report on barrier analysis survey on exclusive breastfeedingpdf.usaid.gov/pdf_docs/pa00mjxr.pdf ·...

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!

Alakara and Sörö Nyowo!

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

Barrier Analysis on Exclusive Breastfeeding, South Karamoja, April 2016

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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.

Exclusive breastfeeding for the first six 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

The Barrier Analysis (BA) survey is based on the ‘Designing for

Behavior Change’ method1, which is a formative research method

that helps to identify the specific determinants that differ

significantly between ‘doers’ and a ‘non-doers’ of a particular

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).

http://www.coregroup.org/resources/384-designing-for-behavior-change-for-agriculture-natural-resource-management-health-and-nutrition

http://www.coregroup.org/resources/404-a-practical-guide-to-conducting-a-barrier-analysis


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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.

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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


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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 involvement.

Data analysis and level of significance. For the manually recorded frequencies and percentages, the

recommended crude ‘15 percentage point difference’ rule was applied to indicate whether a

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.


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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

needed to EBF compared with 5% of the doers. Combining the categories ‘very difficult’ and

‘somewhat difficult’, nearly 85% of the non-doers compared with 40% of the doers had difficulties

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

all of the doers (98.2%) and close to 90% of the non-doers perceived it as ‘very or somewhat serious’

if their child became very thin or would get diarrhea (combined answer options).

Linking the behavior to this condition, nearly three quarters of the doers felt it was ‘very likely’ and

about 10% felt it was ‘somewhat likely’ their child became very thin or would get diarrhea if they did

not EBF. Fewer non-doers believed so, about 40% and 35% felt it was ‘very likely’ or ‘somewhat

likely’, respectively, that their child became very thin or would get diarrhea if they did not EBF.

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

exclusively breastfeeding their baby, they are more ‘on their own’ with little approval from their

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.


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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% 1.89 (0.87-4.08)

+

Not likely at all that child becomes very thin/ gets diarrhoea

5.5% (3)

23.1% (12)

17.6% 0.19 (0.05-0.73)

Very or somewhat likely that child becomes very thin/ gets diarrhoea (combined)

94.5% (52)

76.9% (40)

-17.6% 5.20 (1.37-19.67)

Severity (Q12) Very or somewhat serious if child becomes very thin (combined)*

98.2% (54)

88.5% (46)

-9.7%* 7.04 (0.82-60.66)

Action efficacy (Q13) Very likely that child becomes very thin/ gets diarrhoea if not EBF

72.7% (40)

40.4% (21)

-32.3% 3.94 (1.75-8.86)

Somewhat likely that child becomes very thin/ gets diarrhoea if not EBF

12.7% (7)

34.6% (18)

21.9% 0.28 (0.10-0.73)

+ The p value for the odds ratio is not significant but there is a more than 15% point difference.

* The difference is less than 15% point but the p value of the odds ratio is significant.


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Table 2. Determinants interpretation table.

Behaviors

Determinants Exclusive Breastfeeding

Self- efficacy (Can you do it?)

More Non-doers perceive obstacles than Doers

Self-efficacy (What makes it easier?)

Doers have great confidence due to understanding that breast milk is the most suitable food for the baby.

Non-doers feel that availability of food would make it easier

Self-efficacy (What makes it difficult?)

Non-doers perceive being able to not produce the sufficient amount of milk a challenge

Positive Consequences (What are the advantages?)

Doers see more advantages than non-doers such as health and intelligence of the baby

Negative Consequences (What are the

disadvantages?)

Non-doers become feeling bad when they cannot EBF (various causes)

Social Norms (Who approves?)

INFLUENCING GROUPS

More Non-doers than Doers rely on themselves with no perceived approval from their social group

Social Norms (Who disapproves?)

INFLUENCING GROUPS Not significant

Access (How difficult is it to find the

time you need?) Non-doers have difficulties finding the time to EBF

Cue for Action (How difficult to remember)

Not significant

Divine Will (Does God control/approve?)

Not significant

Policy (Are there policies)

Not significant

Culture (Any cultural taboos?)

