3URJUDP ()63 $SULO

Barrier Analysis for Maternal, Infant and Young Child Feeding and Hygiene Practices for Emergency Food Security Program (EFSP)

April 1, 2020

Acknowledgments

This study was developed and conducted by icddr,b with support from World Vision Bangladesh. We would like to thank the community participants who spent time on providing valuable information to analyze. Then we would like to thank the EFSP project staffs who relentlessly provided support for this study. We specially thank the MEAL team of World Vision for their immediate support to every of our requirements.

This assessment would be difficult to complete without the support from senior members of EFSP nutrition team, livelihood team and MEAL team. We would like to thank Technical Service Organization (TSO) of World Vision’s International for their time required support and guidance throughout the study.

We like to thank Laura H Kwong from Stanford University, USA for her support in reviewing Barrier Analysis report. We are also thankful to the mentors from icddr,b who provided support in preparing tools, designing training and report writing.

Authors

Md. Khobair Hossain*

Dr. Md. Mahbubur Rahman

Dr. Tarique Mohammad Nurul Huda

Dr. Kaniz Jannat

AKM Shoab

Mahbub Ul Alam

Debashish Biswas

Farzana Yesmin

S.M. Raduan Hossin

For contact:

Environmental Interventions Unit,

Infectious Diseases Division, icddr,b

68, Shaheed Tajuddin Ahmed Sarani, Mohakhali,

Dhaka-1212, Bangladesh.

Corresponding email

[email protected]

Acronyms

BA Barrier Analysis

FDMN Forcedly Displaced Myanmar National

IYCF Infant and Young Child Feeding

icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh

USAID United States Agency for International Development

FFP Food For Peace

EFSP Emergency Food Security Program

UNCHR United Nations High Commissioner for Refugees

GAM Global Acute Malnutrition

MEAL Monitoring, Evaluation, Accountability and Learning

EBF Exclusive Beast Feeding

FFQ Food Frequency

FGD Focus Group Discussion

TSO Technical Service Organization

DBC Designing Behavior Change

Table of contents

EXECUTIVE SUMMARY ..................................................................................................................................................... 1 1. INTRODUCTION ..................................................................................................................................................... 5 2. METHODOLOGY .................................................................................................................................................... 6

2.1. Data collection ......................................................................................................................................... 6 2.2. Sampling .................................................................................................................................................. 7 2.3. Definition of studied behaviors ................................................................................................................ 8 2.4. Exclusive Breastfeeding............................................................................................................................ 8 2.5. Dietary Diversity ....................................................................................................................................... 8 2.6. Food Frequency ........................................................................................................................................ 8 2.7. Iron-rich food consumption ...................................................................................................................... 8 2.8. Handwashing at five key times ................................................................................................................ 8 2.9. Barrier Analysis questionnaire ................................................................................................................. 9 2.10. Sampling for Focus Group Discussion ...................................................................................................... 9 2.11. Data analysis .......................................................................................................................................... 10

3. RESULTS ................................................................................................................................................................. 10 3.1. Behavior: Exclusive breastfeeding ................................................................................................................ 10 3.2. Behavior: Dietary diversity ........................................................................................................................... 11 3.3. Behavior: Food Frequency ............................................................................................................................ 13 3.4. Behavior: Iron-rich food consumption .......................................................................................................... 14 3.5. Behavior: Handwashing at five key times .................................................................................................... 15 3.6. Focus group discussion findings ................................................................................................................... 16 3.7. Behavior change material ............................................................................................................................ 17

4. DISCUSSION ........................................................................................................................................................ 18 4.1. Exclusive breastfeeding .......................................................................................................................... 18 4.2. Child dietary diversity ............................................................................................................................ 19 4.3. Food frequency ...................................................................................................................................... 20 4.4. Iron-Rich food consumption ................................................................................................................... 21 4.5. Handwashing ......................................................................................................................................... 22

5. BEHAVIOR CHANGE FRAMEWORK ........................................................................................................................... 22 5.1. DBC-Breastfeeding: Lactating mothers provide exclusive breastfeeding for their child up to 6 months of age 23 5.2. DBC-Dietary diversity: Mothers of children aged 6-23 months who feed a diverse diet to their children containing food from at least 4-7 food groups per day. ..................................................................................... 25 5.3. DBC-Food Frequency: Mothers of children aged 6-23 months who feed their children 3-4 times every day. 27 5.4. DBC-Iron-rich Food consumption: Women of 15-49 years of age consume iron-rich foods every day .. 28 5.5. DBC-Handwashing: Mothers of children aged 0-23 months wash hands at five key times ................... 30

6. CONCLUSION ...................................................................................................................................................... 31 7. REFERENCES ....................................................................................................................................................... 31 8. ANNEXES ........................................................................................................................................................... 33

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Executive Summary Introduction: The goal of the USAID/Food For Peace (FFP)-funded Emergency Food Security Program (EFSP) is to improve the food security and nutrition of 34,112 vulnerable households of Forcedly Displaced Myanmar Nationals (also referred to as Rohingya refugees) and 5,229 vulnerable households of host community members in Cox‘s Bazar District, Bangladesh. The emergency food security program, implemented by World Vision, has two purposes:1) Increase consumption of diverse and quality foods that meet the nutritional requirements of vulnerable households in Refugee Camps and Host Communities and 2) Enhancing the capacity of Refugees and Host Communities to withstand future shocks. To achieve these purposes World Vision Bangladesh will implement behavior change activities related to health and nutrition among the target groups.

Methodology: This study used Barrier Analysis (Kittle Bonnie, 2013) to identify the key barriers and motivators for the following behaviors: 1) exclusive breastfeeding of children <6 months old, 2) consumption of 4 food groups per day (dietary diversity), 3) feeding children 3-4 meals per day (food frequency), 4) consumption of iron-rich foods (specifically, for women of reproductive age), and 5) washing hands at five key times. To identify the key barriers and motivators for a particular behavior, participants from the target groups were asked questions to explore twelve potential behavioral determinants (See annex). The responses from groups of people who had adopted the behavior, classified as “Doers”, and people who had not adopted the behavior, called “Non-Doers”, were compared. Important behavioral determinants were identified by assessing if there was a significant difference in the proportion of Doers and Non-Doers who provided specific responses to the questions about behavioral determinants.

Box-1: Behavioral determinants in the Barrier Analysis framework (Kittle Bonnie, 2013).

Perceived self-efficacy/skills - An individual's belief that he/she can do a particular behavior given his/her current knowledge and skills.

Perceived social norms - The perception that people important to an individual think that he/she should do the behavior. Norms have two parts: who matters most to the person on a particular issue and what the person perceives those people think he/she should do.

Perceived positive consequences - What positive things a person thinks will happen as a result of performing a behavior. These may include advantages (benefits) of the behavior, attitudes about the behavior, and perceived positive attributes of the action.

Perceived negative consequences - The negative things a person thinks will happen as a result of performing a behavior, these will include disadvantage of the behavior, attitudes about the behavior, and perceived negative attributes of the action.

Access – Access has many different dimensions. It includes the degree of availability of the needed resources or services required to adopt a given behavior. It also includes barriers related to cost, geography, distance, linguistics, cultural issues, and gender.

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Cues for action/reminders – This is about the presence of reminders that help a person remember to do a particular behavior or the presence of reminders that help a person remember the steps involved in doing the behavior.

Perceived susceptibility/risk - A person's perception of how vulnerable or at risk he/she feels to the problem that is being addressed/prevented by adopting certain behavior.

Perceived severity – The belief that the problem (being prevented by the behavior) is serious and needs to be prevented.

Perceived action efficacy - The belief that by practicing the behavior one will avoid the problem or the belief that the behavior is effective in avoiding the problem.

Perceived divine will – This is about a person’s belief that it is God’s will (or the gods’ wills) for him/her to have the problem and/or to overcome it. It includes the priority group’s perception of what their religion accepts or rejects and perceptions about the spirit world or magic (e.g., spells, curses).

Policy - Laws and regulations (local, regional, or national) that affect adoption of behaviors and access to products and services required for the adoption of certain behaviors.

Culture - The set of history, customs, lifestyles, values, and practices within a self-defined group. May be associated with ethnicity or lifestyle.

For each recommended behavior 45 ‘Doers’ and 45 ‘Non-Doers’ were interviewed. Thus, a total of 450 participants (for all five behaviors) were sampled purposively and individual interviews were conducted with each participant using standard Barrier Analysis questionnaire. The coded interviews were analyzed to identify responses that were statistically significant between Doers and Non-Doers were analyzed. Focus group discussions were used to explore the reasons why residents practice some behavior and why do not practice. To select the behavior change materials, a ranking exercise was done in the focus group discussion sessions. For the five behavior areas, 10 focus group discussions were conducted (5with Doers and 5 Non-Doers groups) in the selected neighborhoods.

Results: This assessment identified behavioral determinants that were statistically different among women who practiced the recommended behaviors and those who did not. This study identified six key behavioral determinants for exclusive breastfeeding, eight for dietary diversity, six determinants for food frequency, seven determinants for the consumption of iron-rich foods, and six determinants for handwashing.

