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Report on Barrier Analysis survey on

Exclusive Breastfeeding

Location: Selected sites in four districts in South

Karamoja (RWANU project implementation area)

May 2016

i

Table of Contents

Abbreviations ........................................................................................................................................... i

Acknowledgements .................................................................................................................................. i

1. Background and rationale ............................................................................................................... 2

2. Methods .......................................................................................................................................... 2

3. Findings ........................................................................................................................................... 4

4. Recommended activities ................................................................................................................. 8

5. Lessons learned ............................................................................................................................... 9

Annex 1. Survey and training schedules ............................................................................................... 10

Annex 2. Survey questionnaire ............................................................................................................. 12

Annex 3. List of staff, enumerators and supervisors ............................................................................ 17

Annex 4. MS Excel results table ............................................................................................................ 18

Abbreviations

BA Barrier analysis

DBC Designing for behavior change

EBF Exclusive breastfeeding, (to) exclusively breastfeed

LM Lead Mother

MCG Mother care group

RWANU Resiliency through Wealth, Agriculture and Nutrition in Karamoja

Acknowledgements

Thank you to the women for their time during the interviews. Thank you to the Concern team for facilitating the study preparation, questionnaire development, training, data collection and related logistics and transports, including the Field Coordinators for supervision and Health Promoters for sensitization & mobilization ahead of the data collection. Thank you to all drivers for driving us around safely!

Photos on front page: Training participants during a terminology matching game (credit: Gudrun Stallkamp)

Barrier Analysis on Exclusive Breastfeeding, South Karamoja, April 2016 2

1. Background and rationale

The Resiliency through Wealth, Agriculture and Nutrition in Karamoja (RWANU) project is being implemented in four districts of South Karamoja by a consortium headed by ACDI/VOCA with sub- recipients Concern Worldwide and Welthungerhilfe. Concern Worldwide implements the social and behavior change and health systems strengthening components of the RWANU project. The mother care groups (MCGs) approach is used to support cascading trainings from the technical experts at Concern to the household carers within the communities. The approach allows for a wide coverage within a given area and thus contributes to reaching a critical mass for behavior change to happen.

Edžclusiǀe breastfeeding for the first sidž months of an infant's life was promoted during the second

lesson of module 1 of the mother care group (MCG) curriculum. Internal monitoring after the delivery of the session showed a drop from the baseline value of 59% to 2014 and a subsequent increase to 63% (Figure 1). The project target for the endline survey was set at 80%. Figure 1. Overview of prevalence of exclusive breastfeeding from baseline and annual assessments to date. Rationale. There is a need to accelerate increase in the percentage of exclusive breastfeeding, also because the annual surveys are conducted among the beneficiary population while the baseline and

endline assessments are/ will be sampled from the overall population. To facilitate this acceleration,

the project team conducted a barrier analysis survey to investigate if aspects related to exclusive breastfeeding that would help the field teams promote the behavior more effectively.

2. Methods

that helps to identify the specific determinants that differ behavior and that are useful to address during the subsequent implementation phase of a project. The overall process followed for this study is summarized in the graph on the right (see also Annex 1.)

1 The Designing for Behaviour change approach was developed by the CORE Group. The overall method is described here

and a curriculum for the Barrier Analysis survey process specifically can be found here (both on the CORE Group website).

Barrier Analysis on Exclusive Breastfeeding, South Karamoja, April 2016 3 Study date and location. Data was collected on April 6th, 2016 in the four districts of Moroto, Nakapiripirit, Napak and Amudat where the RWANU project is operational. In each district, eligible respondents from two communities were interviewed.

Sample size. As per the DBC/ Barrier Analysis survey guideline, the planned sample size was set to 45

Doers and 45 Non-Doers. The actual sample size was 55 Doers and 52 Non-Doers. Respondents. Data was collected of mothers who had an infant between 6 and 8 months of age. A number of screening questions were applied to establish whether somebody is a Doer, a Non-Doer

or should not be interviewed. Due to the very specific eligibility criteria, including a very narrow child

