioners to organise local communities to influence local development.For example, in Uganda an indigenised practice that demonstrates collective action is shared cultivation groups for widows, known as Aleyaru.This involves digging a garden for and supporting widows, guaranteeing self-sustainability and food security.
The GA emerged to strengthen the global profile of SW and to support the influence of SW in terms of policy creation (Jones and Truell 2012).The GA was originally conceived of four key aims: promoting social and economic equalities; promoting the dignity and worth of peoples; working towards environmental sustainability; and strengthening the recognition of the importance of human relationships (Jones and Truell 2012).More recently those promoting the GA, have rearticulated its aims for a new decade; the current focus is on the theme ubuntu, which highlights the importance of co-designing and cobuilding communities (Mayaka and Truell 2021).In foregrounding an African philosophical tradition, the GA responds to the post/de-colonial context and this has followed a recognition that the GA did not initially gain traction in certain regions, including East Africa (Spitzer and Twikirize 2014).
Working with the URCS, this research study sought to engage with SW and social development practitioners in Uganda to promote their good practice and develop interventions that meaningfully connected to their local context.

Study Aims
It has been argued that concerted efforts are needed to substantially reduce deaths in children under five years old in Sub-Saharan Africa (World Health Organisation 2020).In Uganda specifically, 29% of children under five are stunted as a result of undernutrition (Ministry of Health 2021) and undernutrition is said to be responsible for four in 10 deaths under the age of 5 (UNICEF 2019).Given the prominence of nutrition-related factors in deaths in children under five years old, the study investigated the views and experiences of SW and social development practitioners on child feeding practices in Uganda.Specifically, the study aimed to investigate: Knowledge and attitudes towards child feeding practices in Uganda The challenges and tensions surrounding child feeding in Uganda The support needed to improve nutritional knowledge and practices amongst parents/carers in Uganda Understanding the challenges and tensions surrounding child feeding in Uganda is pivotal to the development of adequate assistance to meet SDG2 and SDG3.Guided by the GA's central principle, our emphasis was on promoting the knowledge and solutions found within that practitioner community.

Approach
Grounded in interpretivism underpinned by relativist ontology (Ryan 2018) the study explored practitioner views and experiences on child feeding in Uganda.
Practitioners shared their perspectives via an online qualitative survey.This was deemed the most appropriate method of collecting data as it allowed busy practitioners to participate in their own time.Data were collected during the earlier stages of the COVID-19 pandemic, so it was critical that participation did not encroach unnecessarily on practitioners' time.Furthermore, child feeding is a sensitive topic involving multiple stakeholders including parents/ carers and health, community and educational organisations.Practitioners' views on child feeding practices are not always positive and can be challenging to discuss, especially when criticisms pertain to their own organisations (Graham, Russo, and Defeyter 2015).Moreover, practitioners are expected to uphold professional attitudes when working with diverse communities, which can lead to social desirability when sensitive topics are raised (Larson and Bradshaw 2017).Therefore, the anonymity offered by online surveys was an asset, allowing practitioners to openly share their views and experiences and reducing the possibility of social desirability (Braun et al. 2021).

Participants
An opportunity sample of twenty-five URCS practitioners (14 males; 10 females; one unspecified) aged 25-45 years (mean age ¼ 30 years) completed the online survey.The study inclusion criteria required that participants were PRACTITIONER PERSPECTIVES ON CHILD FEEDING IN UGANDA aged 18þ years; worked with or for the URCS; and had involvement with child nutrition in the context of their role.
Participants reported their country of origin to be Uganda (n ¼ 23), or United Republic of the Congo (n ¼ 2) and they worked with people from these areas in addition to people originating from Rwanda, Burundi, South Sudan and Eritrea who resided in Uganda.Practitioners held a range of roles across URCS including health programme supervisor, project support volunteer and branch manager, and each had been in post between five months and 19 years (mean time in post ¼ 3.6 years).

Materials
An online qualitative survey (Braun et al. 2021) focusing on practitioners' knowledge, experience and perspectives on child feeding in Uganda was designed collaboratively between Northumbria University and URCS.An initial draft survey was developed by researchers at Northumbria University and shared with URCS colleagues who provided comments and feedback on the appropriateness of the items to the Ugandan context.The final version of the survey was discussed and agreed by the collaborative research team prior to distribution.
The survey presented practitioners with nine open ended questions, each with free text response boxes to allow them to answer in as much detail as they felt necessary.Additionally, practitioners were invited to share details of their age, country of origin, current job role and years spent in their current job role.The survey was hosted on the Online Surveys platform where participants' anonymised responses were stored securely and only accessible to the research team working on the project.

