!barrier!analysis!of!iycfbehaviors!! inerbiland!dohukofidpcamps … · 2017. 6. 23. · 8!!!!...

Barrier Analysis of IYCF Behaviors in Erbil and Dohuk of IDP Camps

Kurdistan Region of Iraq

Assessment Report January 2017

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Acknowledgement This Barrier Analysis was made possible by the dedication of the Hosting Agency UNICEF-‐Iraq, DoH and Samaritan Purse teams (listed below). A special thank you also goes out to the entire UNICEF teams in Erbil & Dohuk Kurdistan Region, Iraq for their help with logistics, coordination, and translation. Finally, this assessment would not have been possible without the mothers or caregivers of children 0 – 23 months living in these camps, who generously contributed their time and shared their experiences. We thank them for their cooperation and participation.

Barrier Analysis Co-‐Facilitator and Team Leader:

Dr. Falah Wadi, Health & Nutrition Officer, UNICEF-‐Erbil, Iraq

Dr. Sagvan Hasan, Nutrition Department Manager, DoH-‐Dohuk, Iraq

Barrier Analysis Individual Interviews Erbil-‐Governorate Dohuk -‐ Governorate Helin Heresh DOH Mahdi Mohammed Salih DOH Aven Jalal DOH Zubair Hasan Abdul-‐Rahman DOH Hazha Khalid DOH Walid Khalid Ibrahim DOH Noor Faeq S.P Shulkar Mohammed Khalid DOH Pakshan Omer DOH Sarkat Hasan Haji DOH Shno Ghafoor DOH Naziha Aarif Sadiq DOH Sajeda Hamid DOH Sherzad Mahmood Hasan DOH Diana Azad S.P Hadiya Hasan Haji DOH Chnar Nash H. center Hanin Mahdi Hamid DOH Gerardale Ann S.P Chinar Ahmed Saaid DOH Mizhda Abdulsalam S.P Abdul-‐Muhsin Mohammed DOH Marline Anwer S.P Othman Husein Omer DOH Moafaq Shreef DOH Dizin Zubair Abdulrahman DOH Dashtew Burhan DOH Glavez Nabi Abdullah DOH Maha Khalid S.P Hawar Muhsen Sulayman DOH Hawrin Ibrahim S.P Ashti Ahmed Said DOH Avin kamal S.P Chemen Shukr Khorshid DOH Hanna Eissa S.P Zahra Ramadhan Omer DOH Noor Zuhair S.P Sherin Mohammed Salih DOH Shahnaz Rashid H. center Chato Murad Kishto DOH Shirin Abbas (Supervisor) DOH

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This Barrier Analysis assessment and training was led by Daniel Hadgu Takea (SBC -‐ Advisor, Tech-‐RRT), with support from Dr. Falah Wadi, Dr. Ali Ataie, Dr. Qasim, Dr. Bakhtiyar and Dr. SM Moazeem from UNICEF-‐Iraq, Dr. Sagvan Hasan & Mr. Walid Khalid Ibrahim from DoH – Dohuk, Iraq, as well as with remote support from Shiromi Perera (Technical Officer, International Medical Corps), Suzanne Brinkmann (Nutrition Advisor, NFSL, International Medical Corps), Andi Kendel (Program Manager, Tech-‐RRT), and Bonnie Kittle (Social Behavior Change Consultant, International Medical Corps).

This Barrier Analysis of Initiation of Breastfeeding within 1 hour, Exclusive Breastfeeding 0-‐5 months, Meal Frequency contain three cooked meals & Meal diversity containing Solid, Semi-‐Solid and Soft foods from at least 4 out of 7 food groups for children 0 – 23 months age in Hasansham U3, Khazer M1, Debaga 1 and 2 camps, Erbil, and Qaymawa, Khanke, Shariya, Bersive 1 camps, Dohuk in Kurdistan Region-‐Iraq, is made possible by the generous support and contribution of the American people through the United States Agency for International Development (USAID). The contents of the report do not necessarily reflect the views of USAID or the United States Government.

All Photographs was credit by: Daniel Hadgu Takea

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Executive Summary

In Mid October 2016, the government of Iraq with allied forces began an offensive to retake Mosul from ISIS and has resulted to date in over 100,0002 Internally Displaced People (IDPs). Those fleeing are mostly highly vulnerable residents from newly retaken areas who require urgent humanitarian assistance to makeshift camps and existing camps around Erbil and Dohuk KRG, Iraq. Currently, there is no direct or standalone nutrition intervention and no systematic SBC activities related to Nutrition except anecdotal and fragmented awareness creation activities by partners in regards to IYCF and caring practices in the camps. Thus, practice of several key Infant Young Child Feeding and caring behaviors remain low.

In recognition of poor behavioral indicators related to IYCF, inappropriate distribution of Infant formula milk in the camps and absence of evidence based behavior change programing, UNICEF as global lead agency for Nutrition within the IASC Humanitarian Cluster System in collaboration with KRG-‐DoH commissioned a Barrier Analysis and training. The main objective of the assessments were:

• To identify the most important context-‐specific determinants of key IYCF behaviors among Mothers/caretakers in Erbil and Dohuk, IDP camps;

• To design a tailored and appropriate communication and behavior change strategy and a set of key behavior change activities;

• To build capacity of key partners in Barrier Analysis methodology

A two-‐day training was conducted for a total of 45 staff from Erbil and Dohuk DoH and Samaritan Purse on the fundamentals of the Barrier Analysis approach, with special focus on structure and process of screening of Doer and Non-‐Doer, interviewing skills, and coding and data interpretation/use. Following the training two Groups of 10 teams of two person each conducted four barrier analysis assessments in two days in Erbil four camps (Hasansham U3, Khazer M1, Debagha 1 and Debagha 2) and in Dohuk four camps (Qaymawa, Shariya, Khanke & Bersive1) on:

1. Initiation of early breastfeeding within 1 hour for targeted mothers with children ages 1 day – 6 months,

2. Exclusive Breastfeeding 0 -‐5 months for targeted mother with children ages 6 – 12 months, 3. Meal Frequency at least three cooked meals a day that contain staple food for targeted mother with

children ages 6-‐23 months 4. Meal diversity containing Solid, Semi-‐Solid and Soft foods from at least 4 out of 7 food groups a day

for targeted mothers with children ages 9-‐23 months

2 UNHCR Iraq Flash appeal Jan 2017 3 Kittle, Bonnie. 2013. A Practical Guide to Conducting a Barrier Analysis. New York, NY: Helen Keller International

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Methodology: A Barrier Analysis (BA)3 methodology approach employs a purposive sampling survey, carried out among a sample of 45 “Doers” (those who practice the behavior) and 45 “Non-‐Doers” (those who do not practice the behavior), for a total of 90 participants per BA4. Accordingly 45 “Doers” and 45”Non-‐Doers” sampled data was collected in each camp for each behavior and a total of 720 Participants in eight IDP camps of Erbil and Dohuk for the four behaviors. Survey responses for open-‐ended questions were coded as a group, and all responses were analyzed for statistically significant differences between Doers and Non-‐Doers using the Barrier Analysis Tabulation Sheet5. “Bridges to Activities” developed to help evidence inform based interpretation, activities, and recommendations based on findings.

Results and Recommendation: The Barrier Analysis confirm results from the individual interviews of 45 “Doers” and 45 “Non-‐Doers” explains differences in Key determinants on mothers of children (ages 1day -‐ 6 months) who initiated breastfeeding within one hour of delivery in Erbil and Dohuk IDP camp found 6 key determinants (Perceived Self efficacy, Perceived Positive, Negative Consequence, Perceived Social Norms, Perceived Access & Perceived Action Efficacy), Exclusive Breastfeeding 0-‐6 months for mothers of children (ages 6 -‐ 12 months) in Erbil and Dohuk IDP camp found 7 Key determinants (Perceived Self efficacy, Perceived Positive Consequence, Perceived Social Norms, Perceived Access, Perceived cue of Action, Perceived Risk & Perceived Action of Efficacy) , Meal Frequency for Mothers of children (ages 6 – 23 months) feed them at least three cooked meals a day that contain a staple/main foods in Erbil and Dohuk IDP camp found 8 Key determinants ( Perceived Self Efficacy, Perceived Positive Consequence, Perceived Negative Consequence, Perceived Social Norms, Perceived Access, Perceived Risk, Perceived Severity & Perceived Divine Will) and Meal Diversity for Mothers of children (ages 9-‐23 months) feeds them meals each day containing Solid, Semi-‐Solid and Soft foods from at least 4 of the 7 food groups in Erbil and Dohuk IDP camp found 8 Key determinants (Perceived Positive, Negative Consequence, Perceived Self Efficacy, Perceived Social Norms, Perceived Access, Perceived Risk, Perceived severity & Perceived Action Efficacy) . The report cites these key determinants and provides recommendations to inform evidence-‐ based activity planning in Nutrition and Health programs in the camps and rural communities in the districts, as well as contribute to advocacy towards the integration of IYCF across all cluster sectors, the allocation of adequate resources, systematic monitoring and evaluation and policy reinforcement that may be necessary to support behavior change in order to reduce immediate and long term nutritional and health negative consequences.

3 Kittle, Bonnie. 2013. A Practical Guide to Conducting a Barrier Analysis. New York, NY: Helen Keller International 4 ibid 5 www.caregroupinfo.org/docs/BA_Tab_Table_Latest.xlsx.