Exclusive breastfeeding: Perceived barriers faced by Non-Doers were low level of self-efficacy, including poor knowledge and skills on breastfeeding and perceived insufficient breast milk. For Doers, enabling behavioral determinants included high perceived self-efficacy, perceived positive consequences, perceived severity of not exclusively breastfeeding, perceived action efficacy, and clearly perceived divine will. Doers stated that breastfeeding was easier when family members help. With regard to perceived social norms, Doers stated that they themselves approve breastfeeding. Doers also reported that their husbands approve of breastfeeding while Non-Doers reported that their husbands also support breastfeeding. Doers perceived

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a positive consequence of breastfeeding to be the good health of their child and perceived the negative consequence of malnutrition to be more severe. Non-Doers perceived that exclusive breastfeeding does not help to prevent malnutrition. Doers thought exclusive breastfeeding can help to prevent malnutrition and they had the understanding that God’s will, curse, and supernatural causes are not linked with malnutrition.

Dietary diversity: Perceived barriers in feeding a child diverse diet reported by Doers were their child’s illness, inability to afford diverse food, their own illness, and unavailability of food while Non-Doers reported that their family’s preferences for particular food items made it difficult to feed diverse food to the child. Other determinants included social norms, perceived positive consequences, perceived severity and susceptibility, perceived action efficacy, perceived divine will, and access. Doers reported that their husbands approve of feeding children a diverse diet. Focus group discussions with Doers revealed that neighbors advise caregivers to feed children (>6 months old) formula instead of providing a diverse diet. Doers perceived that children’s physical and mental health and development are ensured when a child is fed a diverse diet. Non-Doers lack the perception that their children are susceptible to malnutrition and underestimate the severity of malnutrition, which may be a reason they do not practice the behavior.

Food Frequency: The enabling determinants for Doers were social norms, perceived negative consequences, perceived severity, cues for action and culture. They were more likely to report that their husbands were the most important figure for them to approve feeding children 3-4 times per day. Though they had a clear understanding of susceptibility and severity of malnutrition and were more likely to report that having a family meal plan for a child helps to feed 3-4 times per day. Barriers for Non-Doer included the inability to afford food and lack of understanding about the connection between poor feeding practice and malnutrition.

Consumption of Iron Rich Food: For consumption of iron-rich food, perceived barriers for Non-Doers were inability to afford food, lack of awareness about the importance of iron-rich food consumption, lack of accessibility. For Doers, the enablers were husband’s awareness and support, greater access to iron-rich food, self-awareness about consuming iron-rich food and perceiving that anemia is a risk. The other determinants included perceived self-efficacy, social norms, perceived severity and susceptibility, perceived action efficacy, and perceived divine will. Doers reported in FGD that husbands who are aware of the importance of consuming iron-rich food, purchase iron dense foods and that makes it easy to consume. Non-Doers reported poor affordability makes consume iron-rich food difficult. Focus group discussion with Non-Doers revealed that accessibility is a problem for consuming iron-rich food. Though husbands support consuming iron-rich food, many of them in this district, go fishing in the sea for a number of days. The families who are dependent on the market and purchase food products daily cannot always avail food items that they want.

Handwashing: For handwashing at five critical times, perceived barriers among Non-Doers were unavailability of soap and water at the right place. Not being able to remember to wash hand with soap and financial difficulties were also a barrier for them. The enablers for Doers were the availability of soap and water at the designated place, the self-awareness that reminds them to wash their hands, perceived positive consequences of handwashing improving child health.

Recommendations: There are multiple strategies that can be used by the emergency food security program implementation team.

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In order to develop an effective behavior change strategy to promote exclusive breastfeeding, the program implementation team should train its staff about increasing the targeted mothers’ self-efficacy about breastfeeding. They should develop the mothers’ skills of proper attachment and positioning for breastfeeding.

The implementation team should motivate the other members of the family through care groups to assist mothers in the household work so that they can get enough time for breastfeeding.

The promotion of feeding children foods from four food groups per day should involve cash-for-work activities to support the purchasing of diverse foods.

The implementation team should organize home gardening training for beneficiaries to increase the accessibility and availability of food items.

To support feeding of children 3-4 meals per day, the implementation team should discuss using a family meal plan as a reminder mechanism. This meal plan includes child extra food into the three-time family cooking so they can remind that child should be fed three times at least. Alongside this, the mother should continue feeding extra food items like suji (semi-solid powdered rice) and other items.

There is a need for increasing the mother’s understanding of malnutrition including its susceptibility and severity.

Husbands are the most important persons to support women, so the implementation team has to motivate the MenCare group members to increase men’s support for their wives to ensure feeding their child 3-4 times per day.

Improving food frequency would also be supported by cash-for-work activities so beneficiaries can overcome financial barriers to adopt the behaviors.

For increasing the iron-rich food consumption, households should receive training on home gardening to overcome the unavailability of food.

Proper counseling is required on cheap and locally available leafy vegetables that contain iron to reduce perceptions that iron-rich foods are costly. This component can be integrated with home gardening-training so that some extremely poor beneficiaries can increase their accessibility and learn about iron-rich foods. Along with this, the implementation team has to increase beneficiaries’ understanding of anemia and self-awareness about the importance of iron so it helps them remembering iron-rich food consumption.

To promote handwashing at five key times, the availability of soap and water at designated places is required.

To promote handwashing, care groups need to be motivated to remind each other for the behavior.

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Self-awareness about the importance of handwashing of mothers has to be increased so they can wash hands at five key times especially, before feeding their child.

The implementation team has to promote the idea that proper hand wash of a mother or a caregiver keeps children in good health.

To increase understanding by the target audience, billboards with pictorial messages can be set at intersections.

The recommendations further involve engaging care groups including the mother, husband, and grandmother to improve their knowledge, skills, and motivation for them to practice recommended infant and young child feeding behaviors.

1. Introduction After the influx of Forcedly Displaced Myanmar Nationals, the current situation the host communities of Cox’s Bazar have been greatly impacted by the volatility of food prices (ISCG, 2019, Reliefweb, 2019). Many families are changing their consumption patterns, facing sudden increases in food prices and food shortages (WFP, 2017). This behavioral shift may negatively contribute to Infant and Young Child Feeding (IYCF) practices. Recent research findings showed acute malnutrition among children under five in Cox’s Bazar due to food insecurity, illness, poor child-caring practices and breastfeeding habits (ACAPS NPM, 2018). Dietary diversity is also low in Ukhia, particularly among poor households. The proportion of host community households with a poor or borderline Food Consumption Score spiked from 31 percent in 2017 to 80 percent one year later; the dietary diversity also fell from 3.7 to 2.6 percent (WFP, 2018). Research evidence indicates that poor nutritional practices during infancy contribute to poor pre-school nutrition outcomes (Black Re et.a, 2013, WHO, 2008, Avula R, 2013, Ahmed T, 2012).

In late 2017, a nutrition survey found that the health and nutrition status of children 6-59 months was critical as indicated by a global acute malnutrition rate that was found to be above the emergency threshold of fifteen percent (UNCHR, 2019). Additionally, 50% of children 6-23 months were found to be anemic, which poses a significant public health concern (UNCHR,2019). The anemia rate is even for women 15-49 years who are not pregnant or lactating, which is nearly twenty-three percent (Reliefweb, 2019). The poor practice of positive feeding behaviors also affects the poor nutritional outcomes among children under 5 and pregnant and lactating women. According to the latest survey conducted in May 2018, there were poor Infant and Young Child Feeding practices among forcibly migrant people, with only 50% of children being exclusively breastfed in the first months of their lives (UNCHR, 2019). In addition to nutrition, it was found participants improperly washed hands during critical times. Hand washing before eating meals and after using the toilet was moderately practiced while less than 20% of them washed hand after handling child feces (Reliefweb, 2019).

The present high rates of undernutrition highlight the importance of understanding dietary practices such as easily and exclusive breastfeeding. Dietary patterns such as timely and appropriate complementary feeding behaviors are rooted in complex cultural ecologies (Joint Response Plan for Rohingya Humanitarian Crisis, 2019). Early nutrition is crucial for children to survive, grow and develop into healthy adults. They can then lead rewarding lives and productively contribute to their communities (Alessandra N. Bzzano et.al., 2017). The measurement of hygiene behaviors, particularly those related to water and sanitation, is receiving an increasing amount of attention (Deweyet. al.,2011, Boot MT &Cairncross S,

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2994). Nonetheless, almost half of all childhood deaths continue to be linked to nutritional causes (Black, 2013). Alongside maternal nutrition, nutritionally based caring behaviors of families, including breastfeeding and complementary feeding, form the basis of child nutrition (Koletzko, B.; Brands, B.; Poston, L.; Godfrey, K.; Demmelmair, H., 2012). As a result, the potential impact of improved dietary practices on child nutrition has been extensively studied and subsequently promoted for its potential to greatly improve health (Das, J.K.; Salam, R.A.; Imdad, A.; Bhutta, Z.A., 2016, Mangasaryan, N.; Martin, L.; Brownlee, A.; Ogunlade, A.; Rudert, C.; Cai, X, 2012).

Over the last decade, numerous studies on the improvement of nutrition-related behaviors for infants and young children have relied on qualitative research methods, which are well-suited to exploring complex behaviors and their underlying psychosocial and cultural drivers, to investigate infant and young child feeding (Daelmans, B.; Ferguson, E.; Lutter, C.K., 2013, Menon, P.; Rawat, R.; Ruel, M., 2013, Roche, M.L.; Sako, B.; Osendarp, S.J.; Adish, A.A.; Tolossa, A.L., 2017, Burns, J. et.al., 201320-24).

Barrier Analysis (BA) is an effective approach to explore the underlying reasons for not practicing the targeted behaviors. It has been an efficient and accepted approach by NGOs and donors. Barrier Analysis is a rapid assessment tool that is used to identify the barriers that are preventing a target group from adopting a preferred behavior. It also identifies the facilitators and motivators to adopting the behavior. This body of research is likely to contain useful information to further understanding of behavioral approaches to improve child nutrition.