Not significant

Susceptibility (Could you have this

problem?)

Non-doers believe less than Doers that their child can become very thin or get diarrhea

Severity (How serious is the

problem?)

Non-doers believe less than Doers that if is serious if their child became very thin or got diarrhea

Action Efficacy (How effective is the

behavior in solving/preventing the

problem?)

Non-doers are less convinced than Doers that EBF will reduce the risk of malnutrition or diarrhea

Universal Motivators (What do you want most in

life?)

Food (incl. availability, food assistance): 46.7% Good health (own, children, family): 31.8% Livestock (goats, cows, chicken): 20.6% Good hygiene, sanitation: 16.8% Education (own, for children): 16.8% Income source, business, wealth, money: 14.0%


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4. Recommended activities

The recommended activities take into consideration the current progress and status of the project

with the key premise that no new lesson or material may be developed at this stage of the project.

There is scope to include some messages/ reminders/ refreshers about the exclusive breastfeeding

behavior during the MCG revision days conducted at mid stage of each lesson cycle, during the male

change agent trainings and during the sensitization of local and religious leaders and potentially

through the local drama performances. From the technical project team to Field Coordinators via the

Health Promoters and to the Lead Mothers (LMs), the reminders about exclusive breastfeeding

would eventually reach members of the household caregiver groups (HHCGs) either during the

group sessions and/or during the individual home visit counselling sessions by the LMs. The wider

community would be reached through the male change agents, the local or religious leaders and

drama groups.

Based on the findings and within the parameters of the project stage described above, the following

key activities/ messages are recommended (see Table 3).

Table 3. Recommended activities by (significant) determinant in order to accelerate the promotion

of exclusive breastfeeding in SO 2.1.

Determinant Recommended activities

General recommendation

Concern technical team to recall with all change agents* what was ‘learned’ during the Module 2 and to reinforce the promotion of EBF during all interactions with lactating women who have a child below six months of age.

Messages should also be ‘explained’ by saying that EBF is important because… o … it helps with the child’s mental development and this will help the child

to do well at school and learn fast o … it helps to increase the child’s immunity/ ability to fight diseases so the

child stays more healthy o …it is the best food for a child so no other food is necessary for the child

during the first six months.

Self-efficacy Through all change agents*, highlight that breast milk is the most suitable food for an infant, that is it readily available and does not need lengthy preparation (‘it is fast’)

Remind LM to pay extra attention during home visit counselling for HHCG members who currently have a child between 0-5 months and to help the HHCGiver with her particular challenges with EBF. Remind LMs that they can share challenges they encounter during their own MCG sessions with the Health Promoters.

To all change agents*, highlight that it is important for lactating mothers to eat well and drink plenty of water and to promote this. Suggestions to do this may be found in Module 2 (nutrition during pregnancy and lactation). In addition, when promoting the consumption of vegetables harvested from the keyhole gardens, there is an opportunity to emphasize diverse dietary intake by lactating mothers.

Negative consequences

Highlight to ALL change agents* that the message should be about supporting the mother to EBF, that difficulties need to be acknowledged (because it is difficult for a number of reasons) and that mothers should not be pushed in a way that they start to feel bad about not practicing or struggling with practicing the behavior.


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Determinant Recommended activities

Social norms Emphasize importance of EBF and need for support for lactating mothers during sensitization of local and religious leaders, ask drama groups to amend performances in this way, highlight during male change agent sessions.

Ask LMs to highlight during the HHCG sessions that the group members should be supportive to each other on EBF (and other learned behaviors).

Remind LMs to communicate their own support of EBF to HHCG members during HHCG meetings and home visits.

Work with VHTs and communicate to them the need to help everybody feel supported in practicing exclusive breastfeeding.

Communicate during MCG and HHCG sessions to mothers that there is increasing support for EBF by the community.

Access (time) During HHCG sessions and during home visit counselling solicit concrete and practical solutions with the mother herself and with peer mothers on how best to make time for EBF, even when away. Support the mother in putting these into practice (may involve other change agents, too).