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Table of Contents

Acknowledgement ........................................................................................................................................................... 3

Executive Summary ......................................................................................................................................................... 5

1. Introduction .................................................................................................................................................................. 9 1.1 Context .................................................................................................................................................................................................. 9 1.1.1 Geographic description of survey area ................................................................................................................................. 9 1.1.2 Description of the population ................................................................................................................................................... 9 1.1.3 Services and humanitarian assistance .............................................................................................................................. 10 1.2 Barrier Analysis Objectives ......................................................................................................................................................... 11

2. Methodology ................................................................................................................................................................ 11 2.1 Sampling Method ............................................................................................................................................................................ 11 2.1.1 Sample Size .................................................................................................................................................................................... 12 2.1.2 Behavior Definition .................................................................................................................................................................... 12 2.1.3 Barrier Analysis Questionnaire Development ................................................................................................................ 14 2.1.4 Training and Supervision ........................................................................................................................................................ 14 2.1.5 Data Collection ............................................................................................................................................................................. 15 2.1.6 Data coding/ Tabulation and Analysis .............................................................................................................................. 15 2.1.7 Limitation ....................................................................................................................................................................................... 16

3. Results ........................................................................................................................................................................... 16 3.1. Assessment findings .................................................................................................................................................................... 16 Behavior 1: Targeted mothers of children 1 day to 5 months put the newborn to the breast within one hour of delivery .................................................................................................................................................................................................. 17 Behavior 2: Mothers of children ages 0 – 5 months feed them only breast milk ........................................................ 21 Behavior 3: Mothers of children ages 6 –23 months feed them at least three-‐ cooked meal a day that contain a staple/main foods. ............................................................................................................................................................ 25 Behavior 4: Mothers of children ages 9 –23 months feed them meals each day containing Solid, Semi-‐Solid and Soft foods from at least 4 of the 7 food groups. ............................................................................................................... 29

UNIVERSAL MOTIVATOR ............................................................................................................................................. 32

4. Recommendation ...................................................................................................................................................... 32 Behavior 1: Targeted mothers of children 1 day to 5 months put the newborn to the breast within one hour of delivery ...................................................................................................................................................................................... 33 Behavior 2: Mothers of children ages 0 – 5 months feed them only breast milk ...................................................... 35 Behavior 3: Mothers of children ages 6 –23 months feed them at least three-‐ cooked meal a day that contain a staple/main foods. ............................................................................................................................................................ 37 Behavior 4: Mothers of children ages 9 –23 months feed them meals each day containing Solid, Semi-‐Solid and Soft foods from at least 4 of the 7 food groups. ............................................................................................................... 39

5. Conclusion ................................................................................................................................................................ 40

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Acronyms ANC Antenatal Care

BA Barrier Analysis

BFHI Baby Friendly Hospital Initiative

CM Community Mobilization

DOH Directorate of Health

DTM Displacement Tracking Matrix

EBF Exclusive Breast Feeding

EIBF Early Initiation of Breast Feeding

GFD General Food Distribution

GNC Global Nutrition Cluster

HIV Human Immune Deficiency Virus

IDP Internally Displace Person

IFF Infant Feeding Formula

IMC International Medical Corps

IPC Inter Personal Communication

IYCF Infant Young Child Feeding

Kcal Kilo Calorie

KRG Kurdistan Region Government

KRI Kurdistan Region, Iraq

MD Meal Diversity

MF Meal Frequency

MICS Multi Indicator Cluster Survey

NFSL Nutrition, Food Security Livelihood

ORS Oral Rehydration Salt

PDS Public Distribution System

SBC Social Behavior Change

SMART Standardized Monitoring and Assessment of Relief and Transition

TRRT Technical Rapid Response Team

UNICEF United Nations Children fund

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1. Introduction

1.1 Context

The Kurdistan Region comprises the greater part of Iraq’s three northernmost governorates: Dohuk, Erbil and Sulaymaniyah, plus small parts of three neighboring governorates to the south. The population is around 66 million.

Throughout 2015, the humanitarian and security situation in Iraq has been extremely complicated with the effects of intensive conflict in various parts of the country resulting in the displacement of over three million Iraqis, including over one million IDPs hosted in the three Governorates of the Kurdistan Region of Iraq (KRI), alongside the refugee population already hosted there. In addition to the IDPs the KRI hosts 98% of the total number of Syrian refugees in Iraq7.

1.1.1 Geographic description of survey area

Recently displaced IDPs from Mosul and surrounding villages represent a vulnerable population, as they have lived under the control of armed groups (AGs) since June 2014. Due to its isolation from the rest of Iraq and the inaccessibility of aid to the area, food insecurity, a lack of livelihoods, and limited access to healthcare have been particular areas of concern. Most of the IDPs following the recent Mosul operation lived in tents/makeshift homes in the camps while the IDPs who fled during the 2014 lived in established houses. All the pervious established camps have all basic facilities and electricity is also available to some camps, while in the new established camps the services are not as good as the previous established camps.

Most of the IDPs in the camp are not able to leave the camp without authorization, impacting their ability to access other services as well as further increasing their dependency on assistance. Most of the camps in Erbil and Dohuk are hosting IDPs to their full capacity and new plots are under construction.

1.1.2 Description of the population

As of December 2014, the demographic information collected by REACH showed that the average displaced family consists of 5.7 persons, while families in Erbil consist of 4.8 persons on average on this figure and the information from the DTM on the number of IDP families per district.

6 www.parliament.uk/facom.

7 http://www.3rpsyriacrisis.org/wp-‐content/uploads/2016/01/Iraq-‐–-‐Regional-‐Refugee-‐Resilience-‐Plan-‐2016-‐2017.pdf

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KRI hosts 38 per cent of the displaced population in Iraq since 2014. Dohuk hosted 397,014, the largest number of IDPs in KRI, with 99% originally from Ninewa. Additionally, Erbil hosted 346,0808 IDPs mainly from Anbar, Ninewa, Salah al-‐Din and Erbil.

The IDP population in the KRI consists of different religious and ethnic backgrounds: Yezidis from Sinjar district in Ninewa were mainly displaced to Dahuk; Christians from Mosul and the surrounding areas fled North to Dahuk and West to Erbil; and many Muslims fled to Erbil and Sulaymaniyah.

Unlike their ethnicity there are also a language difference between Kurds and Arabs. Communication with IDP communities in Dahuk is often possible in Kurdish being able to read and understand Kurdish, whereas this is not the case in Erbil. Conversely, many of IDP families in Erbil and Dahuk contain at least one member that is able to understand Arabic or Kurdish.

1.1.3 Services and humanitarian assistance

In all the IDP camps there are formal Service and Humanitarian assistance delivery by different partners, government and UN organizations. To effectively and efficiently coordinate the service and humanitarian assistance there are different lead cluster being established. Currently, in Erbil and Dahuk there are Health Cluster, WASH cluster, Education Cluster, Protection cluster, Food security and Livelihood cluster. However, nutrition is embedded under the health cluster and lack attention among many service provider organization despite a huge concern on the IYCF and caring practices of children age 0-‐23 months.

According to MICS 2011, Iraq is experiencing high stunting rates with nearly one-‐fourth (23%) of the children stunted including 10% severely stunted and the current crisis will most likely contribute to the worsening of the situation. The rate of children ever breastfed stood at 92.2%, which is quite a good proportion. However, breastfeeding is initiated late with only 42.8% of women initiating within the first hour after birth. The prevalence of exclusive breastfeeding is extremely low at 19.6%, with most infants receiving additional milk and other liquids from the beginning. Continuation of breastfeeding is poor with only 22.7% of mothers continuing to offer breast milk until the child reaches 24 months. Only about one-‐third (36%) of infants age 6-‐8 months received solid, semi-‐solid, or soft foods. While, more than half of the children age 6-‐23 months (55%) received solid, semi-‐solid and soft foods the minimum number of times.

As highlighted in Infant and Young Child feeding practices CARE guidelines (January 2010), more than 9 million children under 5 years of age die each year globally. 70% of these deaths occur in the first year of life, with malnutrition identified as the major cause. IYCF practices directly impact nutritional status and therefore the survival of children under 2 years of age.9 IYCF activities are an essential part of any nutrition program, especially in a humanitarian crisis when IYCF practices may be affected.

Despite the above facts, there was no major assessment or study done in the camps to understand the

8 http://iraqdtm.iom.int/IDPsML.aspx 9 Infant and Young Child Feeding Practices: Collecting and Using Data: A Step-‐by-‐ Step Guide. Cooperative for Assistance and Relief Everywhere, Inc. (CARE). 2010

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situation in the camps and accordingly to strategize the implementation of the program. Currently, there are fragmental and anecdotal programs implemented in the camps but they are not systematically monitored or supervised on their impact. In order to determine the current nutrition situation in the camps UNICEF as global lead of Nutrition cluster are exerting efforts on establishment of Nutrition Working Groups with the support from GNC and undertaking standard SMART survey, IYCF and SBC assessment through surge support from Tech-‐RRT in the camps.

1.2 Barrier Analysis Objectives The overall objectives of the Barrier Analysis are to assess the key determinants on IYCF practices on four behaviors (Initiation of early breastfeeding with in 1 hour, Exclusive Breastfeeding 0 -‐5 months, Meal Frequency at least three cooked meals a day that contain staple food and Meal diversity containing Solid, Semi-‐Solid and Soft foods from at least 4 out of 7 food groups) and inform evidence based behavior change programing. The specific objective of the assessments were:

• To identify the most important context-‐specific determinants of key IYCF behaviors among Mothers/caretakers in Erbil and Dohuk, IDP camps;

• To design a tailored and appropriate communication and behavior change strategy and a set of key behavior change activities;

• To build capacity of key partners in Barrier Analysis methodology

2. Methodology

Data collection took place from 2 -‐3 January 2017 in four IDP camps (Hasansham U3, Khazer M1, Debagha 1 and Debagha 2) in Erbil and from 11-‐12 January 2017 in four IDP camps (Qaymawa, Shariya, Khanke & Bersive1) in Dohuk. A Practical Guide to Conducting a Barrier Analysis10, was used as the basis for this Analysis.