age range, the project mobilized women with children in the particular age group and asked them to come to a central point on the data collection day. Questionnaire and translation. Questions were formulated to assess the perceptions by both doers and non-doers for the 12 determinants2 as per the DBC methodology. The questionnaire was based on the standard template for two columns. The English questionnaire was prepared ahead of the training (see Annex 2); the Karamojong and Pokot translations were prepared together with the group during the training. Questionnaires were printed and provided to the district teams. Training. The training on April 4th 2016 was facilitated by the study lead and included the following key topics: a) Welcome and overview, b) BA questionnaire (general, in-depth and translation), c) interviewing techniques, d) mock interviews, e) feedback, f) logistics and closing. (see also graphic on the right). See Annex 1 for the schedule. Enumerators and supervisors. Per district, three enumerators collected data who were supervised by a RWANU Field Coordinator of Concern. The enumerators all had prior survey experience and had the required language skills. Supervisors maintained a tally sheet of the number of doers/ non-doers interviewed in their area to ensure the recommended sample size was accomplished. Annex 3 shows the list of enumerators. Data collection. Data was collected on April 5th 2016 from the selected communities in the four districts. Health Promoters had sensitized the communities ahead of the survey and had mobilized mothers who had a child in the eligible age group. Due to the very narrow age bracket and a limited

availability of the field teams for supervision and analysis, this was considered the best process. The

tight network of mother care groups and household carers and in-depth information by the Health Promoters of the population helped with this process. Prospective participants of the study were mobilized at a convenient spot and data collectors applied the questionnaire. Initial screening questions verified eligibility to the survey and eligible study participants were then either interviewed using the doer or the non-doer questions on the form. The supervisors managed a tally sheet or count of how many doer and non-doer had been conducted already and once the quota for one of these groups was fulfilled, they instructed the data collectors to only interview eligible participants from the other group. Survey participants received a small token of appreciation (e.g. package of biscuits or bar of soap) for their participation.

2 The 12 determinants include: Perceived self-efficacy/ skills, social norms, perceived positive consequences, perceived

negative consequences, access, cues for actions/ reminders, perceived susceptibility/ risk, perceived severity, perceived

action efficacy, perception of divine will, policy, and culture Barrier Analysis on Exclusive Breastfeeding, South Karamoja, April 2016 4 Response coding and manual data analysis (frequencies). Following the data collection, the qualitative answers were coded into agreed categories and frequencies counted for each of the generated categories. Simple frequencies were recorded for all pre-coded answers. The coding and analysis was conducted together with the enumerators and supervisors. Frequencies were recorded on flip chart paper initially and later on entered by the study lead into the existing MS Excel

tabulation template developed for barrier analysis data. Due to limited time at during the coding day

with the group, the study lead counted the responses to the last nine pre-coded questions without the group's inǀolǀement. Data analysis and level of significance. For the manually recorded frequencies and percentages, the response/ response category yielded a significantly different response by doers vs non-doers. The pre-designed MS Excel spreadsheet calculates the odds ratio and a p value for the odds ratio (significant at p < 0.05), including automated information/interpretation about the likelihood of doers vs non-doers mentioning a particular response. Based on experience, there is not always full agreement between the two methods in estimating a statistically significant difference between the doers and non-doers. Both methods were used for the current data and a response/ determinant was considered significant if at least one of the methods indicated a significant difference.

3. Findings

The perception of doers and non-doers differed in responses to seven out of the 12 determinants investigated by the survey, including perceived self-efficacy, perceived negative consequences, perceived social norms, perceived access, susceptibility, severity and action efficacy. Most of the responses were identified as significantly different by both of the two methods described in the methods section above; four responses were identified as significantly different by one method only.

Table 1 on page 6 provides an overview of all responses that were found to be significant. Table 2 on

page 7 provides an overview of the determinants, which is in line with the presentation used in the RWANU Social and Behavior Change Strategic Action Plan. The overall results including insignificant results are presented in Annex 4.

Focusing on the significant results, the study revealed that only half of the non-doers felt they were

able with their current skills, knowledge or resources to exclusively breastfeed (EBF) their child while

all of the doers felt able to do this. About three quarters of the non-doers felt they were able to or

possibly able to EBF their child with their current skills, knowledge or resources, while about a quarter of the non-doers believe they are not able to. Doers felt that knowing that breast milk was the only food for a child of that age and the most like food and food that was readily available made it easier for them to EBF their baby (about a third of the doers and nearly no non-doer answered this). Non-doers felt it would make it easier to EBF their child if they had money to buy foods or if they had foods available for the mother to eat properly. Only 10% of the non-doers felt that there were no difficulties with exclusively breastfeeding while more than 40% of the doers expressed that nothing made exclusive breastfeeding (EBF) difficult. More than 40% of the non-doers expressed that not having enough or not having any breast milk makes it more difficult to EBF while less than 20% of doers mentioned this as a difficulty. Barrier Analysis on Exclusive Breastfeeding, South Karamoja, April 2016 5

Nearly all doers and a slightly less than 80% of the non-doers felt there was no disadvantage to EBF.