The study seeks to answer the following questions through conducting Barrier Analysis;

What are the most important barriers and motivators for the adoption of maternal, infant and young child feeding and hygiene practices?

What are the key differences in perceptions of Doers and Non-Doers for what could make a behavior easier or more difficult to adopt?

What messages can help mothers/caregivers adopt recommended maternal, infant and young child feeding and hygiene practices?

Who are the priority and influencing groups for the behaviors under the study?

What are the bridges to activities and activities required to address each of the determinants of behaviors identified in the study?

The primary objective of the study was to explore reasons for not practicing maternal, infant and young child feeding and household hygiene among the targeted population. The Barrier Analysis is used to identify behavioral determinants associated with a particular behavior so that more effective behavior change communication messages and support activities can be developed and disseminated.

2. Methodology

2.1. Data collection The Barrier Analysis method was selected to inform the behavior change strategy that will be employed. Barrier Analysis is a rapid assessment tool used to identify the barriers preventing a target group from

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adopting a recommended behavior(s). It also identifies the facilitators and motivators to adopting the behavior. The Barrier Analysis approach is based primarily on the Health Belief Model (Abraham, C., & Sheeran, P., 2015) and the Theory of Reasoned Action (Alwahaishi, S., & Snášel, V. 2013). Study comprises of individual interviews, conducted among a sample of 45 ‘Doers’ (those who practice the behavior) and 45 ‘Non-Doers’ (those who do not practice) for a total of 90 participants per behavior. In this process, individuals were screened and then classified as Doers and Non-Doers. Then individual interviews were conducted with these respondents using an open-ended questionnaire. Focus Group Discussion (FGD) for Doers and Non-Doers was conducted separately in each of the sampled villages. Selected mothers were interviewed to identify which of the 12 determinants of behavior change were preventing Non-Doers in this population from adopting behaviors as well as which determinants were facilitating adopting behaviors among Doers. ‘A Practical Guide to Conducting a Barrier Analysis’ (Kittle Bonnie, 2013) was closely followed to conduct this study. Data was collected only from the targeted five unions of the host community (Ukhia: Jalia Palong, Raja Palong, Palong Khali; Teknaf: Baharchhara, and Nhila) since these are project implementation areas.

2.2. Sampling According to Barrier Analysis methodology, purposive sampling based on criteria related to the behaviors of interest was used to select study participants. The selection of study locations was purposeful to ensure that the selected communities represent the EFSP program operational area. In total 450 residents were

interviewed for all 5 behaviors of interest in host communities on Cox’s Bazar. Table 1: Distribution of sample size according to Barrier Analysis area

Respondent category

Exclusive breastfeeding for children 0-6 months

Consumption of iron-rich foods by women of childbearing age (15-49 years)

Consumption of foods from at least 4 of the 7 recommended food groups

Feed children 3-4 times/day

Handwashing at the five key times

Doer 45 45 45 45 45 Non-Doer 45 45 45 45 45 Total 90 90 90 90 90

The program areas were quite similar in terms of agro-ecological zones and socio-economic status. However, some diversity could be found in religion, ethnicity and settlement type. The purposive sampling process was used to select participants. Data collectors were familiar with the study locations and fluent in the local language. The study subjects for each behavior were selected conveniently to ensure that data collection teams get the required sample size of Doers and Non-Doers for each behavior under study. The Barrier Analysis data were generated from Doers and Non-Doers. A series of questions based on the definition of the behavior were asked at the beginning of the interview to help if an interviewee was a Doer or a Non-Doer. Doers were then asked a set of questions designed for Doers while Non-Doers were asked a set of questions

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designed for Non-Doer. In this Barrier Analysis, five behaviors were studied in each study location, these were however done on different days though similar communities.

2.3. Definition of studied behaviors Identified five key behaviors for assessment were selected based on the review of a recent survey on nutrition in the host communities in Teknaf and Ukhia sub-districts.

2.4. Exclusive Breastfeeding For this behavior, the mother of children aged 0-6 months was selected who exclusively breastfeed. To assess this behavior, mothers were screened to identify Doer and Non-Doer status and then interviewed. Screening questions included that the day before the interview, in day and night what food or drinks including water in addition to breast milk they had given or not breastfeeding at all. Respondent answering exclusive breast milk was a Doer, and the respondent giving any other liquid was a Non-Doer.

2.5. Dietary Diversity Mothers of children aged 6-23 months who fed a diverse diet to their children containing food from at least 4-7 food groups per day were selected for the interview. To identify Doer and Non-Doer, mothers were screened asking if they had fed their child food from 4 or more food groups per day or if they fed less than 4 food groups per day. Complementary feeding is the transition from exclusive breastfeeding to solid or semi-solid food covering the period from 6-24 months. To meet the evolving nutritional requirements of the developing child during this period, minimum dietary diversity requires children to receive foods from 4 or more of the 7 food groups.

2.6. Food Frequency Mothers of children aged 6-23 months who feed their children 3-4 times per day were selected for the interview. Some conditional meal practices were enquired to identify Doers and Non- Doers. For a child of 6-8 months, a mother feeding breast and a minimum of 2 meals per day was a Doer and less than 2 times was a Non-Doer. For a child of 9-23 months, a mother feeding breast and a minimum of 3 meals per day was a Doer and less than 3 times would be a Non-Doer. For a child of 9-23 months, a mother not feeding breast and a minimum of 4 meals per day was a Doer and less than 4 times was a Non-Doer.

2.7. Iron-rich food consumption Women age between 15-49 years who consume 2 or more food items from iron dense food groups were selected for the interview. Doer and Non-Doer were identified considering their dietary practices. Women who had eaten 2 or more food groups daily was Doer and Non-Doer if they had consumed less than 2 iron-rich food group groups every day. To fulfill women’s dietary iron intake per day they should be eating from 2 or more food groups.

2.8. Handwashing at five key times Mothers of children 0-23 months of age were interviewed to assess this behavior. If a mother had a child of 0-23 months age, if she had washed hands with soap or ash at least 3 or more times out of 5 critical moments the day before the interview then she was identified as a Doer. If a mother had not washed hands with soap or ash or washed hand with soap or ash less than 3 times out of 5 critical moments the day before

the interview then she was considered as a Non-Doer.

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2.9. Barrier Analysis questionnaire Five barrier analysis questionnaires were developed in English following the standard Barrier Analysis questionnaire design. Developed questionnaires were reviewed by World Vision’s Technical Service Organization (TSO), a Barrier Analysis expert. After that, the questionnaires were translated into Bengali. Questionnaires were contextualized by its language, especially the names of foods through a field test. Separate facilitation guides were developed for focus group discussion with Doers and Non-Doers. Most experts recommend using the Doer and Non-Doers methodology which involves individual interviews with priority group members as the Barrier Analysis data collection method. Previously, focus group discussions were considered an acceptable option, but experience has shown that the results with individual interviews are more reliable (Practical Guide to conducting Barrier Analysis, Bonnie L. Kittle, 2013). In this assessment, focus group discussions (FGDs) were used to explore the reasons why residents practice some behavior and why they do not practice. FGDs also intended to select behavior change materials through ranking exercise. A number of sample materials including poster, flipchart, cue card and pictures were showed in the FGD. Opinions about using the banner, billboard and session type were asked verbally. The process of ranking exercise included individual opinion on each of the material and counting the number of responses for each option. For the five behavior areas, 10 focus group discussions were conducted (5with Doers and 5 Non-Doers) in the selected neighborhoods.

2.10. Sampling for Focus Group Discussion Table-2: Sampling for focus group discussion

Union Behavior Doer Behavior Non-Doer

Baharchara Handwashing at five key times (0-23 months)

1 Exclusive Breastfeeding (0-6 months) 1

Nhila Food Frequency (6-23 months) 1 Hand Wash at five key times (0-23 months)

1

Palongkhali Dietary Diversity (6-23 months) 1 Iron-rich Food Consumption (15-49 years

1

Jaliapalong Exclusive Breastfeeding (0-6 months) 1 Dietary Diversity (6-23 months) 1 Rajapalong Iron-rich Food Consumption (15-49

years 1 Food Frequency (6-23 months) 1

Total 5 5

Fieldwork was carried out for 10 days to complete data collection, including individual interviews and focus group discussions. Our field researchers went door to door to identify the Doers and Non-Doers for interview. After receiving verbal consent, interviewers screened the respondent to identify Doer or Non-Doer status before proceeding to the interview. A total of 9 teams each includes 2 members of enumerators interviewed mothers and caregivers using the Barrier Analysis questionnaires. Each team of enumerators worked in pairs. One enumerator asked questions while the other one recorded the responses, the two exchanged roles during the survey.

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2.11. Data analysis Data were analyzed manually by the whole team as part of the training. The data were reviewed and organized into categories based on the responses given for each question during data collection. A code was created for each category of similar responses. The results were tabulated manually on Barrier Analysis Tabulation Excel worksheet and the percentages were calculated. The team then identified the important categories; the ones that show the biggest differences between Doers and Non-Doers. Those responses with a 15-point difference or higher indicate the most significant determinants based on the explanation at A Practical Guide to Conducting Barrier Analysis (Kittle Bonnie, 2013). After coding, the data was tabulated in the Barrier Analysis Tabulation Worksheet for quantitative analysis. Significant determinants were identified with a difference of (p<0.05) or a 15 percent point difference among responses between Doers and Non-Doers. These significant determinants were analyzed to develop Bridges to activities and recommendations. A Bridges to Activities are a more specific description of a required change that should be addressed to the issue revealed by the Barrier Analysis research.