2.1 Sampling Method

A Barrier Analysis (BA)11 methodology approach employs a purposive sampling, carried out among a sample of 45 “Doers” (those who practice the behavior) and 45 “Non-‐Doers” (those who do not practice the behavior), for a total of 90 participants per BA12 as this usually gives the best results in Barrier Analysis. This is based on the results of using a sample size calculator for case-‐control type studies with a p-‐value of 0.05, a Relative Risk of 3.0, an alpha error of 5%, and a power of 80%. Interviewing more than 45 Doers and 45 Non-‐Doers often identifies very small differences between the two groups and ignored given their limited correlation with the behavior. As BA study is similar to a case-‐control study, so it is not necessary to have as rigorous a sampling method

10 Kittle, Bonnie. 2013. A Practical Guide to Conducting a Barrier Analysis. New York, NY: Helen Keller International 11 Kittle, Bonnie. 2013. A Practical Guide to Conducting a Barrier Analysis. New York, NY: Helen Keller International 12 ibid

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or to use population-‐based sampling like other types of surveys (e.g., knowledge, practice, and coverage [KPC] surveys). However, in order for results to be representative of most of the people in the area, we drew respondents from two different ethnic communities residing in Erbil IDP camps and in Dohuk IDP camps.

2.1.1 Sample Size Barrier Analysis is a rapid assessment tool used in community health and other community development projects to identify behavioral determinants associated with a particular behavior so that more effective behavior change communication messages, strategies and supporting activities (e.g., creating support groups, changing community norms, creating alternative activities) can be developed as well as modifies current programing approaches.

To identify the key barriers and motivators, the priority group (Mothers or caregivers) is asked a series of questions to identify up to 12 potential determinants that can block but also facilitate them from taking action. Accordingly 45 “Doers” and 45”Non-‐Doers” sampled data was collected in each camp for each behavior and a total of 720 Participants interviewed in eight IDP camps of Erbil and Dohuk for each of the four behaviors.

2.1.2 Behavior Definition Due to fragmented and anecdotal IYCF activities in the camps four Behaviors were selected by UNICEF’s as the lead of Nutrition responses to be assessed in order to inform evidence based program implementation and behavior promotions. Accordingly the following behaviors were studied: Behavior 1: Targeted mothers put the newborn to the breast within one hour of delivery

In Iraq, according to MICS 2011, breastfeeding is initiated late with only 42.8% of women initiating within the first hour after birth. In emergencies, the risks of not being breastfed and poor feeding practices are heightened, which has a large impact on vulnerability to malnutrition, disease and death in infants and young children. Thus this behavior was selected to understand the barrier determinants practicing the behavior in the IDP camps.

We interviewed mothers of infants 1 day to 6 months of age residing in Erbil and Dohuk IDP camps to assess the above behavior. Early Initiation of Breast Feeding (EIBF) is recommended that mothers put newborn infants to their breast within 1 hour of delivery, known as “early initiation of breastfeeding.” Early initiation of breastfeeding, within one hour of birth, protects the newborn from acquiring infection and reduces newborn mortality13. It facilitates emotional bonding of the mother and the baby14 and has a positive impact on duration of exclusive breastfeeding15. When a mother initiates breastfeeding within one hour after birth, production of breast milk is stimulated. The yellow or golden first milk produced in the

13 Edmond KM et al. Delayed breastfeeding initiation increases the risk of neonatal mortality. Pediatrics, 2006, 117(3):e380–386. 14 Klaus M. Mother and infant: early emotional ties. Paediatrics, 1998, 102:1244–1246. 15 Perez-‐Escamilla R et al. Infant feeding policies in maternity wards and their effect on breastfeeding success: an analytical overview. American Journal of Public Health, 1994, 84(1):89–97

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first days, also called colostrum, is an important source of nutrition and immune protection for the newborn. Initiating infant suckling triggers hormones that can facilitate uterine contraction and placenta delivery, as well as reduce bleeding16.

Behavior 2: Targeted mothers with children 6 – 12 months Exclusively Breast Feeding the newborn child 0-‐5 months.

The prevalence of exclusive breastfeeding is extremely low at 19.6%, with most infants receiving additional milk and other liquids from the beginning (MICS 2011). Historically, since 1997, the distribution of infant formula in North Iraq has increased from 1.8 kg to 3.617 kg per month through the Iraqi policy of distributing infant formula free to all infants as part of Iraq’s Public Distribution System (PDS) for food rations, has also undoubtedly contributed negatively and has influenced parents’ choices. Though, there is no direct nutrition intervention in the camps, there are some IYCF activities embedded under ANC at health facility. Thus this behavior was selected to determine the impact on child feeding practices. We interviewed mothers of infants 6 to 12 months of age residing in Erbil and Dohuk IDP camps to assess the above behavior. As infants grow during the first six months, the likelihood that they are exclusively breastfed becomes less in many settings. Assessing exclusive breastfeeding in infants aged 6–12 months gives information on the duration of exclusive breastfeeding, mother ability to recall easily, and is a confirmation of infants who are exclusively breastfed for the full 6 months. According WHO definition infants 0-‐5 months of age who were fed exclusively with breast milk receive no other liquids, not even water, with the exception of drops or syrup consisting of vitamins, mineral supplements or medicines including ORS. Moreover, exclusive breastfeeding for 6 months confers many benefits to the infant and the mother. Chief among these is the protective effect against gastrointestinal infections, which is observed not only in developing but also in industrialized countries.18 The risk of mortality due to diarrhoea and other infections can increase many-‐fold in infants who are either partially breast-‐ fed or not breastfed at all. In the context of HIV, introducing other milks, foods or liquids significantly increases the risk of HIV transmission through breast milk, and reduces infant’s chances of HIV-‐free survival. For the mother, exclusive breastfeeding can delay return of fertility19.

Behavior 3: Targeted mothers with children 6 – 23 months feed at least three cooked meals a day that contain staple foods.

According to MICS 2011 survey in Iraq only about one-‐third (36%) of infants age 6-‐8 months received solid, semi-‐solid, or soft foods. While, more than half of the children age 6-‐23 months (55%) received solid, semi-‐solid and soft foods the minimum number of times. Most likely this poor trend is more compromised

16 WHO, e-‐Library of Evidence for Nutrition Actions (eLENA): Early initiation of breastfeeding http://www.who.int/elena/titles/early_breastfeeding/en/

17 wfp277992 infant formula 18 Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Geneva, World Health Organization, 2001.

19 https://www.unicef.org/nutrition/files/IYCF_Indicators_part_III_country_profiles.pdf

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with the escalating violence and people displacement, lack of access to get needed foods to feed their children on optimal complementary feeding. Thus, we selected the above behavior to see or understand the current situation within the IDP in the camp and develop strategy and action plan to promote the behavior. We interviewed mothers of infants 6 to 23 months of age residing in Erbil and Dohuk IDP camps to assess the above behavior. The number of meals that an infant or young child needs in a day depends on how much energy the child needs (and, if the child is breastfed, the amount of energy needs not met by breast milk), the amount that a child can eat at each meal, and the energy density of the food offered. When energy density of the meals is between 0.8–1 kcal/g, breastfed infants 6–8 months old need 2–3 meals per day, while breastfed children 9–23 months needs 3–4 meals per day, with 1–2 additional snacks as desired20.

Behavior 4: Targeted mothers with children 9 – 23 months feed Solid, Semi-‐Solid and soft foods from at least 4 out of 7 food groups a day. Families and children in difficult circumstances require special attention and practical support. Around the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided by breast milk, and complementary foods are necessary to meet those needs. An infant of this age is also developmentally ready for other foods. If complementary foods are not introduced around the age of 6 months, or if they are given inappropriately, an infant’s growth may falter. Given, the current situation most of the children in the IDPs camps are compromised for optimal complementary feeding and targeted mothers behavior are also perceived to be affected due to lack of access to the needed food type and availability. Thus, this behavior was selected to understand the current practices in the camp. We interviewed mothers of infants 9 to 23 months of age residing in Erbil and Dohuk IDP camps to assess the above behavior. Minimum dietary diversity is a proxy for adequate micronutrient density of foods. Dietary data from children 6–23 months of age in 10 developing country sites have shown that consumption of foods from at least 4 food groups on the previous day would mean that in most populations, the child had a high likelihood of consuming at least one animal-‐source food and at least one fruit or vegetable, in addition to a staple food21.

2.1.3 Barrier Analysis Questionnaire Development

Four barrier analysis questionnaires were developed in English following the standard BA questionnaire design guidelines and reviewed by a BA expert, IMC-‐ NFSL –Technical Officer and Nutrition Advisor. These questionnaires were then translated into Arabic by a native Arabic speaking translator in Erbil, and back-‐translated and checked by the UNICEF Health and Nutrition Specialist in Erbil (who were all bi-‐lingual, Arabic-‐ and English-‐speakers), and the Arabic version rechecked by data collection team who are Arabic and Kurdish speakers during training.

2.1.4 Training and Supervision

20 https://www.unicef.org/nutrition/files/IYCF_Indicators_part_III_country_profiles.pdf 21 ibid

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A total of 45 enumerators both from DoH and Partners –Samaritan Purse (24 from Erbil and 21 from Dohuk) were recruited. The enumerators had varying levels of experience in conducting surveys. Training for the Barrier Analysis occurred over 2 days in Erbil and Dohuk by employing theoretical and in class role-‐play components. The training was facilitated by the SBC-‐Advisor from Tech-‐RRT with the support of UNICEF Health and Nutrition Specialist and Nutrition Department Manager from DOH-‐Dohuk. Topics covered by the training included:

• Introduction to BA • Overview of methodology and objectives • Data collection process • Questionnaire review and practice • Interview techniques • Data tabulation/coding and analysis

Data Tabulation/coding and Interview techniques practical sessions included role-‐playing and enumerators that required further practice were paired with experienced enumerators during the entire days of data collection and for additional practice and supervision. Two supervisor and two Team leaders were also engaged during the data collection, tabulation and analysis process.

2.1.5 Data Collection During data collection, data collectors approached mothers with targeted age of children for each behavior at their home and asked mothers for private location (mostly inside the house or tent) to conduct the interview, introduced the study and obtained informed consent. Mothers who consented to be part of the study were then screened to determine their Doer or Non-‐Doer status, before proceeding with the survey interview. The data collection was done in (Hasansham U3, Khazer M1, Debagha 1 and Debagha 2) in Erbil and four IDP camps (Qaymawa, Shariya, Khanke & Bersive1) in Dohuk governorate.