Highlight to all change agents* that it requires time to exclusively breastfeed and that lactating mothers require support from others within their family/ manyatta to breastfeed exclusively.

Susceptibility/ risk Ensure that LMs highlight during the HHCG sessions the following points: o Infants and young children are at risk of being very thin or develop diarrhea

but this can be prevented o Malnutrition and diarrhea are serious conditions, and very much so when not

treated. o Exclusive breastfeeding is one way of reducing the risk of an infant to become

sick because it ‘boosts immunity’.

Severity

Action efficacy

* Change agents include lead mothers, Health Promoters, the HHCG members/ peer mothers, male

change agents, Health Educators, the local and religious leaders who are sensitized by the project,

the drama groups, and everybody else who is able to promote the desired behavior.

5. Lessons learned

The overall process went very smoothly, also due to the well experienced data collectors. There is,

however, always room for improvement and a number of lessons learned are listed in the following.

These also included suggestions by the enumerators at the end of the data collection week.

- Have good screening questions that are easy to apply

- Start early in the morning

- Check that data collection day does not fall on a market day within the communities

selected

- In relation to ‘policy’, it would be good to not only ask for whether or not any laws exist but

to also record what they are

- Interviewers should be aware of ‘textbook’ answers vs real practice and understand how to

probe well

- In relation to ‘social norms’ and the choice of the word ‘approves’ it is useful to clarify ahead

of the data collection what to do if somebody answers ‘nobody’ or ‘me’.

- Avoid community level/ manyatta mobilisation and conduct house to house survey, also to

avoid providing biscuit/ soap incentives to respondents.


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Annex 1. Survey and training schedules

Survey schedule

Date Activities

Week 28th March 2016 Survey preparation: questionnaire (design, initial translation), logistics, training

Mon 4th April Training of enumerators

Tue 5th Data collection

Thurs 6th Data coding & analysis

Actual training schedule

Venue: RWANU office in Nakapiripirit

Participants: 12 enumerators and 4-5 supervisors/ selected technical program team members


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Note: due to much more time required to translate and finalize the questionnaire than anticipated,

an actual pilot test was dropped in lieu of doing mock interviews only. This was not ideal but the

enumerator group was quite well experienced so it was considered ‘good enough’ for this short

survey.

The mock interview session was originally planned as follows.

1.5 hours Pre-test at location nearby

Explain procedure

Handout questionnaires and pens

Divide up into district groups with supervisors

Go to area and distribute across

Everybody does 2 surveys

Go back to office/ training room for refreshment break

- Flip chart: nearby, everybody does 2 interviews or until [TIME]

- Slip chart = teams with supervisors (and phone numbers)

Actual data coding schedule


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Annex 2. Survey questionnaire

Note: the Pokot and Karamojong translations of this questionnaire are available from the Concern

team/ shared folders.

GROUP: DOER NON-DOER

Barrier Analysis Questionnaire BEHAVIOUR: Mothers of children 0-5 months old only give breast milk and nothing else to their child

for the first 6 months. [From RWANU behaviour matrix: Women of children 0-5 months breastfeed their child exclusively until 6 months of age.]

For use with: Mothers of children 6-8 months old in Moroto, Napak, Nakapiripirit & Amudat Districts

Intro: Hello, my name is ………………………………….. and I work with Concern Worldwide. We are

conducting a survey and would very much appreciate your participation. I would like to ask you

about you breast feeding your child. This information will help us to develop effective activities and

messages to promote breastfeeding in Karamoja. All information given will be treated as confidential

and will only be used for the purpose of this survey. Your participation in this survey is voluntary and

no services will be withheld from you or your family if you choose not to participate. The

questionnaire should take around 20 minutes to complete. Would you like to participate in this

survey? Do you want to ask anything about the survey?

Demographic Data: Interviewer…………………………………………………………………………. Date……………………………………………………..

District……………………………………………………… Sub-county…………………………………………………….