3. Results

3.1. Behavior: Exclusive breastfeeding Results of the Barrier Analysis on Exclusive Breastfeeding revealed six significant determinants (see annex). From the interview of women, the key significant determinants include self-efficacy, social norms, perceived positive consequences, perceived severity, perceived action efficacy, and divine will. Perceived Self-Efficacy:

Question: With your present knowledge, money, and skills, do you think that you could exclusively breastfeed?

Doers Doers are 2.1 times more likely than Non-Doers to say that with their present knowledge and skills they could exclusively breast feed (p=0.043)

Question: What makes exclusive breastfeeding easy?

Doers Doers are 3.5 times more likely than Non-Doers to say that when family helps exclusive breastfeeding becomes easy (p=0.006)

Doers Doers are 2.6 times more likely than Non-Doers to say that having enough breast milk makes exclusive breastfeeding easy (p=0.026)

Perceived Social Norms:

Question: Who approves exclusive breastfeeding?

Doers Doers are 12.6 times more likely than Non-Doers to say that they themselves approve exclusive breastfeeding (p=0.001)

Non-Doers Non-Doers are 5.5 more likely than Doers to say that husband approve exclusive breastfeeding (p=0.001)

Question: Who disapproves exclusive breastfeeding?

Doers Doers are 3.5 times more likely than Non-Doers to say that no one discourage exclusive breastfeeding (p=0.002)

Question: Who is the most important?

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Doers Doers are 2.1 times more likely than Non-Doers to say that husband is the most important figure to them (p=0.045)

Perceived positive consequences

Question: What is the advantage of exclusive breastfeeding?

Doers Doers are 12.5 times more likely than Non-Doers to say that because of exclusive breastfeeding child remains in good health (p=0.000)

Perceived severity

Question: How serious would it be if your child became malnourished?

Doers Doers are 2.1 times more likely than Non-Doers to say that it would be very serious if their child became malnourished (p=0.044)

Perceived action efficacy

Question: Do you believe that exclusively breastfeeding helps to prevent malnutrition?

Doers Doers are 3.9 times more likely than Non-Doers to say that exclusive breastfeeding helps to prevent malnutrition (p=0.004)

Perceived divine will

Question: Do you think it is because of God's will/curse/supernatural causes that children become malnourished?

Doers Doers are 2.1 times more likely than Non-Doers to say that God’s will, cause and supernatural causes are not linked with malnutrition. (p=0.045)

3.2. Behavior: Dietary diversity Results of the Barrier Analysis on Child Dietary Diversity uncovered eight significant determinants. The key significant determinants include self-efficacy, social norms, perceived positive consequences, perceived susceptibility, perceived severity, perceived action efficacy, divine will, and access. Perceived self-efficacy

Question: What makes feeding foods from at least four groups per day easier?

Doers Doers are 11.6 times more likely than Non-Doers to say that availability of food makes ensuring dietary diversity easier (p=0.000)

Doers Doers are 4.9 times more likely than Non-Doers to say that family preference on meal items that includes child food group makes ensuring dietary diversity easier (p=0.000)

Non-Doers Non-Doers are 2.5 times more likely than Doers to say that ability to afford foods makes ensuring dietary diversity easy (p=0.042)

Question: What makes feeding diverse diet difficult?

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Doers Doers are 14.5 times more likely than Non-Doers to say that child illness makes ensuring dietary diversity difficult (p=0.000)

Doers Doers are 2.4 times more likely than Non-Doers to say that inability to afford makes ensuring dietary diversity difficult (p=0.042)

Doers Doers are 6.8 times more likely than Non-Doers to say that mother’s illness makes ensuring dietary diversity difficult (p=0.000s)

Doers Doers are 5.2 times more likely than Non-Doers to say that food unavailability makes ensuring dietary diversity difficult (p=0.000)

Non-Doers Non-Doers are 4.2 times more likely than Doers to say that family preference on meal items make ensuring dietary diversity difficult (p=0.045)

Perceived Social Norms

Question: Who approves feeding foods from at least four groups per day?

Doers Doers are 6.8 times more likely than Non-Doers to say that husband approves dietary diversity (p=0.001)

Question: Who disapproves feeding foods from at least four groups per day?

Doers Doers are 3.9 times more likely than Non-Doers to say that neighbors disapprove dietary diversity (p=0.004)


Question: What are the advantages of feeding foods from at least four groups per day?

Non-Doers Non-Doers are 2.8 times more likely to perceive good health of child as advantage of feeding diverse diet than Doers (p=0.015)

Non-Doers Non-Doers are 2.7 times more likely to perceive physical growth of child as advantage of feeding diverse diet than Doers (p=0.032)

Question: What are the disadvantages feeding foods from at least four groups per day?

Non-Doers Non-Doers are 3.3 times more likely to say there is no disadvantage of feeding diverse diet than Doers (p=0.005)

Doers Doers are 11.1 times more likely than Non-Doers to say that child spits up breast milk if a child is fed diverse diet (p=0.028)

Perceived susceptibility

Question: How likely is that a child could become malnourished?

Doers Doers are 4.1 times more likely than Non-Doers to say that their child are somewhat likely to become malnourished (p=0.000)

Perceived severity

Question: How serious would be if your child became malnourished?

Doers Doers are 3.7 times more likely than Non-Doers to say that it would be very serious if their child becomes malnourished (p=0.002)

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Perceived action efficacy

Question: Do you believe that feeding food from at least four food groups every day helps to prevents malnutrition?

Doers Doers are 15.9 times more likely than Non-Doers to say that feeding from at least four food groups every day helps to prevent malnutrition (p=0.000)


Question: Do you think it is because of God's will/curse/supernatural causes that children become malnourished?

Non-Doers Non-Doers are 4.2 times more likely than Doers to say that God’s will, curse or supernatural cause are not linked with malnutrition (p=0.045)

Access

Question: How difficult is it to get what you need to feed your child with food from at least four groups?

Non-Doers Non-Doers are 3.8 times more likely than Doers to say that accessing food from at least four groups is very difficult for them (p=0.015)

Doers Doers are 11.1 times more likely to report financial problem for accessing food from at least four groups is very difficult for them (p=0.028)

3.3. Behavior: Food Frequency Results of the Barrier Analysis on feeding child at least 3-4 meals per day uncovered six significant determinants. The key significant determinants include social norms, perceived positive consequences, perceived susceptibility, perceived severity, perceived action efficacy, and culture. Social norms

Question: Who is the most important?

Doers Doers are 2.1 times more likely than Non-Doers to say that husband is the most important for them (p=0.046)


Question: What is the disadvantage of feeding food at least 3-4 times per day? Non-Doers Non-Doers are 3.6 times more likely than Doers to say that feeding food at least

3-4 times per day causes financial problem for them (p=0.034)


Question: How likely is that a child becomes malnourished?

Doers Doers are 2.4 times more likely than Non-Doers to say that their child was somewhat likely to become malnourished (p=0.017)

Non-Doers Non-Doers are 3.6 times more likely than Doers to say that they don’t know how likely is their child to become malnourished (p=0.034)

Perceived severity

Question: How serious would be if your child becomes malnourished?

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Doers Doers are 3.1 times more likely than Non-Doers to say that it would be somewhat serious if their child becomes malnourished (p=0.006)

Cues for action

Question: What makes it easy to remember to feed their child at least 3-4 times per day?

Doers Doers are 2.7 times more likely than Non-Doers to say that having family meal plan makes it easy to remember to feed their child at least 3-4 times per day (p=0.032)

Culture

Question: Are there any cultural rules or taboos that you know of that discourage you feeding at least 3-4 times a day?

Doers Doers are 3.3 times more likely than Non- Doers to affirm that there are cultural rules or taboos that discourage feeding at least 3-4 times per day (p=0.006)

3.4. Behavior: Iron-rich food consumption Results of the Barrier Analysis on consumption of iron-rich foods discovered six significant determinants. The key significant determinants include self-efficacy, social norms, perceived susceptibility, perceived severity, cues for action, divine will and access. Self-efficacy

Question: What makes it easy for you to consume iron-rich food every day?

Doers Doers are 5.1 times more likely than Non-Doers to say that husband’s awareness about iron-rich food makes it easy. (p=0.004)

Non-Doers Non-Doers are12.6 times more likely than Doers to say that ability to afford makes iron-rich food consumption easy (p=0.002)

Question: What makes it difficult?

Non-Doers Non-Doers are 7.3 times more likely than Doers to say that unavailability of iron-rich food makes consumption difficult (p=0.029)

Social norms

Question: Who encourages you consuming iron-rich food every day?

Non-Doers Non-Doers are 3 times more likely than Doers to say that mother approves consumption of iron-rich food (p=0.032)


Question: How likely is it that you could have anemia?

Doers Doers are 3 times more likely than Non-Doers to say that they were somewhat likely to have anemia (p=0.018)

Non-Doers Non-Doers are 9.8 times more likely than Doers to say that they are very likely to have anemia (p=0.008).

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Perceived severity

Question: How serious would it be if you were to have anemia?

Doers Doers are 3.5 times more likely than Non-Doers to say that it would be somewhat serious if they were to have anemia (p=0.019)

Non-Doers Non-Doers are 2.6 times more likely than Doers to say that they don’t know how serious it would be if they had anemia (p=0.022)

Cues for action

Question: What makes it easy to remember to eat iron-rich food every day?