The data collection for the four behaviors were done in two days in each area (Erbil and Dohuk) by 10 paired enumerators who spoke both language (Kurdish and Arabic) but native to either one, and supervised by one UNICEF Health and Nutrition Specialist from Erbil, one Nutrition Department Manager and one Health department staff from DOH-‐Dohuk as well as by the Tech-‐RRT SBC -‐ Advisor to ensure quality. The Nutrition Specialist and Nutrition Department Manager checked questionnaires at the end of the data collection daily. During data collection each paired teams are switching their role when conducting the interview.

2.1.6 Data coding/ Tabulation and Analysis Coding and tabulation of data occurred in Erbil at the end of the two days of data collection while the coding and tabulation in Dohuk was done at the end of the each day through an iterative group process to arrive at a word or phrase that best represented the responses given.

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Once data was coded and tabulated, it was then entered into the Barrier Analysis Tabulation Excel Sheet22 for quantitative analysis in order to identify which determinants were identified as significant differences between Doers and Non-‐Doers. In Barrier Analysis, significance is determined by p-‐value for difference in odds ratio of less than 0.05, or a percentage point difference greater than 1523. Significant determinants were analyzed to develop Bridges to Activities, Activities, and Recommendations. Qualitative data from the completed questionnaires was also recorded in order to better understand and describe the context of significant barriers and facilitators.

2.1.7 Limitation Given that one of the aims of this Barrier Analysis exercise was capacity building in this methodology among government and partners, unfortunately absence of partners working in nutrition limited the diversity of the teams involved in the training and data collection only to DoH and Samaritan Purse staff. In addition, three staff from SP and 1 staff from DoH didn’t show up during the data collection without any justification and notice.

Moreover, most of the IDPs in Erbil camps are native Arabic speaker some staff recruited from DOH face difficulty in Arabic language dialect. The same is true to English language interpreting to particular words and sentences during data coding and tabulation process, so some of the determinants are listed detailed.

3. Results

3.1. Assessment findings In all four behaviors studied a total of 720 mothers or caregivers of children age 0-‐23 months in the eight camps (4 camps in Erbil and 4 camps in Dohuk) were interviewed. The mothers who were studied in the four Erbil camps are homogenous in terms of demographics, culture and religion and speak mainly Native Arabic. Likewise the mothers who were studied in the four Dohuk camps were also homogenous in terms of demographics, culture and religion, with the majority being Yezidis and different from IDPs in Erbil. Thus, the study applied criteria for the stratification of the study in the camps based on these differences. Moreover, the BA behavior related to “Mothers of children 9-‐23 months feeds them meals each day containing Solid, Semi-‐Solid and Soft foods from at least 4 of the 7 food groups” was stratified in the old camp of Debaga 1 in Erbil and Sharya camp in Dohuk as this might likely be correlated to relative stability of the people in the camps and availability of services or markets as well as accessibility to the main city.

22 www.caregroupinfo.org/docs/BA_Tab_Table_Latest.xlsx. 23 Kittle, Bonnie. 2013. A Practical Guide to Conducting a Barrier Analysis. New York, NY: Helen Keller International

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Table 1. Total number of surveys completed per behavior category

Study Area

EIBF within 1 hour EBF 0-‐5 months Meal Frequency 6-‐23 months

Meal Diversity from 4 of the 7 food groups 9-‐23 months.

Total

Doer N-‐Doer Doer N-‐Doer Doer N-‐Doer Doer N-‐Doer

Erbil 45 45 45 45 45 45 44 46 360

Dohuk 45 45 45 45 45 45 45 45 360

In all camp the respondents are categorized by age group of 17 -‐25 years and 26 to 45 years for the four behaviors studied in order to see if there are differences on feeding behaviors practices among the young and older mothers. See Fig below.

The determinants found to be significant for each of the behaviors following data analysis are detailed below.

Behavior 1: Targeted mothers of children 1 day to 5 months put the newborn to the breast within one hour of delivery Six determinants were found to be significant for this behavior from both Erbil and Dohuk governorate.

1. Perceived Self-‐ Efficacy

This determinant refers to an individual’s belief that he/she can do a particular behavior given his/ her current knowledge and skills. Respondents were asked what makes it (or what would make it) easier or more difficult for them to put their newborn to the breast within one hour of delivery.

0 5 10 15 20 25 30 35

Erbil Dohuk Erbil Dohuk Erbil Dohuk Erbil Dohuk

Age (17-‐25 yrs.) Age (26-‐45 yrs.) Age (17-‐25 yrs.) Age (26-‐45 yrs.)

Doer Non-‐Doer

Total number of surveys completed per behavior versus age category

IEBF within 1 hour

EBF for 0-‐5 M

MF at least 3 times for 6-‐23 M child

MD for ages 9 – 23 M feed from at least 4 of the 7 food groups

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Category Research Findings

Erbil Dohuk Doer 14.5 times more likely to say that Having enough

milk made it easier for them to practice early initiation than Non-‐Doer (p=0.000)

3.2 times more likely to say that Health staff advice made it easier for them to initiate early breast feeding within 1 hour compared to Non-‐Doer mothers (P=0.034)

8.4 times more likely to say that Mothers having good health made it easier for them to practice the behavior than Non-‐Doers (p=0.000)

2.5 times more likely to say that No difficulty for them make them easier to practice the behavior compared to Non-‐Doers (p=0.017)

8.9 times more likely to say that support from the Mother, Mother-‐in-‐Law, Sister-‐in-‐Law made it easier for them to practice the behavior than Non-‐Doers (p=0.000)

3.5 times more likely to say that Mother sickness, abdominal pain during breastfeeding and breast milk not able to come out made it difficult to practice the behavior compared to Non-‐Doer mothers (p=0.019)

6.9 times more likely to say that No Difficulty made it easier for them to practice the behavior than Non-‐Doers (p=0.000)

Non-‐Doers 2.6 times more likely to say Mother Sickness, dizziness, abdominal pain, breast milk can not come out made it difficult to practice the behavior than Doers (p=0.016)

6.2 times more likely to say Breast problems made it difficult to practice the behavior compared to Doer (p=0.007)

3.0 times more likely to say Difficult Delivery, CS delivery made it difficult to practice the behavior than Doers (p=0.044)

12.6 times more likely to say difficulty /C section delivery made it difficult to practice the behavior compared to Doer (P=0.002)

4.2 times more likely to say Not having enough Milk made it difficult to practice the behavior than Doers (p=0.045)

-‐11 times more likely to mention that not knowing how to breast feed the child made it difficult to practice the behavior compared to doer mothers (p=0.028)

-‐11% more likely to say Stress made it difficult to practice the behavior than doers.

-‐ 11 times more likely to say that baby is weak and not able to suckle made it difficult to practice the behavior compared to doer (p=0.028)

-‐13 times more likely to say that mother is sick made it difficult to practice the behavior compared to doer (p=0.013)

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According MICS 2011 survey skilled delivery in Iraq is more than 90%; though skilled delivery proportion is very good, this is not translating into good practice of IYCF behaviors. In both governorate assessed IDP camps Non-‐Doers mentioned that difficult deliveries and C-‐section delivery made it difficult to breastfeed their baby within 1 hour. Though most deliveries are attended by skilled staff, it would appear that these staff are not aware of the importance of early initiation, or are not skilled in (or don’t have time to) being able to assist the mother with this early initiation. Further investigation through FGDs with skilled providers may enable a more thorough analysis. Moreover, though it is not significant Non-‐Doer mothers in Dohuk governorate IDP camps mentioned that the cultural norm of Yezidi’s “Mother will not breastfeed immediately after delivery until the religious leader give his blessings”, so some mothers are not able to put the child within 1 hour due to this cultural norms. Furthermore, young mothers have difficulty putting the child within one hour because they don’t know how to breastfeed the child. Majority of the mothers in both areas also mentioned breast problem, mother sickness, abdominal pain make it difficult to put the child to breast within 1 hour of birth. Though, it’s not that much significant mothers in Erbil IDP camps mentioned Stress made them not to practice the behavior, being most of this mothers is come from the recent Mosul crises and need to be given due attention. Ability of children to suckle the breast is also one of the barriers mentioned by Non-‐doer mothers from Dohuk IDP camps. Most Non-‐doer mothers who say that the child is not able to suckle breast milk it is more likely due to the delay of the initiation of breastfeeding within 1 hour due to the cultural practices in these communities. Thus, there is a need for additional support offered from the religious leader on initial breastfeeding without delay to avoid suckling difficulties. 2. Perceived Positive Consequences

This determinant refers to an individual’s behavior advantageous that he/she can do a particular behavior. Respondents were asked; what are the advantageous or would be advantageous of putting your baby within one-‐hour delivery? Category Research Findings

Erbil Dohuk Doer 4.3 times more likely to say Prevent

disease/Immunity compared to Non-‐Doer (p=0.000)

Non-‐Doers 3.0 times more likely to say I don’t know compared to Doer (p=0.032)

8.5 times more likely to say strengthen bones compared to Doers (p=0.015)

Some of the Non-‐doer mothers in Dhouk, especially first time expectant mothers didn’t know the advantages of putting the newborn child to breast within one hour. Moreover, mothers delivering in the

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PHC don’t have the advantage of staying in the maternity ward for 24 hours, and receiving the necessary support and counseling from the health staff, as the staff only working during the day. Moreover, due to high turnover of staff absence of trained staff and lack of regular training schedule compromise the delivery of skilled breastfeeding counselling by the health staff. Conversely, though some non-‐doer mothers know the advantages of the initiation of breastfeeding within 1 hour, however they are not practicing it mainly due to other barriers, such as the cultural norm, breast problem, mother sickness, do not know how to breastfeed and stress etc… 3. Perceived Negative Consequences