Procedure
Following ethical approval obtained through Northumbria University's ethics system (ref: 120.1621),URCS practitioners were provided with a link to participant information, consent and the online survey.
Participants completed the online survey independently.To ensure anonymity, the same link was shared with all participants, click through was not monitored, and no names or other identifying information were requested.Participants were assured they were under no obligation to take part as study participation was completely voluntary.While no questions were identified as being likely to cause distress, participants could omit any questions they did not wish to answer and could withdraw from the study at any time.Additionally, participants were asked to provide a memorable, non-identifying word to appear alongside their data.Participants could contact the research team and provide this memorable word with a request for their data to be withdrawn up to one month following participation.On completion of the survey, participants were presented with written debrief information online, which reiterated the study aims, anonymity and the means to withdraw data.Data were collected in November 2020.

Analysis
Data were analysed through reflexive thematic analysis, which acknowledges the 'researchers' active role in knowledge production' (Byrne 2022(Byrne : 1393)).In line with the phases outlined by Braun and Clarke (2021), data were read repeatedly and coded by the first and second authors before initial themes were generated.The first author specialises in qualitative work with vulnerable children and young adults.The second author has expertise in nutritionrelated interventions and qualitative research in school and community settings.The first and second authors approached the analysis with an awareness that their Westernised experiences and knowledge of child feeding could influence their interpretations of the data.Themes were therefore developed in consultation with the third author who works within the URCS and has valuable experience of the Ugandan context.The third author confirmed that cultural and contextual references were accurately interpreted and represented before final themes were written up with supporting participant quotes from across the dataset.The last author, who is a qualified social worker with experience across various international contexts, reviewed the final themes to ensure they were clearly articulated without reference to the entire dataset.

Findings
The findings reported in this section reflect the perspectives of participants as captured in survey responses.The Discussion section then reflects on these findings in relation to existing literature, as well as suggesting future directions for research.
Three themes were developed from analysis of the data: Lifestyle Choices & Restrictions; Limited Resources & Facilities; and Knowledge & Education.Each theme is subsequently outlined with supporting quotes included from participant survey responses.Quotes are included exactly as they were written by participants to maintain authenticity and accuracy.

Theme 1: Lifestyle Choices & Restrictions
Participants highlighted poverty as a key challenge to child feeding in Uganda, with a lack of income often limiting families' access to good quality, nutritious foods: This issue was said to be further exacerbated as a result of the COVID-19 pandemic: Parents struggled to make a living during the lockdown, and this affected the amount and quality of food that children get (Participant 25).
Suggested methods of supporting families experiencing hardship tended to focus on longer term, practical solutions such as the provision of seeds and the implementation of local gardening initiatives to allow families to grow their own food: Food and seedlings to grow their own food to promote sustainability (Participant 21).
It was also recommended that more direct approaches of giving families nutritional supplements, welfare payments and food to feed their children would be helpful: Provide vulnerable parents with feeds that can help their children grow (Participant 8) However, in some cases, children were considered to be at greater risk of obesity due to overeating and inactivity during the lockdown restrictions imposed during the COVID-19 pandemic.Moreover, participants believed that some poor child feeding practices occur due to 'ignorance' on the part of parents and a lack of willingness to listen and adhere to nutritional guidance: Ignorance of parents about nutrition and living in deep villages where people don't want learn new things instead they still believe in the little knowledge they have and take it to be enough for them (Participant 4).

Theme 2: Limited Resources & Facilities
Participants proposed that some broader, structural challenges relating to resources and facilities served to limit nutritious child feeding in Uganda, beginning in the early post-natal stages with inadequate breastfeeding support: Limited child friendly space in offices.So mothers end up stopping their children from breastfeeding early to attend to office work (Participant 2).
It was argued that more needs to be done to support breastfeeding parents to continue breastfeeding up to six months, but also to establish healthy eating habits for themselves and their children.Participants put forward various, community-based ideas for improving childhood nutrition including home visits, food demonstrations and advocacy work as well as involvement from political and church leaders.However, it was acknowledged that resources are already stretched with insufficient funding or staff available to support such interventions.It was also argued that there are very few professionals with relevant qualifications in nutrition in place to provide appropriate support.In addition, limited access to essential healthcare, clean water and sanitation were issues of concern as diseases such as malaria can intensify undernutrition in children: A lack of access to essential health services and to clean water and adequate sanitation leads to illnesses that prevent children from absorbing nutrients (Participant 22) This lack of access to essential services, nutritious food and support was further exacerbated during COVID-19 lockdown periods with fluctuating food costs and limitations imposed on travel: The parents have not been able to access good health services since some were locked down in villages (Participant 18).