Doers Doers are 17.9 times more likely than Non-Doers to say that self-awareness makes it easy to remember to consuming iron-rich food (p=0.000)


Question: Do you think it is because of God's will/curse/supernatural causes that they could have anemia?

Doers Doers are 2.8 times more likely than Doers to say that God’s will, curse or supernatural cause are not linked with causing anemia (p=0.018)

Access

Question: How difficult is it for you to get iron-rich foods every day?

Non-Doers Non-Doers are 4 times more likely than Doers to say that accessing iron-rich food is very difficult for them (p=0.001)

Non-Doers Non-Doers are 10.3 times more likely than Doers to say that inability to afford makes accessing iron-rich food very difficult for them (p=0.000)

3.5. Behavior: Handwashing at five key times Results of the Barrier Analysis on handwashing explored six significant determinants. The key significant determinants include self-efficacy, social norms, perceived positive consequences, perceived negative consequences, cues for action, and divine will. Perceived self-efficacy

Question: What makes handwashing with soap at five key times easier?

Doers Doers are 4.8 times more likely than Non-Doers to say that availability of soap and water at designated place makes hand washing easier (p=0.000)

Doers Doers are 5.5 times more likely than Non-Doers to say that self-awareness makes hand washing easier (p=0.002)

Non-Doers Non-Doers are 4.2 times more likely than Doers to say that when family members remind handwashing becomes easier (p=0.002)

Question: What makes handwashing with soap at five key times difficult?

Doers Doers are 5.1 times more likely than Non-Doers to say that handwashing is not difficult for them (p=0.004)

Social Norms

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Question: Who approves of handwashing with soap at five key times?

Doers Doers are 3.1 times more likely than Non-Doers to say that they are encouraged by television ads on handwashing (p=0.004)

Question: Who disapproves of handwashing with soap at five key times?

Doers Doers are 3.6 times more likely than Non-Doers to say that no one discourage them to wash hands with soap. (p=0.007)


Question: What are the advantages of handwashing?

Doers Doers are 2.4 times more likely than Non- Doers to say that mother’s practice of handwashing in critical times helps child to be in good health (p=0.042)

Perceived negative consequences

Question: What are the disadvantages of handwashing?

Doers Doers are 5.1 times more likely than Non-Doers to say that there is no disadvantage of hand wash (p=0.006)

Cues for action

Question: How difficult is it to remember to wash hands with soap/ash at five key times every day?

Doers Doers are 2.3 times more likely than Non-Doers to say that remembering to wash hand is not difficult at all (p=0.029)

3.6. Focus group discussions findings Key findings of exclusive breastfeeding showed mothers knew the benefits of breastfeeding while a majority of Non-Doers had a lack of perception of the seriousness of malnutrition. Non-Doer mothers had low skills of proper attachment and positioning of breastfeeding. For dietary diversity, a majority of Non-Doers had lacked in knowledge about food groups while some Doers knew the benefits of rice, green leafy vegetables, fish, meat and local fruits. Non-Doers perceived fish, meat, egg, and fruits to be important food items for their children. They also mentioned these foods were costly for them and this was a barrier to do the behavior. Accessibility was another difficulty for them doing the behavior for several reasons. Husbands often are not available at home since they go fishing in the sea and they have limited opportunities to buy different foods. As the local norm, women generally do not go to market for purchasing so accessibility is an issue for them. Some participants shared they cook two food items three times a meal so there is less scope for ensuring the dietary diversity of the child. Some Doers mentioned they feed formula to their children that they learned from neighbors. For feeding children 3-4 times per day, perception about the negative consequences is mentioned by Non-Doers as a barrier. Mother in laws discourages mothers from feeding 3-4 times because they perceive that child cannot digest foods if fed frequently. Non-Doers also lacked understanding about the connection between poor feeding and malnutrition while Doers had an understanding of the risk of malnutrition as an effect of poor diet. For consumption of iron-rich food both Doers and Non-Doers had knowledge about anemia as ‘decreasing blood in body’ but Non-Doers had poor knowledge about the consequences of anemia. Non-Doers perceive,

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consuming chicken helps increase blood in the body. Doers mentioned spinach and green vegetables that are important to increase blood. Doers reported their husband’s support was important for consuming iron-rich foods. For handwashing, the majority of both Doers and Non-Doers had a lack of knowledge about five critical times of handwashing. Non-Doers reported unavailability of soap and water close to the toilet was the main barrier for not being able to wash hands. Some other Non-Doers think lack of reminder was a barrier for their handwashing. The inability to spend money on the soap for handwashing was mentioned by some Doers and Non-Doers.

3.7. Behavior change materials In the focus group discussion, ranking exercise was conducted to select behavior change materials. As referred in the following table, most of the participants like flipchart for an educational session with participants. Group communication was also highly preferred by them.

Table-3: Ranking on behavior change materials Material Type Total

point Reasons for suggesting FGD ID and Frequency of response

Flipchart 60 They liked the picture/illustrations because these illustrations are attractive and easy to understand for those who cannot read or write.

Doers at Rajapalong FGD on iron-rich food consumption (12)

Non-Doers at RajapalongFGD on food frequency (10)

Doers at Jaliapalanog FGD on exclusive breastfeeding (10)

Non-Doers at Jaliapalong FGD on dietary diversity (10)

Doers at Baharchara FGD on Handwashing (9)

Non-Doers at Baharchara FGD on exclusive breastfeeding (9)

Cue card 16 Cue card can be hanged in a relevant place at home so they can remember practicing the particular behavior.

Doers at Rajapalong FGD on Iron-rich food consumption (5)


Non-Does at Rajapalong FGD on food frequency (02)

Doers at Baharchara FGD on handwashing (3)

Non-Doers at Baharchara FGD on exclusive breastfeeding (3)

Banner 07 Everyone can see and learn the recommended behavior.

Doers at Palongkhali FGD on Dietary Diversity (07)

Poster 02 If poster is given then they can use at home

Doers at Palongkhali FGD on dietary diversity (02)

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even if they are not literate.

Group communication

23 In group everyone can raise the voice.

Everyone can have equal opportunity to talk.

In the group meeting they can share issues with others.



Non-Doers at Jaliapalong FGD on dietary diversity (07)

Individual communication

02 In individual meeting all the issues related to their family can be shared.


4. Discussion This section presents the discussion about behavioral determinants that serve as motivators or barriers to the targeted behaviors. Only significant determinants are discussed here.

4.1. Exclusive breastfeeding The results indicate that self-efficacy is important for facilitating exclusive breastfeeding. There is a need for growing self-efficacy among mothers through tailored counseling and skilled support. Insufficient knowledge and skills of breastfeeding is a barrier for Non-Doer mothers to practice exclusive breastfeeding. The implementation team has to work on improving the knowledge of positioning an attachment of the baby while breastfeeding. Non-Doers also do not feel as motivated as Doers in exclusively breastfeeding their children. For mothers that do exclusively breastfeed, one barrier is insufficient breast milk; mothers perceive that they are physically weak and they cannot produce enough breast milk. This result suggests that misconception about milk production has to be decreased. Family member’s support is another important enabling factor stated by Doers that make breastfeeding easy. In local practice, a mother has to do all the household work which often becomes a burden for them making breastfeeding and child care difficult. Support from a sister in law or mother in law in doing household work would make it easier for a mother to breastfeed. The implementation team can focus on reducing the burden of work of mothers by motivating family members to assist mothers in their home tasks. Social norms which prescribe authority and decision making primarily to men in a household, are another important determinant for exclusive breastfeeding. Though Non-Doers are not practicing proper breastfeeding, they reported that the husband approves exclusive breastfeeding, mostly. Thus, husbands are potential influencers for mother’s breastfeeding. This indicates that a husband can be utilized as an enabler in promoting exclusive breastfeeding. Doer’s responses indicate that they are aware of the importance of breastfeeding. So, mothers are the key actors in promoting breastfeeding if they are given the proper knowledge and skills of breastfeeding. Doers understand that exclusive breastfeeding can keep their child in good health and protected from diseases. This implies that Doers recognize one of the primary benefits of breastfeeding is the child’s good health. This perception of positive consequences can be an enabler for promoting exclusive breastfeeding. Doers

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perceived severity or seriousness of malnutrition to be very high and they are practicing breastfeeding thinking that malnutrition can be a very serious problem for their children. It demonstrates that the perceived seriousness of malnutrition can be a potential enabler to practicing exclusive breastfeeding. Action efficacy is another significant determinant of breastfeeding behavior. This indicates Doers understand the relationship between exclusive breastfeeding and reducing the likelihood of their child becoming malnourished. On the contrary, Non-Doers think breastfeeding cannot help to prevent the malnutrition of children. Implementers of the EFSP project need to ensure that mothers have the correct understanding of these causal relationships so that they fully understand the importance of why they need to practice exclusive breastfeeding with their child. Doers have a strong opinion that there is no relationship between malnutrition and God’s will or curse or any natural causes. So, there is no need to address this determinant because this is not influencing their perception.