Section A. Screening

Questions A B C

1. Do you have a child who was born in August or September?

Yes No Don’t know/ won’t say

2. Did you ever breastfeed that child?

Yes No Don’t know/ won’t say

3. What were the first foods or little snacks that you or anybody else gave to the child?

Don’t know/ won’t say

4. When did you or somebody else give this to your child?

At six months

Before six month Don’t know/ won’t say

DOER (all of the following)

NON-DOER (all of the following)

DO NOT INTERVIEW

Question 1 = A Question 1 = A Question 1 = B or C

Question 2 = A Question 2 = A Question 2 = B or C

Question 4 = A Question 4 = B Question 4 = C

GROUP: DOER NON-DOER (do not mention to respondent)


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Section B. Research Questions

Perceived Self- Efficacy

DOER 1. With your knowledge, resources, and skills, do you think you could only give breast milk and nothing else to your child for the first 6 months?

a. Yes b. Possibly c. No d. Don’t Know

NON-DOER With your knowledge, resources, and skills, do you think you could only give breast milk and nothing else to your child for the first 6 months?

a. Yes b. Possibly c. No d. Don’t Know

Perceived Positive Consequences (Advantages)

DOER 2. What are the advantages of you only giving breast milk and nothing else to your child for the first 6 months?

NON DOER What would be the advantages of you only giving breast milk and nothing else to your child for the first 6 months?

PROMPT ‘what else?’

Perceived Negative Consequences (Disadvantages)

DOER 3. What are the disadvantages of you only giving breast milk and nothing else to your child for the first 6 months?

NON DOER: What would be the disadvantages of you only giving breast milk and nothing else to your child for the first 6 months?


Perceived Self- Efficacy

DOER 4. What makes it easier for you to only give breast milk and nothing else to your child for the first 6 months?

NON DOER: What would make it easier for you to only give breast milk and nothing else to your child for the first 6 months?


DOER 5. What makes it difficult for you to only give breast milk and nothing else to your child for the first 6 months?

NON DOER: What would make it difficult for you to only give breast milk and nothing else to your child for the first 6 months?



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Perceived Social Norms (Approves/Disapproves)

DOER 6. Who are the people who approve of you only giving breast milk to your child for the first 6 months?

NON-DOER Who are the people who would approve of you only giving breast milk and nothing else to your child for the first 6 months?

PROMPT ‘who else?’

DOER 7. Who are the people who disapprove of you only giving breast milk to your child for the first 6 months?

NON-DOER Who are the people who would disapprove of you only giving breast milk and nothing else to your child for the first 6 months?

PROMPT ‘who else?’

Perceived Access – 1

DOER 8. How difficult is it to find the time you need to give only breast milk to your child for the first 6 months?

READ the first 3 RESPONSES a. Very difficult

b. Somewhat difficult

c. Not difficult at all

Don’t know

NON DOER How difficult would it be to find the time you need to give only breast milk to your child for the first 6 months?




Don’t know

Perceived Access – 2

DOER 9. How difficult is it to find a suitable place you need to give only breast milk to your child for the first 6 months?




Don’t know

NON DOER How difficult would it be to find a suitable place you need to give only breast milk to your child for the first 6 months?




Don’t know


15

Perceived Cues for Action/ Reminders

DOER 10. How difficult is it to remember to only give breast milk and nothing else to your child for the first 6 months every time you feed her/him?




Don’t know

NON DOER How difficult do you think it would be to remember to only give breast milk and nothing else to your child for the first 6 months every time you feed her/him?




Don’t know

Perceived Susceptibility

DOER 11. How likely is it that a child becomes very thin or gets diarrhoea in the first 6 months if she/he is given drinks or food other than breast milk only?

READ the first 3 RESPONSES a. Very likely

b. Somewhat likely

c. Not likely at all

Don’t know

NON DOER How likely is it that a child becomes very thin or gets diarrhoea in the first 6 months if she/he is given drinks or food other than breast milk only?


b. Somewhat likely


Don’t know

Perceived Severity

DOER 12. How serious would it be if your child became very thin?