Theme 3: Knowledge & Education
The final challenge to nutritious child feeding in Uganda was said to be a lack of adequate knowledge around nutrition.Participants suggested that parents are not given enough information about good nutrition to allow them to provide healthy meals for their children and responding to the lack of information available to parents, particularly mothers, was a primary recommendation.Training, and education were frequently mentioned and the production and distribution of nutrition promotion materials for mothers was deemed essential.It was noted that even when food is available, some practitioners do not see parents as knowledgeable enough about which foods are best: Parents are not sensitized on how to prepare a balanced diet for the children (Participant 15) Interestingly, when participants were asked about where they acquired knowledge of nutrition to support their work, most had not engaged in any formal training.Most were reliant on experience gained through practice and their own reading around relevant materials: I have no formal qualification in nutrition, but I work closely with the community to support them promote healthy nutrition in child feeding (Participant 11).
Participants proposed several potential mechanisms for educating people about healthy childhood nutrition including 'sending medical team in villages for village meetings' and 'peer to peer education'.It was argued that information needed to be widely disseminated to reach communities, and parents needed to be sensitized to the importance of good nutrition.Additionally, it was suggested that health practitioners and teachers should be provided with training as they are well placed to encourage positive nutritional habits amongst children and families.Moreover, whilst mothers were frequently cited as key targets for nutritional interventions to support nutritious child feeding, one participant pointed out that: Men need to be involved in all feeding interventions, as they maintain or perpetuate some negative practices (Participant 25).

Discussion
Drawing on the perspectives of SW and social development practitioners, the current study investigated knowledge and attitudes; challenges and tensions; and support needs surrounding child feeding practices in Uganda.Practitioners' survey responses encompassed three themes.The first theme of Lifestyle Choices and Restrictions highlighted issues of inequality throughout Uganda, with practitioners suggesting some parents are unable to afford nutritious foods while others are able to afford foods but are unsure what would be best nutritionally to feed their children.The second theme, Limited Resources and Facilities, focussed on challenges faced by practitioners and parents in relation to a lack of resources and facilities available to support nutritious child feeding.The final theme, Knowledge and Education, suggested that a lack of knowledge and education around child feeding served to exacerbate poor child feeding practices.
Taken together, these themes draw attention to the complex nature of the child feeding context and support a 'multi-dimensional approach' to food security as proposed by the United Nations (2020) in addressing SDG2.However, it is essential that local, contextual considerations do not get lost within broader, global policies.For example, included in the multi-dimensional approach proposed under SGD2 are social protections, which serve to build and protect finances and assets to alleviate poverty (Slater and McCord 2009).While social protection programmes can safeguard against household-level food insecurity, their impacts on the diets of mothers and children may be limited by contextual factors such as a lack of access to professional support and food buying facilities (Abay et al. 2022;Berhane, Hoddinott, and Kumar 2017).Therefore, in line with the GA aim of ubuntu, which focuses on co-production and collaboration, any approaches to tackle food insecurity and improve child feeding practices should consider the needs and complexities of the communities that they intend to help.This is reflected in the Ugandan SW context, which increasingly seeks to create space for indigenous and local knowledge (Luwangula et al. 2019).
In support of this, practitioner suggestions around how to improve child feeding in Uganda focused predominantly on sustainable community interventions and sharing of knowledge and experiences locally.Previous research has shown that community engagement programmes aimed at improving health outcomes can work when communities are embedded in the development and decision making from initiation of ideas to execution of programmes (Mbalinda et al. 2011).However, while Mbalinda et al. (2011) have argued that investment is needed to ensure programmes are sustainable and evolve over time, practitioners in the current study argued that a lack of resources, financial investment and staff, particularly those with nutrition-related expertise, are challenges to nutritious child feeding in Uganda.These should therefore be considered central issues for SW in Uganda and underscore how capacity building and collaborative working within communities could support long term, sustainable health outcomes if important contextual factors are acknowledged and incorporated.
Whilst well-resourced, community-driven interventions potentially offer a promising avenue for the improvement of nutritious child feeding, it is important to recognise that food insecurity is governed by cultural ideas and practices (Trefry, Parkins, and Cundill 2014).Given that family are the first and most important mechanism of support within the African context, bringing together multiple agencies to solve problems 'looks alien in the African context because in most cases problems are solved within the family', potentially offering a level of challenge to the application of ubuntu for SW in Uganda (Mugumbate and Nyanguru 2013: 94).Moreover, it is essential that the implementation of nutrition-based interventions does not undermine the value of indigenous knowledge.
In the current study, some practitioners suggested parental knowledge of nutrition was lacking, and the persistence of indigenous knowledge is a barrier to change.However, Tabuti and Van Damme (2012) argue that indigenous knowledge in Uganda could play an important role in poverty alleviation, the management of natural resources and environmental sustainability, though its value and transferability across generations has been eroded by Western influences, which are seen as superior.Our findings therefore overwhelmingly speak to the need to engage existing local networks, including the church, school and political leaders, to effectively and sustainably support nutritious child feeding.Furthermore, in line with the GA aims of inclusivity and co-building, it is important that the value of indigenous knowledge and practices in Uganda are considered as a mechanism to promote positive change rather than something to be eradicated.