4.2. Child dietary diversity The result indicates that perceived self-efficacy is a significant behavioral determinant for ensuring child dietary diversity. Doers believe that the availability of foods from all food groups is very important to ease ensuring child dietary diversity. This availability means having a home gardening option and market is at a close distance. Non-Doers think having the ability to afford foods is key to ensure dietary diversity. This data reinforces the idea that access is a key determinant for child dietary diversity. Having greater accessibility helps a family feed the child at least 4 groups of food. Family preference for the daily meal is another important factor that makes maintaining dietary diversity easy for Doers. Non-Doers think the family preference of meal items is a barrier to maintaining a diverse diet for the child. In the focus group discussion, it was found that meals are cooked considering men’s preference. From the Doer's perspective, there are several barriers stated. Doers report that child illness makes it difficult feeding diverse foods to the child. This may be because they lack skills of feeding a sick child. EFSP implementation team has to educate mothers and caregivers about sick child feeding techniques. Another barrier reported by Doers is the inability to purchase foods. It implies that they have a misperception about food groups that are not expensive. They perceive that all foods important for dietary diversity are expensive. While animal-sourced foods are relatively expensive, leafy greens and colorful vegetables are inexpensive and locally available around the homestead and can be used to support child nutrition. The implementation team has to promote local low-cost food groups to ensure dietary diversity. Doers perceived another barrier to food diversity, that of their self-illness. Given that women are responsible for doing all household tasks, meal preparation for the family is disrupted when a mother becomes ill. EFSP implementation team can educate mothers about their self-care to remain healthy and encourage men to share the responsibility of doing household tasks such as cooking, cleaning etc. The social norms are another important behavioral determinant for Doers to promote child dietary diversity. Among the family members, husbands mostly encourage mothers to feed children with diverse types of foods. It seems that husbands are potential enablers for ensuring child dietary diversity. Doers also think neighbors disapprove feeding a diverse diet. Neighbors often encourage women to use formula feeding (based on the television ads information) as well as advise mothers not to rely only on family food for feeding children. Additionally, focus group discussion findings revealed misconceptions among mothers about proper complementary feeding practices. This raises the need for increased education through counseling about provision of diverse meals every day. In the local context, for the extended family, it is

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difficult to plan a meal that suits everyone. Generally, family meals are prepared considering the choice of male members and elderly members of the family. Family members have to be taught how to support and play a positive role in including child food groups in the daily family meals. This activity can be integrated into MenCare groups awareness sessions so that the perception about the roles of male caregivers in ensuring child dietary diversity is increased. The perceived advantage of feeding a diverse diet is significantly higher among Non-Doers compared to Doers. However, knowledge is not enough for adopting a behavior and having a positive perceived advantage of feeding diverse diet cannot help alone adopt the behavior. Even though Non-Does are aware of positive consequences of feeding diverse food to children, they are not practicing the behavior. They believe that feeding a diverse diet can ensure the child’s physical growth and it can keep a child in good health, and that there are no disadvantages coming from feeding a diverse diet. In summary, Non-Doers have positive perceptions about feeding diverse diet, but these perceptions are not enough for the adoption of feeding diverse diet. As data indicates, the accessibility to food is actually the strong motivator for adoption of feeding diverse diet. In regards to the accessibility to food diversity, Non-Doers think availing different food groups is very difficult for them whereas Doers think availing food from different groups is not difficult at all for them. This finding helps better understand that although Non-Doers have a clear perception of the positive and negative consequences of feeding a diverse diet, accessibility to diverse food is a major barrier for them to practice this behavior. Doers also reported financial barrier to access food from at least four groups. Thus, the implementation team should focus on increasing accessibility to diverse foods. They can impart training on home gardening for beneficiaries so that they can increase the availability and accessibility of foods. They should be taught the importance of low cost, locally available foods that contain good nutritional value. Perceived susceptibility is another important determinant to understand barriers and enablers around dietary diversity. Doers have the perception that their children are somewhat likely to become malnourished if they are not fed with diverse foods. On the other hand, Non-Doers believe their children are not likely at all susceptible to become malnourished. It seems Non-Doers do not have a clear understanding of malnutrition. Lack of susceptibility perception is a barrier for Non-Doers to practice feeding diverse diet. On the other hand, having clear understanding of malnutrition is influencing Doers to practice the behavior. It seems that having proper understanding about malnutrition can be an enabling factor for practicing dietary diversity. Concerning perceived severity, Doers understand that malnutrition can be very serious, so perceived severity serves as a motivator for providing diverse food to the child. Doers are showing a positive attitude admitting that feeding food from at least four food groups helps to prevent malnutrition. Non-Doer’s lack of a clear understanding of the relationship between malnutrition and poor feeding practice is a barrier. Non-Doers reported more often that they do not know any local belief like God’s will or curse or supernatural causes is linked with malnutrition. This indicates that perceiving divine will is not important to address in behavior change communication.

4.3. Food frequency Doers indicate that husbands are the most important figure in encouraging the feeding of children 3-4 times per day. EFSP implementation team has to work on motivating MenCare group building awareness among care groups about infant and young child feeding to influence behavior change. Doers have a strong opinion

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that feeding 3-4 times per day has no negative consequence whereas Non-Doers think feeding 3-4 times a day is difficult because of the inability to afford. Focus group discussion explored that they (Doers) do not cook a separate meal for children because they perceive it causes extra expenditure. They cannot spend extra money for that. As a result, the poor families cannot arrange complementary feeding alongside continued breastfeeding. The implementation team has to work on reducing the perception that child meal causes extra expenditure. The cash for work component should be integrated with nutrition so that participants can overcome the barrier. Also, there is a need for training on how to manage inexpensively an infant and young child feeding. Doers are feeding children 3-4 meals per day and perceive that malnutrition is somewhat serious. On the other hand, Non-Doers indicated that they don’t know about the likelihood or consequences of severe malnutrition, so they may lack the motivation to practice frequent feeding. Improving Non-Doers’ understanding of malnutrition may be an influential enabler for behavior change. Doers can remember to feed their child 3-4 times a day with the help of having a family meal plan for a child. For this question, a significant number of Non-Doers did not give any response. From the focus group discussions with Non-Doers, it was found that Non-Doers had very low levels of understanding about infant and young child feeding and food groups for the child. So, it may be more of an issue of lack of knowledge, rather than an inability to remember because one cannot remember to practice a behavior if the person does not know what the behavior is about. Doers are practicing the behavior, even though they think there are cultural rules that discourage feeding 3-4 times per day. On the other hand, mothers who are not practicing the behavior think there is no cultural rule or taboo that discourages feeding enough number of times per day. In the focus group discussions, it was found that the community believes frequent feeding would cause indigestion for the child that could even result in diarrhea. These findings uncovered potential cultural barriers for Doers but the barrier for Non-Doer is not clear. However, since the Doers are practicing the behavior; the barrier may not be highly influential to affect the current behavioral status.

4.4. Iron-Rich food consumption The results demonstrate that the husband’s awareness is the key enabling factor for iron-rich food consumption by the mothers who are practicing the behavior. In the focus group discussions, it was found that in some families’ husbands are conscious about their wives’ health. Women find iron-rich food consumption is easy when their husband purchase those items regularly. Husband’s awareness about women’s need for iron can be a potential enabling factor for behavior change. Non-Doers think unavailability makes iron-rich food consumption difficult for them. These results indicate that Non-Doers perceive iron-rich foods must be costly. In the focus group discussion, they mentioned that animal food sources of iron are costly and not available always in remote areas. It also seems that they lack knowledge about green leafy vegetables to be also a source of iron. These leafy vegetables are not expensive and easily available in their homestead areas and local markets. EFSP implementation team can increase their understanding of alternative sources of iron-rich food. Non-Doers also reported that their mothers encourage them to consume iron-rich food. That means they mostly communicate with their mothers regarding their health issues rather than sharing their issues with their mother in law. In Bangladesh culture (particularly in the rural areas), after marriage women stay at in-law’s house where they live together with their husband, mothers in law and other extended family members. Not being able to communicate with husband and mother in law for their urgent issues may be a barrier for women to adopt the appropriate behaviors. The implementation team has to focus on improving communication between care groups

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members and their close family members they have daily interaction with, such as husbands and mothers in law. Lack of knowledge about serious consequences of anemia can also be a barrier for Non-Doers. Both groups, neither Doers nor Non-Doers could name any of the benefits of consuming iron-rich food. It seems both groups lack understanding about the link between iron deficiency and anemia and thus lack motivation. Non-Doers do not know about the seriousness of anemia and are unconscious about the serious consequences of becoming anemic. The implementation team should focus on developing a clear understanding of the benefits of consuming iron-rich foods.

4.5. Handwashing Results demonstrate that self-efficacy is a significant determinant for handwashing behavior. For Doers, the availability of soap and water at the designated place and self-awareness are important factors easing handwashing at five key times. On the other hand, Non-Doers think reminder from family members is a key factor to ease handwashing. In comparing both the groups, Doers have self-awareness whereas Non-Doers depend on family members’ reminders for handwashing. Developing self-awareness about the need for handwashing and educating family members to remind mothers to wash their hands could increase handwashing rates among Non-Doers. About the difficulties related to handwashing, Doers think handwashing is not difficult for them. Overall, it seems the availability of soap and water at designated place and self-awareness are potential enablers for handwashing behavior change. Social norms also play a vital role in handwashing behavior. Television advertisements played a significant role in encouraging Doer’s to wash hands, hence a mass media campaign about handwashing could be beneficial. Another barrier for Non-Doers comes out of the perceptions about positive and negative consequences of handwashing practices. Doers have the perception that proper handwashing by a mother can keep the baby in good health by reducing the chance of transmitting germs. They are also clear that hand washing has no disadvantages. In contrast, Non-Doers could not mention any significant advantages of handwashing. Having the perception of child good health for the practice of proper handwashing is an important enabler for behavior change thus the implementation team has to promote these positive perceptions among the beneficiaries of the EFSP program. Cues for action are another significant determinant for handwashing behavior. Doers think remembering to wash hands is not difficult at all whereas Non-Doers think it is somewhat difficult. Considering the self-efficacy about handwashing along with this finding, reminder for handwashing can be an important factor for Non-Doers to influence their behavior.

