The study used an analytical cross-sectional design within an epidemiological framework to assess maternal adherence to infant feeding recommendations and investigate associated maternal demographic, psychosocial, and childbirth predictors. The study design was considered suitable because it facilitated the exploration of national practices regarding infant feeding while examining their association with different factors [26].

A diverse sample of mothers from multiple governorates in Oman was conveniently recruited from health centers between October 2023 and March 2024. Health centers are governmental facilities affiliated with the Ministry of Health and provide a free, safe, and accessible setting for health services [27]. With a national vaccination rate of 99% for children younger than 3 years [28], health centers were deemed a suitable setting for reaching the study participants.

The healthcare centers involved were located in varied geographical settings, including urban and rural areas, which provided access to mothers from diverse community settings. This variation often corresponds to sociodemographic factors, which increases heterogeneity of the sample.

This study gathered data from the nine largest governorates in Oman (from a total of 11 governorates), which include the majority of the population attending Ministry of Health primary care services. These governorates encompassed 29 cities, where 120 health centers were approached for data collection. The large number of recruited health centers was intended to reduce facility-level selection bias and to capture geographic variation in practices.

A convenience sampling technique was used to recruit the study participants. The study involved mothers of children aged one to 3 years. Since the focus is on actual infant feeding practices, it was important for mothers to provide a comprehensive report of their practices during their child’s first year of life. Furthermore, mothers of children older than 3 years may have difficulty recalling their infant feeding practices. Eligible participants were mothers who could read and write in Arabic, since the questionnaire was in Arabic, and who provided informed consent. Exclusion criteria included mothers with a cognitive disability affecting their understanding of the survey, non-Omani mothers since the study aimed to understand the practices from a cultural perspective, and mothers who had already answered the survey for another child.

A total of 28 research assistants (RAs) were recruited and trained to follow a standardized data collection protocol. According to the protocol, RAs attended health centers during morning shifts, where they approached and greeted potential participants for a quick eligibility screening. Mothers who met the inclusion criteria were invited to participate in the study and handed the consent form, which included detailed information about the study on its front page. After obtaining consent, the RAs provided a data collection form and remained on-site to assist and address any questions raised by the participants.

The sample size was calculated using multivariable linear regression analysis, focusing primarily on the effects of individual predictors. Following the guidelines set by Maxwell [29], and assuming a small effect size (R² = 0.02), a two-sided significance level of 0.05, and a statistical power of 80%, a minimum of 403 participant is required. However, we aimed to recruit 0.5%–1% of the child population in each governorate [30], supporting the study’s epidemiological framework (Supplementary Material 1). Efforts were made to enhance diversity by recruiting from varied geographic regions and a large number of health centers across Oman. Data collection continued at health centers within each governorate until the target sample size was achieved or no additional participants could be recruited.

The study’s primary outcome was IFP reflected as the maternal adherence to infant feeding recommendations. The studied maternal demographic factors included age, education, parity, and family income. The maternal psychosocial factors included infant feeding beliefs (IFB), receipt of infant feeding counseling, and self-reported infant feeding knowledge level. We also investigated potential confounders relative to childbirth history, including birth status, mode of delivery, and Neonatal Intensive Care Unit (NICU) admission.

The researchers used a validated Arabic Infant Feeding Practices and Beliefs descriptive questionnaire developed by Al Yazeedi et al. (2025). The 54-item questionnaire has two main sections. The first section includes 34 items addressing sociodemographic characteristics (11 items), birth and clinical history (11 items), and infant feeding history during the first year (12 items). The second section contained 20 items designed to provide a comprehensive assessment of infant feeding practices and beliefs.