READ the first 3 RESPONSES a. Very serious

b. Somewhat serious

c. Not serious at all

Don’t know

NON DOER How serious would it be if your child became very thin?

READ the first 3 RESPONSES a. Very serious

b. Somewhat serious

c. Not serious at all

Don’t know


16

Perceived Action Efficacy

DOER 13. How likely is it that your child would have become very thin if you had not given only breast milk for the first 6 months?

READ the first 3 RESPONSES

a. Very likely

b. Somewhat likely


Don’t know

NON DOER How likely is it that your child would have become very thin if you had not given only breast milk for the first 6 months?


b. Somewhat likely


Don’t know

Perceived Divine Will

DOER 14. Do you think that God approved of you giving only breast milk to your child for the first 6 months?

Yes

No

Don’t know

NON DOER: Do you think that God would have approved of you giving only breast milk to your child for the first 6 months?

Yes

No

Don’t know

Policy

DOERS: 15. Are there any community laws or rules in place that you know of that made it more likely that you give only breast milk and nothing else to your child for the first 6 months?

Yes

No

Don’t know

NON-DOERS: Are there any community laws or rules in place that you know of that could have made it more likely that you give only breast milk and nothing else to your child for the first 6 months?

Yes

No

Don’t know

Culture

DOERS: 16. Are there any cultural rules or taboos that you know of for or against giving only breast milk and nothing else to your child for the first 6 months?

Yes

No

Don’t know

NON-DOERS: Are there any cultural rules or taboos that you know of for or against giving only breast milk and nothing else to your child for the first 6 months?

Yes

No

Don’t know

Universal Motivators

DOERS and NON-DOERS: What are the things that you want most in life?

End of survey. Thank the participant for her time.


17

Annex 3. List of staff, enumerators and supervisors

, study lead , questionnaire translation support and supervision

, recruitment and support with enumerators , general support

Enumerators and supervisors

Nakapiripirit

1. (Supervisor)

2.

3.

4.

Napak

1. (Supervisor)

2.

3.

4.

Amudat

1. (Supervisor)

2.

3.

4.

Moroto

1. (Supervisor)

2.

3.

4.


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Annex 4. MS Excel results table

Barrier Analysis Tabulation Sheet Selected communities in Moroto, Napak, Nakapiripirit and Amudat districts, Karamoja, Uganda, 6th April 2016

Behaviour: Mothers of children 0-5 months old only give breast milk and nothing else to their child for the first 6 months.

Total Doers 55 <--Be sure to complete these two cells!

Total NonDoers 52

Determinants Doers: +Exp. (A)

Non Doers: +Exp. (B)

Non Doers: - Exp. ( C)

Doers: - Exp. (D)

Non Doers %

Doers %

Diff. Odds Ratio

SE Confidence Interval

p-value Comment (auto function)

Lower Limit

Upper Limit

Perceived Self-efficacy - 1

Q 1. Believes that she can practice the behavior with present knowledge, skills, time, and resources.

Doers 54 formula adjusted accordingly

Yes 54 26 0 26 50% 100% -50% #DIV/0! 0.000 #VALUE!

Possible 0 14 54 38 27% 0% 27% 0.00 #DIV/0! 0.000

No 0 12 54 40 23% 0% 23% 0.00 #DIV/0! 0.000

Don't know 0 0 54 52 0% 0% 0% #DIV/0!

(Yes/Maybe [calculated]) 54 40 0 12 77% 100% -23% #DIV/0! 0.000 #VALUE!

Missing data 0 0 54 52 0% 0% 0% #DIV/0!

Perceived self-efficacy - 2

Q 4. What makes it easier

Enough milk, healthy mother, milk available 26 21 29 31 40% 47% -7% 1.32 0.39 0.62 2.85 0.473

Breast milk is the only food at that age, most liked food, fast/ immediately available food

16 1 39 51 2% 29% -27% 20.92 1.05 2.66 164.64 0.000 Doers are 20.9 times more likely to give this response than NonDoers.

