A Mixed Methods Study on How Urban Slum Food Environments Influence Caregivers' Feeding Practices for Children Under Five Years in Pune, India

In India there is a high prevalence of poor complementary feeding practices. Around 1 in 2 caregivers introduced complementary foods to infants at 6-8 months, while 1 in 4 infants had the minimum dietary diversity, and 1 in 10 consumed the minimum acceptable diet. A worrisome trend being observed is the widespread consumption of ultra-processed foods (UPFs) among children across all socioeconomic groups in India. In informal settlements in Mumbai, nearly 60% children under 6 years were found to be consuming UPFs daily. Increased UPF consumption contributes significantly to the prevalence of double burden of malnutrition in India.

Pune is a rapidly growing mega-city in Maharashtra with a population of 9.4 million, which includes over 1.2 million slum-dwellers, including around 300,000 children under-five years of age. In 2020, only 6% infants had adequate diets and 12% achieved dietary diversity. Specific data is lacking on time of introduction of complementary foods and no data are available on slum-dwelling populations. The United Nations Human Settlements Program defines a slum as "a group of individuals who live under the same roof, and that lack one or more of the following conditions: access to improved water, access to improved sanitation, sufficient living space, the durability of housing, and secure tenure". Slums are a unique and complex ecosystem where caregivers face multiple, intersecting challenges when making food choices for their children. These settings are often marked by limited infrastructure, economic constraints, and a high density of informal food vendors-conditions that may promote the availability and consumption of unhealthy foods.

The food environment defined as "consumer interface within the food system that encompasses the availability, affordability, convenience, quality and promotion, and sustainability of foods and beverages in wild, cultivated, and built spaces" is increasingly recognized as a key determinant of dietary behavior. Yet there is limited evidence from Indian slum settings on how food environments influence infant and young child feeding (IYCF) practices. Most existing research focuses on maternal knowledge or household-level factors, with minimal attention to the broader environmental and structural influences.

This study responds to this gap by assessing the 5 A's of the food environment (availability, accessibility, affordability, acceptability, and accommodation), and by exploring how these dimensions interact with caregivers' perceptions of convenience, food safety, and prestige, as well as their ability to understand and use food labels. These factors are particularly relevant in urban slums, where informal food systems dominate, and where unhealthy foods may be more readily available and aspirationally consumed. Therefore, the objectives of this study are:

1. To characterize the food environment in selected slums of Pune using the 5 A's framework: availability, accessibility, affordability, acceptability, and accommodation. 2. To explore caregivers' perceptions of food safety, food prestige, and convenience as additional drivers of food choice within the slum context. 3. To assess caregivers' awareness, understanding, and use of packaged food labels, especially in relation to identifying foods for young children. 4. To examine how the local food environment and food choice drivers interact to influence caregivers' feeding practices, with a particular focus on the consumption of unhealthy foods and sugar-sweetened beverages among children under five. 5. To disseminate findings through awareness sessions and cooking competitions.

• Number and types of food outlets in the study location [Time frame: An average of 1 year]
• Type of foods being promoted in the study locations [Time frame: An average of 1 year]