The IFP section includes 10 items, most of which were answered using multiple-choice options. Mothers were asked about various IFP based on the WHO infant feeding recommendations [31]. The first item assessed exclusive breastfeeding during the first 6 months, with responses recorded on a five-point Likert scale ranging from “never” to “always.” The second item asked about breastfeeding continuation through the first year, with responses recorded as “yes” or “no.” The remaining items addressed the timing of introducing formula milk, complementary foods, animal protein, 100% fresh juice, yoghurt, egg, unmodified milk, and honey. The third to tenth items offered four age-range options in months as response choices. Responses to the ten items were then categorized and scored as meeting = 1 or not meeting = 0 the WHO infant feeding recommendations, resulting in a total IFP score ranging from 0 to 10 [32]. The first item responses were sorted as follows: 1 = always, 0 = mostly, sometimes, rarely, and never [31].

Following the IFP section, there were 10 four-point Likert-scale items addressing infant feeding beliefs, with response options: strongly disagree, disagree, agree, and strongly agree. The ten items related to infant feeding beliefs were similar to those in the IFP section, but were written to focus on beliefs.

The questionnaire’s validity was established through face and content validation methods. Pilot testing demonstrated acceptable test-retest reliability r = 0.73 [p = 0.007] and r = 0.65 [p = 0.005] for IFP and IFB, respectively. Further details about the development of the questionnaire are published in another manuscript [32].

Researchers secured ethical approval from the Research and Ethics Committee at the College of Nursing, Sultan Qaboos University (CON/IG/2022/9) and the Health Studies and Research Approval Committee at the Ministry of Health (MOH/CSR/23/26906). The data collection front page included information about the study and a consent statement. In addition, anonymity was maintained in the study as no identifying information, such as name, date of birth, or medical record number, was collected. Data were stored in a password-protected computer, and paper-based questionnaires were stored in a locked cabinet inside a locked office.

Data were entered into the SPSS program version 23, checked for accuracy, and cleaned, resulting in the removal of surveys with ≥20% missing data. The maternal demographic characteristics, infant feeding counseling, and infant feeding knowledge, besides childbirth history variables, were analyzed using frequency and percentages, while means and standard deviations were reported for IFP and IFB. Percentages were calculated using the number of non-missing responses for each variable.

Inferential statistics, including Pearson correlation, were used to examine associations between IFP and IFB. Independent t-tests were used to assess differences between IFP scores across demographic characteristics, infant feeding counseling, childbirth status, delivery mode, and NICU. One-way ANOVA was used to compare IFP scores across infant feeding knowledge categories (high, moderate, low). Multivariable linear regression analysis was run to assess the significant predictors. The assumption of normality, linearity, homoscedasticity, and multicollinearity was assessed before running the analysis. The significance level was set at p < 0.05.

Table 1 presents the participants’ characteristics. Mothers were predominantly 18–35 years old (n = 2,218, 73.1%) and had less than a baccalaureate-level education (n = 1986, 65.4%). Most had one to three children (n = 1954, 64.4%), and a monthly family income under 1,000 Omani Riyals (∼2,596 USD) (n = 1966, 64.8%). Less than half received infant feeding counseling (n = 1,312, 43.2%), and 53.4% (n = 1,621) reported moderate infant feeding knowledge.

Majority of children were distributed across three age groups during the time of data collection: 34.5% (12–17 months), 29.1% (18–23 months), and 28.9% (24–29 months). The sex distribution was almost even (51.3% male; 47.5% female). Most were born full-term (n = 2,612, 86.0%), via vaginal delivery (n = 2,307, 76.0%), and without NICU admission (n = 2,799, 92.2%).

Table 2 presents the frequencies and percentages of IFP and IFB, highlighting several discrepancies between practices and beliefs. The results suggested that the practice of exclusive breastfeeding during the first 6 months was much lower than the belief (35.8% versus 93.5%). Additionally, while 85.7% believe it is healthy to introduce complementary foods at 6 months of age, 68.8% report actually practicing it. Similarly, 82.5% of mothers perceive the introduction of yogurt after 6 months as a healthy practice, but only 62.6% actually do so. Secondary analysis showed that many introduce yogurt either too early (19.6% before 6 months) or too late (14.1% after the child turns 1 year), with 27.1% introducing solids between four and 5 months (Supplementary Material 2). Moreover, the analysis shows that there are generally less favorable beliefs associated with introduction of fresh juice (36.2%) and infant formula (58.8%), which align with the observed feeding practices. Interestingly, the percentages for favorable fresh cow’s milk and honey practices were higher than the reported beliefs, at 48.2% and 52.3%, respectively, as shown in Table 2.