Implications for Research, Policy and Practice
Participants proposed a range of mechanisms for improving child feeding in Uganda including the provision of seeds, and training in 'backyard gardening' (i.e.small scale food growing); developing educational materials that can be shared through community initiatives, particularly those involving peer to peer PRACTITIONER PERSPECTIVES ON CHILD FEEDING IN UGANDA learning and support.However, participants also suggested a lack of resources and staff, particularly those with nutritional qualifications, were barriers to change in child feeding practices in Uganda.While the MIYCAN Strategy (2021) notes the need for health care workers to prioritise nutrition, it also makes clear the necessity of the Ministry of Health working in partnership with other agencies; our findings demonstrate that SW practitioners can contribute meaningfully to efforts to address SDG3 through nutrition related interventions and therefore investment in training should extend to SW practitioners.
As well as highlighting the relevance of the GA goals and key considerations for SW practitioners, our collaboration revealed existing tensions within the networks that contribute to scholarly knowledge production.For example, working with overseas partners, particularly those who are at the front line of delivering services, requires time and a level of flexibility difficult to achieve within the constraints of time-limited research funding structures.Our experiences aligned with those of Dusdal and Powell (2021) particularly around time constraints, distribution of labour and communication.Specifically, we found the research placed considerable demands on our partners to support participant recruitment in a short period of time to meet funding deadlines.Additionally, in line with Dusdal and Powell (2021), we found there was a need for tasks and expectations to be reviewed and amended as the project progressed.The nomination of key contacts in the UK and Uganda enabled this.Again, these are important considerations for practitioners and researchers looking to engage in international collaborative work, particularly where time limited funding is attached to the project.While engagement with the GA can support students of SW to develop the knowledge, skills and values needed for international social work (Palattiyil et al. 2019), awareness of these wider considerations relating to collaboration is also valuable.

Limitations & Future Directions
Interestingly, though studies in Uganda have shown that food insecurity negatively impacts mental health (Sweetland et al. 2019), supporting parents in this regard was not something that emerged from our study.While peer support was recommended by practitioners as a potential intervention, this appeared to be focussed specifically on improving nutritional outcomes.Furthermore, some practitioners championed breast feeding support as a way of improving health outcomes from birth.However, there was no acknowledgement of the importance of pre-conception and pre-natal nutrition and the impacts this can have on early child development (King 2016).Future work might investigate how a holistic approach to families and communities, incorporating mental health and/or emotional support alongside nutritional interventions, might enable parents and people of child-bearing age to best use the resources available to them.Moreover, it is important to acknowledge that this study drew on the perspectives of practitioners only.Further research is needed to examine the views and experiences of parents and children to understand their needs and whether the suggested interventions in the current study are appropriate and accessible to those they are expected to support.

Conclusion
The challenges encountered in this collaborative research study served to emphasise several practical considerations that need to be addressed in the funding and implementation of international collaborative research.Despite such challenges, the lessons learnt from this collaborative project are invaluable for cross cultural knowledge on child feeding.Moreover, suggestions for advancing international SW and better integrating the GA have been highlighted, strengthening the SW profession by building linkages between global challenges/immediate concerns and country specific local responses.
PRACTITIONER PERSPECTIVES ON CHILD FEEDING IN UGANDA Some families do not have what to eat and others eat only one meal a day due to poverty.(Participant 17)