5. Behavior Change framework Based on the discussions above on significant determinants, some bridges to activities have been identified to promote behavior change among EFSP beneficiaries. A set of activities has been also suggested to support each of the bridges to activities for each identified determinant. The implementation team has to follow those activities and prepare relevant Behavioral Communication Change (BCC) materials to promote targeted behaviors in project areas. The following tables contain the behavior change framework for each of the five behavioral areas of the EFSP project.

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5.1. DBC-Breastfeeding: Lactating mothers provide exclusive breastfeeding for their child up to 6 months of age

Priority Group Priority Group: Host community mothers of children U5 enlisted in EFSP from Ukhia and

Teknaf areas

Influencing Group: Husband, Mother-in-law

Determinant Perceived self-Efficacy, Social norms, Perceived positive consequences, Perceived Severity, Perceived action efficacy and Divine will

Bridges to activities Improve the knowledge and skills about breastfeeding including positioning and attachment to increase breast milk supply.

Improve and grow efficacy among mothers about communicating with mother in law if they need any support for ensuring breastfeeding.

Decrease the perceptions that mothers have insufficient breast milk hence they are unable to breastfeed.

Increase the support of family members so that they can assist mothers for the household work and mother can get time for breastfeeding.

Increase husband’s involvement and role play in exclusive breastfeeding. Increase the engagement of members especially husband and mother in law for their

responsibility to provide psychosocial support to mother. Increase the perceptions that exclusive breastfeeding can ensure good health for child. Increase knowledge about malnutrition and its bad effects on child health. Increase understanding about the connection between poor breastfeeding and

malnutrition. Increase the perception that exclusive breastfeeding reduces the chance for the child to

be malnourished. Expand the perception that malnutrition is not connected with God’s will or curse or

supernatural cause’s rather poor breastfeeding practice is responsible for child malnutrition.

Activities Session content may be

To support perceived self-efficacy

Mothers should be taught about the advantage of exclusive breastfeeding (for example: physical growth, mental growth, avoid disease) through groups sessions as well as individual counseling so their knowledge increases.

Mothers should be taught about the disadvantage of not breastfeeding the child (for example: wasting, more disease, malnutrition) through group sessions as well as individual counseling so they understand the risks associated with poor exclusive breastfeeding.

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Mothers should be taught about managing the misperception about insufficient breast milk using verbal persuasion. The objective of this activity to grow their self-efficacy about exclusive breastfeeding.

Mother should be trained about proper positioning and attachment through visualizing educational materials, videos or doll demonstration so they learn and gain skills of proper breastfeeding.

Mothers should be taught in group or individually about the fact that anemic mothers should continue exclusive breastfeeding because it helps anemic mothers to delay menstrual cycle that helps them not losing blood. This activity will motivate them about breastfeeding.

To support social norms

Husbands and mothers in law should be motivated through group sessions to support mothers for exclusive breastfeeding of the infant. This will increase family support for Exclusive Breastfeeding.

To support perceived positive consequences

Mothers and caregivers should be taught through group sessions about the notion that children that are exclusively breastfeed will be more intelligent. This will motivate them for practicing exclusive breast feeding.

Mothers should be taught through group sessions that exclusive breastfeeding helps for a better bonding between mother & child.

To support perceived severity

Mothers should be taught through group sessions that non-exclusively breastfeed babies are susceptible to malnourishment and wasting

To support perceived action efficacy

Mothers should be taught through group sessions that exclusive breastfeeding can protect their child from being malnourished.

Specific BCC materials

Use of Flip charts to enhance understanding Strengthening Counseling skills of service providers (Mother Leaders)

Poster/ Pictorial cards to be delivered to mothers Use of flipchart including indicative illustrations to educate care group members

Use of pictorial cards for showing proper attachment and positioning for breastfeeding

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5.2. DBC-Dietary diversity: Mothers of children aged 6-23 months who feed a diverse diet to their children containing food from at least 4-7 food groups per day.

Priority Group Priority Group: Host community mothers of <5children enlisted in EFSP from Ukhia and Teknaf areas


Determinant Perceived self-Efficacy, Social norms, Perceived positive consequences, Perceived susceptibility & Severity, Perceived action efficacy and Access

Bridges to activities Increase mother’s knowledge about child food groups. Increase the perception that low cost foods like leafy and colorful vegetables are

nutritious. Increase the perception that adding child food groups in the family daily meals eases

the diet diversity for the child. Increase husband’s sense of responsibility to purchase different food items for child. Increase mother’s knowledge about sick child feeding. Increase mother’s knowledge about child health care so that child does not fall ill

frequently. Increase mother’s knowledge about their self-care so that they do not fall ill frequently. Increase the perception that homemade food is sufficient for child nutrition and there

is no need for formula feeding. Increase caregivers/ family members’ supportive role in keeping child food groups in

daily family meal. Increase the perception that feeding the child with diverse foods helps keeping the

child in good health. Reduce the wrong perception that feeding diverse food makes the child throw up milk

and food. Increase the perception that if not fed with diverse nutritious type of foods, baby may

become malnourished. Increase the perception that feeding diverse diet can protect their child from

malnutrition. Improve access to different types of food groups by providing knowledge about low

cost locally available food items from child food groups. Activities Session content may be

To support perceived self-efficacy Mothers and mothers in law should be taught about different food groups using food

posters in group sessions. It will increase their understanding on different food groups for children.

Mothers and mothers in law should be taught about the nutrition value of different food groups. This will make them understand the importance of these foods for the child.

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Husbands and mother in laws should be taught about the importance of their support for ensuring child food groups in the daily family meal. Mother in law and husband should assist mothers in cooking so becomes easy for them to do household work and prepare diverse foods altogether.

Men members of care groups should be taught about their role for ensuring child dietary diversity. They have the responsibility to purchase foods from 4 of 7 seven food groups.

Mothers should be trained individually or in group about techniques of sick child feeding and child care.

To support social norm Mothers and husbands should be taught about the difference between homemade food

and formula. For example, formula food is expensive whereas homemade diverse food is sufficient and good for child nutrition.

Mothers in law should be taught in group meetings about their role in supporting for cooking food groups necessary for children and including those foods in family daily food diet.

To support perceived positive consequences Mothers, husbands and mothers in law should be taught in group meetings about the

benefits of diverse food diet. It will help them understand the positive reasons for adopting the behavior.

Mothers should be taught in group meetings about the reasons why child throws up breast milk. This will make them understand that child does not throw-up because of feeding diverse foods.

To support perceived susceptibility and severity

Mothers should be taught in group meetings about the connection between poor diet and malnutrition. It will motivate them adopting the proper behavior.

To support perceived action efficacy

Mothers should be taught in group meetings that feeding child with diverse and nutritious foods can help to avoid malnutrition.

To support access

Mothers should be taught in group meetings about the nutritional values of food items that are available locally, close to their homes and not expensive. Encourage them to use these food items for the daily diet of children.

Specific BCC

▪ Develop educational BCC materials Pictorial BCC materials like flipchart, food poster Prepare food groups posters to hang inside household walls

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5.3. DBC-Food Frequency: Mothers of children aged 6-23 months who feed their children 3-4 times every day.

Priority Group Priority Group: Host community mothers of <5children enlisted in EFSP from Ukhia

and Teknaf areas


Determinant Social norms, Perceived positive consequences, Perceived susceptibility & Severity, Cues for action and Culture

Bridges to activities Increase husband’s involvement in child feeding process. He should provide support and encourage the mother for feeding the child 3- 4 meals per day.

Increase engagement of family members for their support to mother for providing sufficient number of meals to the child.

Increase mother’s knowledge about child infant and young child feeding. Decrease the perception that feeding children 3-4 times per day does cause extra

expense for a poor family. Increase risk perception among mothers that poor infant and young child feeding

can cause malnutrition for their children and this malnutrition can be serious. Increase caregivers’ engagement in infant and young child feeding process at

family level to help reminding mothers for feeding children 3-4 times per day. Reduce the community beliefs that frequent feeding causes indigestion problem

for the child. Activities Session content may be

To support social norm Husbands should be taught in MenCare group about the importance of their role

in supporting mothers for ensuring 3-4 times per day. It will enhance husband’s engagement and support in child feeding process.

Caregivers including mother in laws should be taught in group meetings about their role in supporting mothers for ensuring 3-4 meals per day for the child. It will enhance caregivers support on feeding.

Mothers should be taught in group sessions about infant and young child feeding process using pictorial materials, video to increase their understanding about frequency of feeding. It will help mothers be more supportive about feeding children 3-4 meals per day.

To support perceived positive consequences Mothers and husbands should be taught in separate group sessions about the

prices of low-cost foods items. Food chart can be visualized comparing the prices of foods to make them understand that low cost vegetables have good nutritional value and it does not cause financial problem for a poor family.

To support perceived susceptibility and severity

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Mothers should be taught in group sessions about the link between poor diet and risk of malnutrition. Also, discussion should focus on the fact that malnutrition can be very serious for their children’s health.

To support cues for action Mothers and husbands should be taught in separate group sessions about their

roles in supporting and reminding mothers for feeding enough number of times per day. It will reinforce mothers to feed children 3-4 times per day.