This determinant refers to an individual’s behavior disadvantageous that he/she can do a particular behavior. Respondents were asked, what are the disadvantageous or would be disadvantageous of putting your baby within one-‐hour delivery? Non-‐Doer mothers from Dohuk are 8.5 times more likely to give the response that early initiaition causes a child to have diarrhea, or vomiting compared to Doer mothers (p=0.015). Meanwhile, there is no significance in the response between Doer and Non-‐doer mothers in Erbil. Mothers from Dohuk IDP camps have the perception that colostrum, which will help to expel baby’s first dark stool, causes diarrhea in the child. Thus, Non-‐doer mothers in Dohuk IDP camps perception about the negative consequence of initiating breast feeding within 1 hour is more related to the perception of the yellow/golden milk making a child sick, such as diarrhea or vomiting. This indicates the common misconceptions among the population that may also be reinforced by the lack of support from health staff on counseling during pre and post delivery. 4. Perceived Social Norms

This determinant refers to an individual’s perception of the approval or disapproval of doing a behavior by people considered to be important in an individual’s life. Respondents were asked who approves or disapproves of them of putting your newborn baby within one hour of delivery? Doer mothers in Dohuk are 3.8 times more likely to give the response that Doctors/health staffs are likely to approve the behaviors compared to Non-‐Doer mothers (p=0.002). At the same time, -‐11% of Non-‐Doer mothers in Dohuk are more likely to say Religious Leaders are likely to disapprove compared to Doers. Conversely there is no significant difference between doer and non-‐doer mothers in Erbil. Most of the Doer mothers who practice the behavior in Dohuk IDP camps mentioned that Doctors or health staff approve. While, older mother Non-‐doers mentioned that religious leaders are less approving of putting the child to the breast within one hour. This mainly could be related to the culture and religious norm practiced in the population. 5. Perceived Access

This determinant refers to an individual’s accessibility that he/she can do a particular behavior. Respondents were asked how difficult or would it to put their newborn to the breast within 1 hour of birth.

The study found that Doers in Erbil are 2.3 times more likely to say that it was Not difficult at all to

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access the resources they need to do this behavior than Non-‐Doers (p=0.029). Doers from Dohuk are 3.2 times more likely to give indicate it was Very difficult to access the resources needed to practice the behavior compared to Non-‐doer mothers (p=0.034).

The studied population in Dohuk IDP camp was different demographically from the studied people in Erbil culturally and religiously, accordingly doer mothers mentioned that it was very difficult putting the child to the breast within one hour, which is likely due to the cultural norms practiced by the people. So, doer mothers are more likely to mention this than non-‐doer mothers, obviously since Non-‐doer mothers are not practicing and they didn’t face this difficulty.

6. Perceived Action Efficacy

This determinant refers to an individual’s perception of Does the behavior work to prevent/overcome the disease or problem, respondents were asked How likely is it that if you put your newborn baby within one hour delivery, do you think that would increase the likelihood of him/her receiving the colostrum?

Non-‐doer mothers in Dohuk are 4.1 times more likely to give say that it is Not likely at all to receive colostrum if the baby is put to the breast within the first hour compared to Doer mothers (p=0.019). Meanwhile, there is no significant difference between Doer and Non-‐Doer mothers in Erbil.

As mentioned previously Non-‐doer mothers from Dohuk IDP camps didn’t know that the child is receiving colostrum. Since some mothers have to wait more than 1 hour until the religious leader arrives to do the blessings. According to one mother in Dohuk IDP camps she said that “ I wasn’t able to put my baby within 1 hour to my breast after delivery, because the religious leader at the time is not in the camp and I am obliged to wait for three hours until he returns back and give his blessings before I put to the breast”.

Behavior 2: Mothers of children ages 0 – 5 months feed them only breast milk Seven determinants were found to be significant for this behavior from both Governorate Erbil and Dohuk.


This determinant refers to an individual’s belief that he/she can do a particular behavior given his/ her current knowledge and skills. Respondents were asked what makes it (or what would make it) easier or more difficult for them to give only breast milk to your baby for the first 6 months


Erbil Dohuk Doer 28 times more likely to say that

Ready availability of breast milk and no preparation need made it easier for them to practice giving only breast milk than Non-‐Doer (p=0.000)

11.4 times more likely to say that Ready availability and No preparation needs make them to practice the behavior compared to Non-‐Doer (p=0.013)

7.4 times more likely to give response that No 11.4 times more likely to give this

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Difficulty for them to practice the behavior than Non-‐Doers (p=0.000)

response Good suckling of baby make them to practice the behavior compared to Non-‐Doer mothers (p=0.013) 11.7 times more likely to give this response that No difficulty make them to practice the behavior compared to Non-‐Doers (p=0.006)

Non-‐Doers 11.3 times more likely to give this response Not having enough milk than Doers (p=0.000)

-‐11 times more likely to give this response that Mother Stress make them difficult to practice the behavior compared to Non-‐doers (p=0.028)

Historically, the Iraqi policy of distributing infant formula free to all infants as part of Iraq’s Public Distribution System (PDS) for food rations have also undoubtedly contributed negatively and has influenced parents’ choices. In addition, the inappropriate infant feeding formula distribution in the camps might have negatively affected the practice of exclusive breastfeeding. Most mothers not practicing Exclusive Breast Feeding in Erbil IDP camps mentioned that they have the perception that breast milk is not enough for the child and they need the baby to have additional milk. One mother in Erbil said that “giving only breast milk is not enough, thus I give him infant formula, which I do for the other kids too.” While the issue of formula feeding is pervasive, it didn’t come up enough during the BA which might mean that it is considered an acceptable practice and therefore a further qualitative assessment (such as FGDs) is necessary to better understand this particular issue. Moreover, Non-‐doer mothers in Dohuk IDP camp also mentioned that they could not exclusively breast feed the child because of the stress. One mother mentioned in Dohuk IDP camps that “the fear from the atrocity happens before her displacement ” makes her not able to exclusively breastfeed.

2. Perceived Positive Consequences

This determinant refers to an individual’s behavior advantageous that he/she can do a particular behavior. Respondents were asked What are the advantages or would be the advantageous of giving only breast milk to your baby for the first six months?


Erbil Dohuk Doer 16 times more likely to give this

response Growth (Physical & Mental) compared to Non-‐Doer (p=0.000)

Non-‐Doers 2.7 more likely to give this response healthy teeth and bones compared to Doer (p=0.037)

4.2 more likely to give this response it is best compared to Doer mother (p=0.045)

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Though most of the Non-‐doer mothers know the advantages of exclusively breastfeeding by stating “it is best” during tabulation it was asked what is meant by “ it is best” they said that it was “God’s gift”, despite, they are not practicing it. Moreover, most of the Doers and Non-‐Doers know the disadvantages of not exclusively breastfeeding in all assessed IDP camps in Erbil and Dohuk governorate. Non-‐doers have other determinants such as perception of not having enough milk so wants to have infant formula, lack of experience or do not know how to breastfeed, no support from religious leader, access to religious leader and difficulty remembering to only breast feed when their baby gets older.

3. Perceived Social Norms

This determinant refers to an individual’s perception of the approval or disapproval of doing a behavior by people considered to be important in an individual’s life. Respondents were asked who approves or disapproves of them of only giving breast milk to your baby for the first 6 months.

Category Research Findings Erbil Dohuk

Doer 3.6 times more likely to give this response All my family compared to Non-‐Doer (p=0.008)

Non-‐Doers 4.9 times more likely to give this response My Self compared to Doer (p=0.025)

Overall there are no significant differences between doers and non-‐doers. However, Doers are more likely to say that all my family approves the behavior. Doer mothers in Dohuk mentioned that the majority of their family members approve of the practice compared to Non-‐doer mothers. While, Non-‐doer mothers from Erbil mentioned that they themself approves of the behavior compared to doer mothers.

4. Perceived Access

This determinant refers to an individual’s accessibility that he/she can do a particular behavior. Respondents were asked : How difficult was it to get the support you need to give only breast milk to your baby for the first 6 months?

Non-‐doer mothers in Dohuk are 3.9 times more likely to say it is very difficult to get the support they need to feed their child only breastmilk for the first six months compared to Doers (p=0.004). Conversely, Doer mothers in Dohuk are 2.6 times more likely to say it is Not difficult at all compared to Non-‐Doer Mothers (p=0.020).

Overall, particularly in Dohuk governorate IDP camps Non-‐doer mothers are more likely to mention that it

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is very difficult to get the support they need to give only breast milk especially among older mother. In Dohuk IDP camps Non-‐doer mothers are more likely to mention it is very difficult which could be related to the culture and norm practices, while in Erbil IDP camps there is no significant difference between Doer and non-‐doer mothers. Moreover, the lack of designated breastfeeding areas in the primary health center, food distribution areas and registration places likely might compromise practicing the behaviors.

5. Perceived Cue of Action/Reminder

This determinant refers to an individual’s ability that he/she can easily remember to do a particular behavior. Respondents were asked how difficult or would it to feed the child only breast milk for the first six months?

Non-‐Doer mothers in Dohuk are 2.7 times more likely to give say it is very difficult to remember to give the child only breast milk compared to Doer mothers (p=0.037). Meanwhile, there are no significant differences between Doer and Non-‐Doer mothers in Erbil.

Overall in both camps though there is significant difference between doer and Non-‐doer mothers, however, Non-‐Doer mothers in Dohuk IDP camps mention that it is very difficult to remember to only give breast milk.

6. Perceived Risk

This determinant refers to an individual’s perception of the behavior susceptibility Can I get the disease/have the problem doing a behavior. Respondents were asked How likely or would it be likely is that your child will become malnourished in the next year?

Doer mothers in Dohuk is 3.5 times more likely to say that it is Not likely at all compared to Non-‐doer mothers (p=0.006). Meanwhile, there are no significant differences between Doer and Non-‐Doer mothers in Erbil

Overall in both areas (Erbil and Dohuk) IDP camps the likelihood of a child becoming malnourished was perceived As high in Non-‐doer mothers. However, the high perception of the child not becoming malnourished is significantly high (p=0.006) in Dohuk doer mother compared to Non-‐doer mothers. Meanwhile, there are no significant difference in Erbil IDP camps between doer and Non-‐Doer mothers.