Health education, knowledge about importance of EBF, advice by health worker, knowledge that the baby will grow

10 6 45 46 12% 18% -7% 1.70 0.56 0.57 5.08 0.335

When the mother is near or with the baby, not collecting firewood, mother has enough time

17 13 38 39 25% 31% -6% 1.34 0.43 0.57 3.14 0.496

Enough money to buy foods, availability of foods for the mom

11 25 44 27 48% 20% 28% 0.27 0.44 0.11 0.64 0.002 NonDoers are 3.7 more likely to give this response than Doers.


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Other: Reduced expenses to buy food for the child, responsibility when child is health, aby will love her as a mother, supportive people at home

6 5 49 47 10% 11% -1% 1.15 0.64 0.33 4.03 0.826

Q 5. What makes it difficult

Not difficult 23 5 32 47 10% 42% -32% 6.76 0.54 2.33 19.63 0.000 Doers are 6.8 times more likely to give this response than NonDoers.

Lack of food, presence of hunger, no money to buy

18 22 37 30 42% 33% 10% 0.66 0.40 0.30 1.46 0.306

Little or no breast milk, not enough for twins 10 22 45 30 42% 18% 24% 0.30 0.45 0.13 0.73 0.006 NonDoers are 3.3 more likely to give this response than Doers.

Advice against EBF by health worker when mom is sick, painful or swelling breasts

11 10 44 42 19% 20% -1% 1.05 0.49 0.40 2.73 0.920

Lack of knowledge 3 4 52 48 8% 5% 2% 0.69 0.79 0.15 3.25 0.640

Far away from baby, away from home for long time, too much work

19 14 36 38 27% 35% -8% 1.43 0.42 0.63 3.28 0.394

Lazyness to continuously EBF 1 0 54 52 0% 2% -2% #DIV/0! 0.329

When child is sick 2 1 53 51 2% 4% -2% 1.92 1.24 0.17 21.88 0.592

When mother dies 0 2 55 50 4% 0% 4% 0.00 #DIV/0! 0.142

Perceived social norms

Q 6. Who approves

Health Promoter (RWANU), RWANU leaders, Concern staff, RWANU staff

26 19 29 33 37% 47% -11% 1.56 0.39 0.72 3.38 0.261

VHTs and TBAs 6 3 49 49 6% 11% -5% 2.00 0.74 0.47 8.45 0.338

Friends, community memebers, other mothers, peers/ age mates, neighbours

17 10 38 42 19% 31% -12% 1.88 0.46 0.77 4.60 0.165

Health workers, midwives, nurses 26 20 29 32 38% 47% -9% 1.43 0.39 0.66 3.10 0.357

Sister, own mothers, mother-in-law, own parents, husband, co-wives, uncle, aunt, grandparents

22 22 33 30 42% 40% 2% 0.91 0.39 0.42 1.96 0.808

Lead Mothers, Mother Care Groups 18 15 37 37 29% 33% -4% 1.20 0.42 0.53 2.73 0.664

Respondent herself 22 29 33 23 56% 40% 16% 0.53 0.39 0.25 1.14 0.103

Nobody 4 1 51 51 2% 7% -5% 4.00 1.14 0.43 37.03 0.190

God 1 0 54 52 0% 2% -2% #DIV/0! 0.329

Development partners 0 1 55 51 2% 0% 2% 0.00 #DIV/0! 0.301

Q 7. Who Disapproves

Nobody 46 41 9 11 79% 84% -5% 1.37 0.50 0.52 3.64 0.525

Health workers (due to medical condition) 1 0 54 52 0% 2% -2% #DIV/0! 0.329


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Sister-in-law, grandmother, relatives, brother-in-law, co-wife, mother-in-law, own mother

3 7 52 45 13% 5% 8% 0.37 0.72 0.09 1.52 0.155

Friends, neighbours, community members 6 4 49 48 8% 11% -3% 1.47 0.68 0.39 5.54 0.568