About a quarter of the non-doers, however, mentioned that there were situations when not being able to EBF it made the mother feel bad. This included when she felt she did not have enough or

little milk only or when the child was not growing thin or not very fast. Similarly, slightly less than

15% of the non-doers (compared with no doers) felt it was a disadvantage when the mother did not

have enough food to produce, when she was sick, or when she did not have enough time because she is the primary breadwinner of the family. About 55% non-doers felt they were the only person who approved of EBF compared with 40% of the doers. Slightly more than 40% of the non-doers mentioned it was very difficult to find the time finding the time to EBF. About 60% of the doers and about 45% of the non-doers felt it was very likely that their child became very thin or would get diarrhea and nearly all doers (94.5%) and three quarters of the non- doers felt that it was very likely or somewhat likely their child became very thin or would get diarrhea (combined answer options). This meant that close to a quarter of the non-doers and just 5%

of the doers felt it was not likely at all that their child became very thin or would get diarrhea. Nearly

if their child became very thin or would get diarrhea (combined answer options). In summary, there seems to be more confidence among the doers that they can exclusively breastfeed their baby for six months, that breast milk is the most adequate food for a baby, that there are no disadvantages to exclusively breastfeeding and that EBF helps to prevent a child becoming very thin or getting diarrhea, which they all consider a very or somewhat serious condition. In contrast, there is much less confidence among non-doers that they can exclusively breastfeed

their baby for six months and they find it difficult in general. They do not consider that breast milk as

the most adequate food for a baby. Their concerns relate to a shortage of breast milk, which is perceived due to a shortage of food for the lactating mothers in order to produce sufficient milk. This food shortage is being perceived due to either low purchasing power or limited availability of foods at the household level in general. Many non-doers seem to have a bad feeling about their not

social group and they find it difficult to find the time to exclusively breastfeed. Fewer non-doers than

doers feel there is a risk their child could become malnourished or get diarrhea, perceive this as very

or somewhat severe condition, which could be prevented by exclusive breastfeeding. Barrier Analysis on Exclusive Breastfeeding, South Karamoja, April 2016 6 Table 1. Determinants that were significantly different between doers and non-doers, either based on the 15% difference rule or the p value of the odds ratio, or both.

Determinant Doers %

(frequency)

Non-Doers %

(frequency) % point difference

Odds Ratio

(95% C.I.)

Sample size (n) for questions 1-3

Questions 4-16

54
55
52
52

Perceived self-efficacy (Question (Q)1, Q4, Q5)

Thinks she is able to EBF with current skills/

knowledge/ resources

100.0%

(54) 50.0%
(26) -50.0%

Thinks she is possibly able to EBF with current

skills/knowledge/resources 0% (0) 26.9%
(14)

26.9% 0.00

Does not think she is able to EBF with current skills/ knowledge/ resources 0% (0) 23.1%
(12)

23.1% 0.00

Thinks she is or is possible able to EBF with current skills/ knowledge/ resources (combined) 100%
(54) 76.9%
(40) -23.1% Breast milk is the only food at that age, most liked food, fast/ immediately available food 29.1%
(16) 1.9% (1) -27.2% 20.92 (2.66-164.64) Enough money to buy foods, availability of foods for the mom 20.0% (11) 48.1%
(25)

28.1% 0.27

(0.11-0.64)

Not difficult to EBF 41.88%

(23) 9.6% (5) -32.2% 6.76 (2.33-19.63) Little or no breast milk, not enough for twins 18.2% (10) 42.3%
(22)

24.1% 0.30

(0.13-0.73)

Perceived negative consequences (Q3)

No disadvantage to EBF 98.1%

(53) 78.8%
(41) -19.3% 14.22 (1.76-114.66) Mother has a bad feeling when there is little or no milk or when child grows thin/ not very fast 1.9% (1) 25.0%
(13)

23.1% 0.06

(0.01-0.45) Mother has not enough food to produce breast milk; it's hard to breastfeed when the mother is sick; there is no time to breast feed if she's the bread winner* 0% (0) 13.5% (7)

13.5%* 0.00

Perceived social norms (Q6)

Only respondent herself approves+ 40.0%

(22) 55.8%
(29)

15.8% 0.53

(0.25-1.14)+

Perceived access (Q8)

Very difficult to find the time needed to EBF 5.5% (3) 42.3%
(22)

36.9% 0.08

(0.02-0.29) Very or somewhat difficult to find the time needed to EBF (combined) 40.0%
(22) 84.6%
(44)

44.6% 0.12

(0.05-0.31)

Susceptibility/ risk (Q11)

Very likely that child becomes very thin/ gets

diarrhoea+ 61.8%
(34) 46.6%
(24) -15.7% 1.89quotesdbs_dbs25.pdfusesText_31

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