This determinant refers to an individual’s perception of Does the behavior work to prevent/overcome the disease or problem, respondents were asked How likely is it that your baby would have become malnourished if you only breast fed for the first 6 months.

Non-‐Doers in Erbil are 2.1 times more likely to give say it is Not Likely at all than Doers (p=0.045). Conversely, Doers in Dohuk are 2.8 times more likely to say it is Not likely at all than Non-‐Doers (p=0.008).

Doer Mothers in Dohuk IDP camps are to respond there is not likely at all that a child become

25

malnourished if only breastfed for six months compared to non-‐doer mothers. The likely hood of doer mother knowledge and practice make them to give this response. Conversely, Non-‐doer mother in Erbil IDP camps are responded not likely at all that a child become malnourished compared to Doer Mothers (p=0.045). Despite the likely hood of having knowledge, the mothers are not practicing the behaviors, this could be attributed to other determinant such as the perception of the milk is not enough for the child and lack of support.

Behavior 3: Mothers of children ages 6 –23 months feed them at least three-‐ cooked meal a day that contain a staple/main foods.

Seven determinants were found to be significant for this behavior both in Erbil and Dohuk governorates.


This determinant refers to an individual’s belief that he/she can do a particular behavior given his/ her current knowledge and skills. Respondents were asked what makes it (or what would make it) easier or more difficult for them to fed at least three-‐ cooked meal a day that contains staple/main foods.


Doer 2.1 times more likely to say Having enough foods made it easier for them to feed three cooked meals than Non-‐Doer (p=0.046)

11.7 times more likely to say No difficulty in practicing the behavior compared to Non-‐doers (p=0.006)

12.3 times more likely to say Support from family and neighbor made it easier for them to feed three cooked meals than Non-‐Doers (p=0.001)

2.8 times more likely to say no difficulty in practicing the behavior compared to Non-‐Doers (p=0.022)

3.3 times more likely to say No Difficulty for them to practice the behavior than Non-‐Doers (p=0.010) 3.9 times more likely to say that Lot of work/No time made it difficult for them to practice the behavior than Non-‐Doers (p=0.006)

Non-‐Doers 3.4 times more likely to say Not enough foods/ difficulty getting foods made it difficult for them to practice the behavior than Doers (p=0.026)

-‐11% times more likely to say Allergies make it difficult to practice the behavior compared to Doer mothers. 7.3 times more likely to say Poor Appetite of the

child made it difficult for them to practice the behavior than Doers (p=0.029)

In both governorate IDP camps there are Non-‐doers who do not practice the behavior, however, the Doers who practice the behavior are more likely to say that there are no difficulties to feeding the child. Moreover, Doers also mentioned that a lot of work to do and a lack of time make it difficult. Regardless to the above perception from both governorate IDP camps, the Non-‐doers from Erbil IDP camps stated that

26

not having enough food or difficulty in getting food made it difficult to practice the behavior These mothers likely arrived recently to the camps. Moreover, child’s poor appetite made it difficult to feed the child. Meanwhile, Non-‐doers from Dohuk IDP camps mentioned that Allergies made it difficult to practice the behavior.


This determinant refers to an individual’s behavior advantageous that he/she can do a particular behavior. Respondents were asked What are the advantages or would be advantages of feeding your child at least three meals each day.


Doer 2.4 times more likely to say that Brain Development, Smart, active, strong made it advantageous for them to practice the behavior than Non-‐Doers (p=0.042)

3.5 times more likely to say that Prevent Sickness made it advantageous for them to practice the behavior than Non-‐Doers (p=0.045)

Non-‐Doers 7.3 times more likely to say Give minerals and vitamins would have made it advantageous Doers (p=0.029)

Again Non-‐Doer mothers from Erbil IDP camps are more likely to mention enough minerals and vitamins as the advantage of feeding at least three meals compared to Doer mothers (p=0.029). However, they are not practicing the behavior likely due to other determinants such as difficulty getting food, poor appetite of the child, multiple meals will make the child sick (diarrhea, vomiting). Conversely, there are no significant differences between doer and non-‐doer mothers practicing the behavior in Dohuk IDP camps.

3. Perceived Negative Consequences

This determinant refers to an individual’s behavior disadvantageous that he/she can do a particular behavior. Respondents were asked What are the disadvantages or would be the disadvantages of feeding your child at least three meals each day.


Doer 3.6 times more likely to say there are No Disadvantages compared to Non-‐Doers (p=0.003)

4.9 times more likely to say there are No disadvantages compared to Doers (p=0.025)

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Non-‐Doers 2.6 times more likely to say that Diarrhea/Vomiting and Allergies made it disadvantageous for them to practice the behavior than Doers (p=0.016)

Overall in both governorate IDP camps (Erbil and Dohuk) Non-‐doer mothers responded that the disadvantages of feeding the child at least three meals each day were: make them sick (diarrhea, vomiting and allergic) (P=0.011), and most mother’s of children aged 6-‐23 months say they don’t know the disadvantages of feeding three cooked meals per day for the child. This could be attributed to the norm and culture of those particular Yezzidi communities by stating I don’t know (p=0.017) compared to doer mothers. The Non-‐doer who respond make them sick (diarrhea, vomiting and allergic) are from Erbi IDP camps, this may be attributed to hygiene and sanitation practices and needs to be investigated, while there are no significant differences between doers and Non-‐doers mother in Dohuk IDP camps.


This determinant refers to an individual’s perception of the approval or disapproval of doing a behavior by people considered to be important in an individual’s life. Respondents were asked who approves or disapproves of them of you feeding your child at least three meals each day.

Non-‐Doers are 3.4 times are more likely to give this response myself compared to Doers (p=0.026), in Erbil, while there are no major significant differences between Doer and Non-‐Doer mothers in Dohuk.

There are no significant differences on approval of feeding child three meals a day in both governorate IDP camps. Though, Non-‐doers from Erbil approve by themselves of feeding a child three meals a day, however, difficulty of getting foods she needs, child poor appetite and child get diarrhea, vomiting likely affected not to practice the behavior.

5. Perceived Access

This determinant refers to an individual’s accessibility that he/she can do a particular behavior. Respondents were asked How difficult or would it be difficult is it for you to get the food you need to feed your child at least three times a day?

Doer mothers in Dohuk are 3.5 times more likely to give say it is Not difficult compared to Non-‐Doer mothers (p=0.019), while there are no significant differences between Doer and Non-‐doer mothers in Erbil.

There is no significant difference between Doer mothers and Non-‐doer mothers in Erbil and Dohuk IDP camps getting they food that need to feed the child at least three meals per day. However, Doers say it is Not difficult at all compared to Non-‐Doer mothers in Dohuk IDP camps. While, there are no significant difference between doer and Non-‐doer mothers in getting the foods they need to feed the child at least three times a day other factors such as lack of people who approve or support to do the behavior are likely to affect to practice the behavior.

6. Perceived Risk

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This determinant refers to an individual’s perception of the behavior susceptibility Can I get the disease/have the problem doing a behavior. Respondents were asked How likely or would it be likely is that your child will become malnourished in the next year

Non-‐Doers in Erbil are 2.7 times more likely than Doers to respond that it is Somewhat Likely that the child becomes malnourished in the next year (p=0.014), while, Doers in Erbil are 3.5 times more likely to give this response Not Likely at all than Non-‐Doers. Conversely, Doer mothers in Dohuk are also 3.5 times more likely to give this response Not-‐Likely at all than Non-‐Doers.

Non-‐doer mothers from overall assessed IDP camps likely to say that somewhat likely (p=0.008) and very likely (p=0.027) that the child becomes malnourished in the next year. While, doer mothers from overall assessed IDP camps respond that it is not likely at all (p=0.000) compared to Non-‐doer mothers. So, mothers who practice the behavior are more confident to say that the children will not become malnourished next year than non-‐doer mothers.

7. Perceived Severity

This determinant refers to an individual’s perception of the behavior is the disease/problem serious doing a behavior. Respondents were asked How serious will or would it be if your child became malnourished?

Non-‐Doers in Erbil are 2.3 times more likely to give this response Very Serious than Doers (p=0.028), while, Doers are 3.5 times more likely to give this response Not serious at all than Non-‐Doers. Meanwhile, Doer mothers from Dohuk are 2.4 times more likely to give this response compared to Non-‐Doers.

Overall Non-‐doer mothers from both governorate (Erbil and Dohuk) IDP camps to say that it is very serious (p=0.026) if the child became malnourished, while doer mothers from the above IDP camps mentioned that it is not serious at all if the child become malnourished (p=0.002). Doer mother is confident enough as long as feeding the child three times a day if the child get malnourished they believe that it is not that much serious as they are practicing the behaviors.

8. Perceived Divine Will

This determinant refers to an individual’s perception of the behavior Is it God’s will that I prevent/ overcome the disease or problem doing a behavior. Respondents were asked Do you think that God approves or would approves of you feeding your child at least three times per day every day?

Doers in Erbil 11.4 times are more likely to give this response May Be and No than Non-‐Doers (p=0.013). Meanwhile, 20% of Doers in Dohuk are more likely to give this response Yes compared to Non-‐Doer mothers.

The determinant divine will founded through field-‐work and lessons learned (unpublished) to be very important to many behaviors particularly (Health and Nutrition). This includes the priority group’s perceptions of what their religion accepts or rejects. Overall doer mothers from both governorate IDP camps responded that No God does not approves of feeding their child three times per day every day compared to Non-‐doer mothers (p=0.014). Doer mothers from Erbil IDP camps are more likely to say No compared to Non-‐Doer mothers (p=0.013). One Doer mother from Erbil IDP camps explained “If I am lazy

29

enough and didn’t make him feed three times a day, I should not justify that it’s God will, because it was my laziness that makes him not to be fed three times a day.”