To support access Mothers and husbands should be trained on home gardening to help them

cultivate green leafy vegetables around their home. Mothers, husbands and mothers in law should be taught in separate group

sessions that there are some other reasons that causes indigestion problem in children.

Specific BCC

▪ Develop educational BCC materials Pictorial BCC materials like flipchart Cue card may be prepared with child feeding information

5.4. DBC-Iron-rich Food consumption: Women of 15-49 years of age consume iron-rich foods every day


and Teknaf areas


Determinant Perceived self-efficacy, Social norms, Perceived susceptibility & Severity, Cues for action and Access

Bridges to activities Increase husbands’ awareness about the importance of iron-rich food consumption by women.

Increase husbands’ sense of responsibility for availing iron-rich foods for their wives.

Increase knowledge about iron requirements among mothers and girls’ adolescents.

Increase the knowledge that green leafy vegetables contain great amount of iron that are affordable even for a poor family.

Increase communication and information sharing between mothers in law and mothers.

Increase the knowledge about the benefits of consuming iron-rich food every day among women, husbands and mothers in law.

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Increase risk perception about anemia and its serious effect on women’s health.

Increase self-awareness about iron-rich food consumption to improve mother remembering capacity.

Increase women’s interest in collecting and consuming green leafy vegetables that are available around their home and that are less costly.

Activities Session content may be To support self-efficacy

Husbands should be taught in MenCare group sessions about the importance of iron-rich food for their wives. They should be explained that their awareness is important for increasing the consumption of iron-rich foods by women.

Mothers, adolescents and mothers in law should be taught in group sessions about the need for iron-rich food consumption, iron-rich food items, their availability, cost and effectiveness of avoiding anemia.

To support social norms Mothers and mothers in law should be taught in group sessions about the

importance of sharing and discussing their needs and wishes. It will help mothers gain the confidence to voice the need for support from family related to food items and cooking.

Women and mothers in law should be taught in group sessions about the importance of mother in law’s supporting role in ensuring iron-rich foods daily consumption. It will influence mothers in law to support the cooking of iron rich foods.

To support perceived positive consequences Mothers, husbands and mothers in law should be taught in separate group

sessions about the benefits of consuming iron-rich foods daily. To support perceived susceptibility and severity

Mothers and adolescents should be taught in group sessions about the connection between not consuming iron-rich food and anemia. Also, discussion should be focused on the serious health consequences of anemia for women and adolescents.

To support cues for action Mothers should be engaged in group session activities such as food card

identification for raising their self-awareness. It will help them to grow their tendency to remember consuming iron-rich food in daily basis.

To support access Women and mothers in law should be taught in group sessions that green leafy

vegetables available around their homestead garden are rich in iron and easy to access.

Specific BCC Develop educational BCC materials Pictorial BCC materials like flipchart, poster, food cards Cue card may be prepared with dietary diversity information Bill board can be set at intersection depicting green leafy vegetables

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5.5. DBC-Handwashing: Mothers of children aged 0-23 months wash hands at five key times


and Teknaf areas


Determinant Perceived self-efficacy, Social norms, Perceived positive consequences and Cues for action

Bridges to activities Increase the availability of soap and water at designated places for washing hands with soap at five key times.

Increase the discussions about hand washing within families. Expand the idea that mother’s hand washing practice helps baby remain in good

health. Increase the understanding about benefits of washing hands with soap in five key

times. Increase family members’ involvement in reminding mothers about hand

washing in five key times.

Activities Session content may be To support self-efficacy

Husbands should be trained using financial literacy training on how to manage household expenditures. This will help them better understand budgeting and increase the affordability of purchasing soap for hand washing. Motivate them (including mothers) to ensure access to water close to toilets and other required places.

Mothers should be taught in group sessions about the five critical times required to wash hands with soap. This will make them aware about the times that require handwashing.

To support social norm

Women and mothers in laws should be taught in group sessions about the importance of hand washing in critical times. It is important to grow a common feeling in family that they do not like if someone of their family does not wash hands.

To support perceived positive consequences Mothers should be taught in group sessions that baby remains in good health if

caregivers wash hands with soap especially before feeding the child. It will create positive understanding among caregivers about the benefits of hand washing.

Mothers, husbands and mother in laws should be taught about the benefits of handwashing. It will motivate them for washing hands for their health benefits.

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To support perceived susceptibility and severity Mothers should be taught in group sessions about the relationship between not

washing hands with soap and diarrhea. Also, there is need to discuss that dirty hands can be very serious for child as well as adult’s health. This will create the sense about the risk of not hand washing.

To support cues for action

Mothers, husbands and mothers in law should be motivated so they can remind each other for hand wash with soap. It will solve the problem of not being able to remember handwashing.

Specific BCC

Develop educational BCC materials Pictorial BCC materials like flipchart Demonstrate handwashing techniques Cue card may be prepared with hand washing information Bill board can be set at intersection depicting hand washing techniques

6. Conclusion

This study has explored several barriers and enablers related to infant and young child feeding practices. These practices are strongly associated with gender issues at family level. Practicing proper infant and young child feeding becomes burden for a mother along with performing household works. Family members especially husbands and mothers in law’s support is important to reduce a mother’s work burden. The implementation team has to work at individual level and sensitize targeted mothers, their husbands and mothers in law. Engaging this care group into the program, all the bridges to activities and activities proposed have to be implemented according to local context.

7. References 1. Kittle Bonnie.2013. A Practical Guide to Conducting a Barrier Analysis. New York, NY: Helen Keller

International. Accessed on 1 December 2019. https://pdf.usaid.gov/pdf_docs/PA00JMZW.pdf 2. ISCG. Multi-sector Needs Assessment Taknaf and Uhkia Upazilas, Bangladesh. 2019. 3. Reliefweb. Joint response Plan for Rohingys Humanitarian Crisis (January-December). 2019. 4. WFP. Rohingya Emergency Vulnerability Assessment (REVA) - SUMMARY REPORT Cox’s Bazar,

Bangladesh, December 2017. 5. ACAPS NPM. Rohingya crisis. Host Communities Review.2018. 6. WFP. Rohingya Refugee Emergency Food Security Update. December 2018. 7. Black RE, Victora CG, Walker SP, Bhutta Za, Christian P, de Onis M, et al. Maternal and child nutrition

and overweight in low-income and middle-income countries. Lancet. 2013;382:427-451. 8. World Health Organization. Strengthening action to improve feeding of infants and young children 6-

23 months of age in nutrition and child health programs: Report of proceedings. Geneva; 6-9 October 2008.

9. Avula R, Menon P, Saha KK, Bhuiyan MI, Chowdhury AS, Siraj S, et al. A program Impact Pathway Analysis Identifies Critical Steps in the Implementation and utilization of a Behavior Change

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Communication Intervention Promoting Infant and Child Feeding Prctices in Bangladesh. J. Nutr. 2013; 143(12):2029-2037.

10. Ahmed T, Mahfuz M, Ireen S, Ahmed AM, Rahman S, Islam MM, et al. Nutrition of Children an dwome in Bangladesh: Trends and directions for the future. J Health Popul Nutr. 2012; 30(1):1-11.

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13. Joint Response Plan for Rohingya Humanitarian Crisis, 2019. http://reporting.unhcr.org/sites/default/files/2019

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8. Annexes Box-1: Behavioral determinants in the Barrier Analysis framework (Kittle Bonnie, 2013).

1. Perceived self-efficacy/skills - An individual's belief that he/she can do a particular behavior given his/her current knowledge and skills.

2. Perceived social norms - The perception that people important to an individual think that he/she should do the behavior. Norms have two parts: who matters most to the person on a particular issue and what the person perceives those people think he/she should do.

3. Perceived positive consequences - What positive things a person thinks will happen as a result of performing a behavior. These may include advantages (benefits) of the behavior, attitudes about the behavior, and perceived positive attributes of the action.

4. Perceived negative consequences - The negative things a person thinks will happen as a result of performing a behavior, these will include disadvantage of the behavior, attitudes about the behavior, and perceived negative attributes of the action.

5. Access – Access has many different dimensions. It includes the degree of availability of the needed resources or services required to adopt a given behavior. It also includes barriers related to cost, geography, distance, linguistics, cultural issues, and gender.

6. Cues for action/reminders – This is about the presence of reminders that help a person remember to do a particular behavior or the presence of reminders that help a person remember the steps involved in doing the behavior.

7. Perceived susceptibility/risk - A person's perception of how vulnerable or at risk he/she feels to the problem that is being addressed/prevented by adopting certain behavior.

8. Perceived severity – The belief that the problem (being prevented by the behavior) is serious and needs to be prevented.

9. Perceived action efficacy - The belief that by practicing the behavior one will avoid the problem or the belief that the behavior is effective in avoiding the problem.

10. Perceived divine will – This is about a person’s belief that it is God’s will (or the gods’ wills) for him/her to have the problem and/or to overcome it. It includes the priority group’s perception of what their religion accepts or rejects and perceptions about the spirit world or magic (e.g., spells, curses).

11. Policy - Laws and regulations (local, regional, or national) that affect adoption of behaviors and access to products and services required for the adoption of certain behaviors.

12. Culture - The set of history, customs, lifestyles, values, and practices within a self-defined group. May be associated with ethnicity or lifestyle.

List of attachments to the report

1. Barrier Analysis questionnaires

2. Focus group discussion guides

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3. Standard Operating Procedure (SOP)

4. Barrier Analysis excel tabulation sheet

5. Focus groups discussions key findings

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