Perceived positive consequences

Q 2. Advantages Doers: 54 formula adjusted accordingly

Child is healthy 36 34 18 18 65% 67% -1% 1.06 0.41 0.47 2.37 0.889

Child is growing, has vitamins, high blood count, strong bones, strong teeth

34 37 20 15 71% 63% 8% 0.69 0.42 0.30 1.56 0.370

Baby is strong, gives energy, is playful 22 27 32 25 52% 41% 11% 0.64 0.39 0.30 1.37 0.248

Prevents diarrhea/ diseases, child is not sickly, stronger immune system, gets colostrum

34 30 20 22 58% 63% -5% 1.25 0.40 0.57 2.72 0.579

Child has good appetite and desire for other foods

0 2 54 50 4% 0% 4% 0.00 #DIV/0! 0.146

Prevents kwashiorkor, thinness, malnutrition 5 2 49 50 4% 9% -5% 2.55 0.86 0.47 13.78 0.262

Brighter mind, clever, good development 9 7 45 45 13% 17% -3% 1.29 0.55 0.44 3.75 0.645

Improves the digestive system, has no 'closed mouth'

4 2 50 50 4% 7% -4% 2.00 0.89 0.35 11.42 0.428

Perceived negative consequences

Q 3. Disadvantages Doers: 54 formula adjusted accordingly

No disadvantage 53 41 1 11 79% 98% -19% 14.22 1.06 1.76 114.66 0.002 Doers are 14.2 times more likely to give this response than NonDoers.

Mother has a bad feeling when there is little or no milk or when child grows thin/ not very fast, mother has not enough milk

1 13 53 39 25% 2% 23% 0.06 1.06 0.01 0.45 0.000 NonDoers are 17.7 more likely to give this response than Doers.

Dangerous for the child when it refuses the breast

0 1 54 51 2% 0% 2% 0.00 #DIV/0! 0.306

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 7 54 45 13% 0% 13% 0.00 #DIV/0! 0.005 #DIV/0!

Perceived Access - 1

Q 8. How difficult is it to find the time necessary to do the behavior?

Very difficult 3 22 52 30 42% 5% 37% 0.08 0.66 0.02 0.29 0.000 NonDoers are 12.7 more likely to give this response than Doers.

Somewhat difficult 19 22 36 30 42% 35% 8% 0.72 0.40 0.33 1.57 0.409

Not difficult 32 28 23 24 54% 58% -4% 1.19 0.39 0.56 2.56 0.652

Don't know 0 0 55 52 0% 0% 0% #DIV/0!

(Very/ somewhat difficult [calc.]) 22 44 33 8 85% 40% 45% 0.12 0.47 0.05 0.31 0.000 NonDoers are 8.3 more likely to give this response


21

than Doers.

Missing data 0 0 55 52 0% 0% 0% #DIV/0!

Perceived Access - 2

Q 9. How difficult is it to find a place necessary to do the behavior?

Very difficult 0 1 55 51 2% 0% 2% 0.00 #DIV/0! 0.301


Not difficult 52 45 3 7 87% 95% -8% 2.70 0.72 0.66 11.05 0.155

Don't know 0 0 55 52 0% 0% 0% #DIV/0!

(Very/ somewhat difficult [calc.]) 3 7 52 45 13% 5% 8% 0.37 0.72 0.09 1.52 0.155

Missing data 0 0 55 52 0% 0% 0% #DIV/0!

Cues for Action/ Reminders

Q 10. How difficult is it to remember to do the behavior?

Very difficult 1 0 54 52 0% 2% -2% #DIV/0! 0.329


Not difficult 48 43 7 9 83% 87% -5% 1.44 0.55 0.49 4.18 0.507

Don't know 0 0 55 52 0% 0% 0% #DIV/0!

(Very/ somewhat difficult [calc.]) 7 9 48 43 17% 13% 5% 0.70 0.55 0.24 2.03 0.507

Missing data 0 0 55 52 0% 0% 0% #DIV/0!

Perceived Susceptibility/ Risk

Q 11. How likely is it that a child becomes very thin or gets diarrhoea in the first 6 months if she/he is given drinks or food other than breast milk only?