Behavior 4: Mothers of children ages 9 –23 months feed them meals each day containing Solid, Semi-‐Solid and Soft foods from at least 4 of the 7 food groups. Eight determinants were found to be significant for this behavior both in Erbil and Dohuk governorates.


This determinant refers to an individual’s behavior advantageous that he/she can do a particular behavior. Respondents were asked What are the advantages or would be advantages of feeding your child meals each day containing Solid, Semi-‐Solid and Soft foods from at least 4 of the 7 food groups.


Doer 4.8 times more likely to say Good Growth/Strong Bone made it easier for them to practice the behavior than Non-‐Doers (p=0.003)

4.3 more likely to say Good health and make child smart make it easier to practice the behavior compared to Non-‐doers (p=0.000)

Non-‐Doers 2.3 More likely to say Good health/Make child Smart compared to Doers (p=0.029)

The overall response from the assessed IDP camps in Erbil and Dohuk Non-‐doer mothers do not know the advantages of feeding a child each day from at least 4 of the 7 food groups (p=0.035) compared to doer mothers.

2. Perceived Negative Consequences

This determinant refers to an individual’s behavior advantageous that he/she can do a particular behavior. Respondents were asked What are the disadvantages or would be disadvantages of feeding your child meals each day containing Solid, Semi-‐Solid and Soft foods from at least 4 of the 7 food groups?


Non-‐Doers 3.9 more likely to say the child will become overweight compared to doers (p=0.003) -‐13% more likely to say I don’t know compared to Doers (p=0.013)

There is no significant different response between doer and non-‐doers mothers on disadvantages of feeding child 4 foods out of 7 food groups in Erbil camp compared to Dohuk IDP camps. Non-‐doer mothers

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in Dohuk IDP camp to respond that they don’t know the disadvantageous of not feeding child at least 4 foods out of 7 food groups compared to doer mothers. Moreover, Non-‐doer mothers responded feeding at least 4 foods out of 7 food groups make the child overweight (p=0.003). This indicates that non-‐doers are not aware of the importance of adequate nutrition for the healthy development of a child.


This determinant refers to an individual’s belief that he/she can do a particular behavior given his/ her current knowledge and skills. Respondents were asked what makes it (or what would make it) easier or more difficult for them to feed at least Solid, Semi-‐Solid and Soft foods from 4 out of 7 food groups age 9-‐23 months per a day.


Doer 3.3 more likely to say Good health compared to Non-‐Doer (p=0.028)

Non-‐Doer 3.0 more likely to say having a good income or resource compared to doer (p=0.005) -‐22% more likely to say Having a time compared to Doers (p=0.001)

Non-‐doer mothers from Erbil and Dohuk IDP camps to respond that getting help from someone makes easier to practice the behavior compared to doer mothers, while some say nothing will make them easier to practice the behavior of feeding a child at least 4 foods out of 7 food groups each day (p=0.031).

Non-‐doer from Dohuk IDP camps report having enough money would make it easier to feed a child at least 4 foods out of 7 food groups than doer mothers (p=0.005), in addition, though it is not significant, having enough time also would make it easier to practice the behavior.


This determinant refers to an individual’s perception of the approval or disapproval of doing a behavior by people considered to be important in an individual’s life. Respondents were asked who approves or disapproves of them of feeding your child meals each day containing Solid, Semi-‐Solid and Soft foods from at least 4 of the 7 food groups.

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Overall in Erbil and Dohuk IDP camps doer mother responded that husband (p=0.000) and all family (p=0.012) approve feeding a child at least 4 foods out of 7 food groups each day compared to Non-‐doer mothers. While, Non-‐doer mothers from the above camps did not have any one to approve the behavior and practice (p=0.000). Conversely, Non-‐doer mothers from both governorate IDP camps mentioned that their husband disapprove on feeding a child at least 4 food out of 7 food groups each day. One mother from Erbil IDP camp said “ Since my husband is a jobless he didn’t have enough money to buy the food so the children eat from the same family food we prepared”

5. Perceived Access

This determinant refers to an individual’s accessibility that he/she can do a particular behavior. Respondents were asked How difficult or would it be difficult is it for you to get the food you need to feed your child at least four foods out of seven food groups each day?

There are no significant differences between Doer and Non doers mothers in Erbil and Dohuk IDP camps, however, overall Non-‐doer mothers from both governorate IDP camps responded that it was very difficult to access or get the food they need to feed a child at least 4 foods out of 7 food groups (p=0.023). Interestingly, the resilience of the people is very strong and the availability of foods is not bad, you can see a picture from the cover page. There are two issues that prevent people to access to practice the desired behavior: 1. Most of the markets are outside of the camps, so often it was not able to access them due to restriction to go out of the camp due to security reasons. 2. Money to buy this food items on daily bases. Most of the IDP in the camps does not have access to Income Generating Activities (IGA). Facilitating access to markets and IGA or introduction Cash/voucher for the four food groups for targeted house hold with child 6-‐23 months in the camp likely improve to practice the behavior

6. Perceived Risk


Doer 5.3 more likely to say that Husbands approve compared to Non-‐doers (p=0.000)

2.1 more likely to give say All my family approve compared to Non-‐Doer (p=0.045)

7.0 more likely to say No One disapprove compared to Non-‐Doer (p=0.034)

Non-‐Doers 32.8 times more likely to give say that No One approves compared to Doers (p=0.000)

2.7 more likely to say No one approves compared to doers (p=0.037)

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This determinant refers to an individual’s perception of the behavior susceptibility can I get the disease/have the problem doing a behavior. Respondents were asked How likely is it that your child would become malnourished if you feed him/her foods from at least four out of the seven food groups each day?

Doer’s mothers in Dohuk are 2.4 more likely to give this response unlikely at all compared to Non-‐Doer mothers. Since, mothers are feeding the child from this 4 food groups it is unlikely to become the child malnourished. While, the perception of Doers and Non-‐doer mothers in Erbil more or less similar.

7. Perceived Severity

This determinant refers to an individual’s perception of the disease or problem seriousness, respondents were asked How serious is it that your child would become malnourished if you feed him/her foods from at least four out of the seven food groups each day?

Non-‐Doers 58.9 times are more likely to give this response Some What Serious than Doers (p=0.000) in Dohuk. Since this are Non-‐Doer Mothers they are not sure and have doubt on the impact of the feeding from 4 food groups compare to doer mothers.


This determinant refers to an individual’s perception of Does the behavior work to prevent/overcome the disease or problem, respondents were asked How likely is it that your child would become malnourished if you feed him/her foods from at least four out of the seven food groups each day?

Non-‐Doer mothers in Erbil are 7.0 times more likely to give this response Very Likely compared to Doer mothers. The non-‐doer mother they do not have the knowledge of the efficacy of the feeding from 4 foods out of 7 food groups on preventing malnutrition.

UNIVERSAL MOTIVATOR At the end of each interview, data collectors asked respondents, “What is the one thing you desire most in life?” To uncover universal motivators in all assessed IDP Camps, regardless of the four assessed behaviors. The majority of respondents answered with “Back to Home”, followed by “Finish studying” as the most important themes. Common responses given in Erbil governorate IDP camps and in Dohuk governorate IDP camps “Back to Home and protection”.

4. Recommendation Hence, the overall purpose of this Barrier Analysis study in the IDP camps is to seek evidence based information on four behaviors to inform behavior change programming.

The Tech-‐RRT SBC Advisor drafted the initial Bridges to Activities based on findings, what is practically and culturally appropriate in the assessed camps.

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Behavior 1: Targeted mothers of children 1 day to 5 months put the newborn to the breast within one hour of delivery Table 2. Provides programmatic recommendations for each behavioral determinant that was found significant during the Barrier Analysis

Determinants Bridge to Activities Recommendation

Perceived Self-‐ Efficacy

Increase the knowledge that mothers have enough breast milk and able to breastfeed within the first hour after delivery.

-‐ Develop messages on breastfeeding to be integrated into trainings, counseling, etc such as:

ü Mothers have enough breast milk and able to breastfeed within the first hour after delivery

ü by putting the baby on the breast immediately after birth milk production will be stimulated

ü Sick or stressed mothers are still able to breastfeed within the first hour of delivery and it is beneficial for the mother to do so

ü There may be some discomfort when starting to breastfeed, but that it is normal, and there are things a mother can do to reduce the discomfort

ü Putting a newborn baby within one hour of delivery to the breast, increases the likelihood of him/her receiving the colostrum

ü Colostrum (yellow/golden milk) does not make a child sick (such as causing diarrhea or vomiting)

-‐ Work to increase community awareness of the importance of early initiation of breastfeeding. Show video breastfeeding crawl in the BFHI, ANC and Community center. So mothers see what newborn can do. -‐ Support Mothers with C-‐section or complications to be assisted by birth attendants to breastfeed as soon as possible within health facility, followed by trained community social worker at home visit. -‐ Train community social workers in counseling to facilitate proper positioning and

Increase the knowledge to put baby on the breast immediately after birth, to stimulate production of Milk. Increase the perception that baby is able to suckle when you put to breast within the first hour of delivery. Increase the knowledge that sick or stressed mothers are still able to breastfeed within the first hour of delivery and it is beneficial for the mother to do so

Increase the perception that there may be some discomfort when starting to breastfeed, but that it is normal, and there are things a mother can do to reduce the discomfort

Increase ability of mothers to breastfeed within the first hour, even if they have difficulty during delivery and delivered by C-‐section.

Perceived Positive Consequence

Increase the knowledge of the advantages of initiation of breastfeeding within 1 hour for both the baby (especially preventing disease and increasing immunity) and the mother’s health.