Table 1 shows that the mean IFP score was 6.36 (SD = 1.72) and the mean IFB score is 28.91 (SD = 2.95). Below are details related to the bivariate analysis with maternal demographic, maternal psychosocial, and childbirth history factors.

A multivariable linear regression analysis was conducted for both IFP and IFB. Cases with missing values for any variables included in the regression analysis were excluded through listwise deletion. Ultimately, the analysis model included 2,723 participants for both IFP and IFB.

The IFP multivariable linear regression analysis was statistically significant (p < 0.001) and accounted for 11% of the variance (Adjusted R² = 0.108). This analysis identified several independent predictors of IFP scores. Healthier beliefs about infant feeding correlated with higher scores (B = 0.17, p < 0.001). Mothers who received counseling on infant feeding demonstrated higher scores (B = 0.17, p = 0.01). Conversely, maternal education of at least a baccalaureate degree and a family income of at least 1000 OMR were linked to lower scores (B = −0.23, p = 0.001 and B = −0.21, p = 0.004, respectively). Mothers with moderate or low infant feeding knowledge exhibited poorer practices compared to those with high knowledge level (B = −0.23, p < 0.001 and B = −0.34, p = 0.01, respectively). Mothers who delivered via cesarean section had lower IFP scores (B = −0.18, p = 0.02). However, mother’s age, parity, birth status, and NICU admission were not significant predictors to IFP (see Table 4).

For the IFB model, the multivariable linear regression was also statistically significant (p < 0.001) and accounted only for 4% of the variance (Adjusted R² = 0.035). Significant predictors included maternal education of at least a baccalaureate degree (B = 0.56, p < 0.001), family income equal to 1000 OMR or more (B = 0.41, p = 0.001), and receipt of infant feeding counseling (B = 0.48, p < 0.001). Furthermore, low infant feeding knowledge was associated with a decrease in IFB scores (B = −1.35, p < 0.001).

This research benefits from a large, multi-governorate health center–based sample, which enhances the applicability of its results throughout Oman. Additionally, it is one of the few studies in the MENA region that quantitatively investigates the pattern and factors influencing infant feeding practices and beliefs. However, some limitations should be noted. The cross-sectional nature of the study limits the ability to establish causal relationships. The convenience sampling approach and exclusion of two governorates may limit national generalizability. Moreover, since the data is self-reported, there may be a risk of social desirability bias. In addition, recall bias is possible because mothers of children aged one to 3 years were asked to report feeding practices during the first year of life. Finally, the IFB model explained a small portion of the outcome variance, suggesting that additional associating factors warrant investigation.

The findings of this study have several implications for practice and future research in Oman and similar settings. Health systems need to prioritize equitable access to comprehensive counseling services, not merely breastfeeding. Incorporating nutrition counseling into routine antenatal and postnatal care, may serve as an effective strategy. Additionally, infant feeding campaigns should adopt culturally sensitive approaches that acknowledge local traditions while correcting misconceptions. Collaboration with community leaders, who often influence infant feeding decisions, may enhance the effectiveness of these initiatives.

Future research in Oman and comparable settings should employ longitudinal designs to explore the causal pathways linking maternal education, income, and counseling with infant feeding beliefs and practices. It is also important to investigate the role of fathers and extended family members, who often influence feeding decisions but remain understudied in this context.

This study highlights critical determinants to healthy infant feeding among mothers in Oman. Mothers who received infant feeding counseling exhibited higher adherence to the recommendations. Conversely, mothers with high educational attainment or family income demonstrated lower adherence to healthy infant feeding practices. These findings highlight the need for further exploration of mediating sociocultural influences on infant feeding among educated mothers, such as workplace infant-feeding policies and parental leave. Clinically, healthcare providers should enhance access to tailored, structured infant feeding counseling, emphasizing its critical role in promoting optimal feeding practices.