Very likely 34 24 21 28 46% 62% -16% 1.89 0.39 0.87 4.08 0.104

Somewhat likely 18 16 37 36 31% 33% -2% 1.09 0.42 0.48 2.47 0.828

Not likely at all 3 12 52 40 23% 5% 18% 0.19 0.68 0.05 0.73 0.009 NonDoers are 5.2 more likely to give this response than Doers.

Don't know 0 0 55 52 0% 0% 0% #DIV/0!

(Very/ somewhat likely [calculated]) 52 40 3 12 77% 95% -18% 5.20 0.68 1.37 19.67 0.009 Doers are 5.2 times more likely to give this response than NonDoers.

Missing data 0 0 55 52 0% 0% 0% #DIV/0!

Perceived Severity

12. How serious is the problem/disease?

Very serious 47 38 8 14 73% 85% -12% 2.16 0.49 0.82 5.70 0.113

Somewhat serious 7 8 48 44 15% 13% 3% 0.80 0.56 0.27 2.39 0.692

Not at all serious 1 5 54 47 10% 2% 8% 0.17 1.11 0.02 1.54 0.080

Don't know 0 1 55 51 2% 0% 2% 0.00 #DIV/0! 0.301


22

(Very/ somehwat serious [calculated]) 54 46 1 6 88% 98% -10% 7.04 1.10 0.82 60.66 0.042 Doers are 7 times more likely to give this response than NonDoers.

Missing data 0 0 55 52 0% 0% 0% #DIV/0!

Perceived Action Efficacy

Q 13. How likely is it that [her child] can get the problem/disease if s/he does not do the behavior.

Very likely 40 21 15 31 40% 73% -32% 3.94 0.41 1.75 8.86 0.001 Doers are 3.9 times more likely to give this response than NonDoers.

Somewhat likely 7 18 48 34 35% 13% 22% 0.28 0.50 0.10 0.73 0.007 NonDoers are 3.6 more likely to give this response than Doers.

Not likely at all 6 12 49 40 23% 11% 12% 0.41 0.54 0.14 1.18 0.093

Don't know 2 1 53 51 2% 4% -2% 1.92 1.24 0.17 21.88 0.592

(Very/ somewhat likely [calculated]) 47 39 8 13 75% 85% -10% 1.96 0.50 0.74 5.21 0.174

Missing data 0 0 55 52 0% 0% 0% #DIV/0!

Perception of Divine Will

Q 14. Thinks God approve(s) of her/him doing the behavior

Yes 44 43 11 9 83% 80% 3% 0.84 0.50 0.32 2.22 0.721

No 10 7 45 45 13% 18% -5% 1.43 0.54 0.50 4.08 0.504

Don't know 1 2 54 50 4% 2% 2% 0.46 1.24 0.04 5.26 0.525

Missing data 0 0 55 52 0% 0% 0% #DIV/0!

Policy

Q 15. Is aware of policies, laws, regulations for or against doing the behavior

Yes 37 34 18 18 65% 67% -2% 1.09 0.41 0.49 2.43 0.836

No 17 16 38 36 31% 31% 0% 1.01 0.42 0.44 2.29 0.988

Don't know 1 2 54 50 4% 2% 2% 0.46 1.24 0.04 5.26 0.525

Missing data 0 0 55 52 0% 0% 0% #DIV/0!

Culture

Q 16. Is aware of cultural habits or taboos for or against the behavior

Yes 14 7 41 45 13% 25% -12% 2.20 0.51 0.81 5.97 0.118

No 38 43 17 9 83% 69% 14% 0.47 0.47 0.19 1.17 0.101

Don't know 3 2 52 50 4% 5% -2% 1.44 0.93 0.23 9.00 0.694

Missing data 0 0 55 52 0% 0% 0% #DIV/0!

Note: the ‘#DIV/0’ error occurs if at least for one of the doers or the non-doers have either 0 or 100% responses to a particular answer option. The OR cannot be calculated and thus there is p value either.

report on barrier analysis survey on exclusive breastfeedingpdf.usaid.gov/pdf_docs/pa00mjxr.pdf ·...

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