Perceived Negative Consequence

Decrease the perception that the colostrum (yellow/golden milk) makes a child sick (such as causing diarrhea or vomiting)

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Perceived Social Norms

Increase the perception that Doctors/ health staff support early initiation of Breastfeeding Increase the perception that religious leaders approve of early initiation of Breastfeeding

attachments during breastfeeding with the help of a trained health care professional nearby -‐ Train all birth attendants to give skilled support to mothers for skin-‐to-‐skin contact immediately after delivery, allowing the baby to attach to the breast when he/she is ready and assistance with breastfeeding difficulties. -‐ Increase community awareness about the advantages of initiation of breastfeeding within 1 hour, including the developed messages, through different communication channels. Especially in the IDP camps use community radio or recorded messages and channel through mounted megaphone in the strategic areas so mothers can hear messages while doing the chores in their homes. -‐ Discuss with mothers that the first yellow/golden milk (colostrum) is the mother’s natural butter and will help to expel baby’s first dark stool. Through one-‐to-‐one counseling, mother-‐to-‐mother support group and ANC/ PNC follow up. Additionally, explain to mothers that the initial breastmilk is sufficient for their baby.

-‐ Increase community/religious leader awareness through special events on the advantages of early initiation for both mother and baby. Discuss the issue of immediate blessings versus early initiation and how to resolve this issue. -‐ Using this knowledge religious leaders should then provide routine sermons on the advantages, as well as discussing the issue of immediate blessings -‐ Advocate messaging and training for all birth attendants to support initiation of breastfeeding within 1 hour with C-‐section delivery mothers.

Perceived Action Efficacy

Increase the perception that putting a newborn baby within one hour of delivery to the breast increases the likelihood of him/her receiving the colostrum.

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Behavior 2: Mothers of children ages 0 – 5 months feed them only breast milk Determinants Bridge to Activities Recommendation


Increase the perception that Breast Milk is readily available and no preparation is needed

-‐ Develop messages on breastfeeding to be integrated into trainings, counseling, MtMSG’s curricula, etc such as:

• Breast Milk is readily available and no preparation is needed

• Mothers have enough breast milk to give their baby for the first 6 months

• Even mothers that are stressed can breastfeed

• Babies can suckle well • Good physical and mental growth is a

benefit of exclusive breastfeeding • Breast milk is best/ “God’s gift” for

the child • Non-‐exclusively breastfed infants can

become malnourished -‐ Integrate breastfeeding support and messages with wider public health and other sector (WASH, Health, Protection, Food Security, Education) Work with Government of Iraq and Camp management to implement the International code for marketing of breastmilk substitutes -‐ Establish referral process with MtMSGs and Peer Groups to help identify mothers with breastfeeding difficulties due to breast problem and stress.

-‐ Train all birth attendants and community social workers on optimal breastfeeding (including the above developed messages) as well as to be translated into local language and posted on ANC, maternity ward. Advocate for implementation of BFHI in all health facilities. -‐ Develop a brochure with key messages and pictures about breast feeding to be hung at home as a reminder for mothers -‐ Disseminate developed messages through Radio episode, TV, MtMSG’s, religious leaders, and special occasions in the camps. -‐ Provide designated private space for woman

Increase the perception that mothers have enough breast milk to give their baby for the first 6 months. Increase the perception that even mothers that are stressed can breastfeed Increase the perception that babies can suckle well


Increase the knowledge that good physical and mental growth is a benefit of exclusive breastfeeding

Reinforce the perception that giving only breast milk is best/ “God’s gift” for the child.

Perceived Access Increase the ability of mothers to get the support they need to only give breastmilk for the first 6 months

Perceived cues of action

Increase the ability of mothers to remember to only give breastmilk for the first 6 months


-‐

Increase the perception that babies who do not exclusively breastfeed are likely to become malnourished

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to breastfeed or express milk in the health facility, distribution areas or other public areas. -‐ Develop counseling cards and other IEC materials on all developed messages -‐ Develop simple manual how to facilitate group discussion pertaining to IYCF on the seven core indicators. -‐ Give testimonial about the advantageous of only breastfeeding for a child 0-‐5 months by inviting influential people through radio spot, TV interview or through special occasion in the camps. -‐ Conduct focus group discussions to better understand the perception and knowledge of the causes of malnutrition and the links with breastfeeding

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Behavior 3: Mothers of children ages 6 –23 months feed them at least three-‐ cooked meal a day that contain a staple/main foods. Determinants Bridge to Activities Recommendation


Increase the ability to have enough foods at least to cook three meals a day that contain staple/main foods to feed a child.

-‐ Conduct a market survey to look at what foods are available and at what costs

-‐ Involve other family members in learning appropriate feeding techniques.

-‐ Support mothers through home visit and educate them on appropriate complementary feeding, such as FATVAH (Frequency, Amount, Thickness, Varity, Active Feeding and Hygiene) -‐ Conduct cooking demonstrations using locally available foods. -‐ Through MtMSGs mobilize/encourage older mothers to teach the younger mothers in feeding technique and cooking meals. -‐ Encourage Community Social Workers to conduct more home visits during meal times during the critical child ages 6 – 8, 9-‐11 and 12-‐23 months. -‐ Develop Promoter counseling card of meal frequency. Include more messaging highlighting child’s physical and mental growth. -‐ Develop messaging to be disseminated through various channels, such as: • Feeding three cooked meals that contain staple food: prevents sickness, increases brain development, and makes the child active, and smart and strong

• Even children with poor appetite can still be fed three meals a day that contain staple/main foods to feed a child

• Family and neighbors will support mothers in cooking three meals a day that contain

Increase the perception that family and neighbors will support mothers in cooking three meals a day that contain staple/main foods. Increase the perception that it’s affordable to cook three meals a day that contain staple/main foods to feed a child.

Increase the perception that even children with poor appetite can still be fed three meals a day that contain staple/main foods to feed a child


Increase the knowledge that feeding three cooked meals that contain staple food prevents sickness, increases brain development, and makes the child active, smart and strong,

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Decrease the perception that feeding your child at least three meals each day may cause the child to have diarrhea, vomiting and allergies,

staple/main foods. • It’s affordable to cook three meals a day that contain staple/main foods to feed a child

• Babies that are not fed three cooked meals that contain staple foods a day are likely to become malnourished, which is a serious issue

-‐ Disseminate developed messages through local radio, health staff, community social workers and MtMSGs about negative consequence of not properly fed child. -‐ Invite influential mother’s to give testimonial speech, doing cooking demonstration and feeding children. -‐ Develop pictorial cards and posters on texture, type of food and post on billboard in the camps strategic areas. -‐ Develop radio, TV spot on type and texture of locally available food preparation. Conduct focus group discussions to better understand the perception and knowledge of the causes of malnutrition

Perceived Susceptibility

Increase the perception that babies that are not fed three cooked meals that contain staple foods each day are likely to become malnourished, which is a serious issue

Perceived Severity

Perceived Divine Will Reinforce the perception that God approves of feeding a child at least three times per day every day

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Behavior 4: Mothers of children ages 9 –23 months feed them meals each day containing Solid, Semi-‐Solid and Soft foods from at least 4 of the 7 food groups. Determinants Bridge to Activities Recommendation


Increase the perception that consuming foods from at least four of the seven different food groups each day will improve the baby’s growth, strengthen bones and make them healthy and smart.

-‐ Conduct a market survey to look at what foods are available and at what costs -‐ Develop messaging to be disseminated through various channels, such as:

• Consuming foods from at least four of the seven different food groups each day will improve the baby’s growth, strengthen bones and make them healthy and smart

• Feeding a child 4 foods per day is affordable

• Preparations of 4 foods per day does not take much time.

• Increase the perception that a child will not become overweight if feeding 4 foods per day.

• Feeding a child from 4 food groups per day protects from malnutrition, which is a serious issue.

• Feeding foods from at least four food groups per day will not cause a child to become malnourished.

-‐ Disseminate the developed messages through MtMSG’s, Recorded messages, local Radio, TV and entertainment education in the camp. -‐ Develop promoters guidance counseling card on the advantages of feeding a variety of foods from 4 food groups to child. -‐ Conduct cooking demonstration once a week in the community as well as in MCH waiting areas at least from 4 foods out of 7 food groups with affordable locally available foods. -‐ Demonstrate to mothers on handling and keeping foods for a long time to make safer. Suggest the following steps; -‐ Keep clean (foods, utensils) -‐ Separate raw and cooked (use bowls with cover) -‐ Cook food thoroughly -‐ Keep food at safer temperature -‐ Use safer water


Increase the perception that a child will not become overweight if feeding 4 foods per day.

Perceived Self Efficacy

Increase perception that feeding a child 4 food per day is affordable.

-‐ Increase the perception that preparation of 4 foods per day does not take much time.

Perceived Social Norms

Increase perception that husbands approve of feeding baby’s from at least four foods per day each day.

Perceived Access Increase the ability to get the food needed to feed a child at least four foods out of seven food groups each day

Perceived Risk Reinforce the perception that feeding a child from 4 food groups per day protects from malnutrition is a serious issue.

Perceived Severity


Decrease perception that feeding foods from at least four food groups per day will cause a child to become malnourished.

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Emphasis when mothers want to feed child to heat the food before feeding the child. -‐ Invite influential leaders, respected health staff, respected women by the community to radio spot or TV or camp community event to emphasis the support needs from family members of feeding a child 4 foods out of 7 food groups available locally each day. -‐ Advocate to camp management to allow mothers to get foods they need to feed the child 4 foods out of 7 food groups from nearby markets. -‐ Advocate with food security and livelihood cluster on food voucher for targeted household with children 6-‐23 months to make foods more affordable. -‐ Erect pictorial billboards with seven food groups in strategic camp location to be seen easily.

5. Conclusion

Rapid and significant increases in initiation of breastfeeding within one hour, exclusive breast feeding for children aged 0-‐5 months, meal frequency feeding minimum of at three cooked meals per day for children age 6-‐23 months, and meal diversity feeding four foods out of seven food groups a day for children age 6-‐23 months are possible. The activities developed are doable if integrated, multi-‐level programs of advocacy and social mobilization exerted in behavior and social change at individual, cultural, institutional and governmental levels in order to tackle the identified barriers during the formative research.

!barrier!analysis!of!iycfbehaviors!! inerbiland!dohukofidpcamps … · 2017. 6. 23. · 8!!!!...

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