State of Palestine: Investing in assessment positively impacted programming for complementary feeding
Amani Jouda is a Health and Nutrition Officer at UNICEF, State of Palestine.
Fairooz Abuwarda is an Early Childhood Development Officer at UNICEF, State of Palestine.
Rana Awad is a Health and Nutrition Officer at UNICEF, State of Palestine.
Adriana Zarrelli is a Nutrition Expert- Consultant UNICEF, State of Palestine.
Kanar Qadi is a Health and Nutrition Specialist at UNICEF, State of Palestine.
The State of Palestine, and in particular the Gaza Strip, is affected by a protracted humanitarian crisis with acute consequences including lack of access to services, displacement, high rates of poverty, and unemployment. As such, Palestinian families faced multiple constraints – economic, political, market, social, or cultural – that prevented most young children from receiving a nutritious, safe, affordable, and sustainable diet. Access to nutritious foods, clean drinking water, and good quality health services were limited and the resources and capacities of caregivers were already stretched thus limiting attention on infant and young child feeding (IYCF) practices.
Nutrition situation analysis
In 2020 (PCBS & FSS, 2020), one in three households (31.2%) was estimated to be severely or moderately food insecure, this increased by 4.2% between 2018 and 2020 and, in 2022, 70% of households in Gaza and 21% in the West Bank reported difficulties meeting essential food needs because they could not afford them (OCHA, 2022). Of the one in four people in Gaza Strip (23%) who had a poor food consumption score, most (80%) were also receiving some form of humanitarian aid.
Only 40.6% of children were first breastfed within one hour of birth (39.6% in West Bank, 41.9% in Gaza) and 43.3% of children less than six months were exclusively breastfed (44.8% in West Bank, 41.6% in Gaza) (PCBS, 2021). The same survey also showed gaps in the diets of infants and young children, with no more than 35% of children six to 23 months of age consuming a minimum adequate diet and only 44.7% meeting the minimum dietary diversity – which differed between Gaza (35.1%) and the West Bank (50.8%).
The nutrition status of children below five years showed that 8.7% of children were moderately or severely stunted which had increased since 2014 (7.4%). Younger children were more affected with stunting affecting 10.5% of children aged 12 to 17 months and 12.4% of children aged 18 to 23 months. Moderate and severe wasting affected 1.3% of children under five, while 8.6% were overweight and 1.9% severely overweight (PCBS, 2021).
Access to health and nutrition services was sub-optimal; for instance, almost one in four women (22.3%) aged 15 to 49 years with a live birth in the last two years did not access a post-natal care visit which was over one in three (30.0%) in the West Bank (PCBS, 2021).
This article describes UNICEF's support to partners to implement interventions to improve young children’s diets during the complementary feeding period in the West Bank and Gaza Strip, building on the results of a barrier analysis. The interventions aim to support the government and community members to prevent the double burden of malnutrition by establishing healthy dietary behaviours to improve the nutritional status and the diets of children aged six to 24 months.
UNICEF works in the State of Palestine to address a variety of health, nutrition, and development issues affecting pregnant and lactating women and children under five years of age, including social and behaviour change programming. The World Food Programme (WFP) implements unconditional food assistance to non-refugee Palestinians who are living below the poverty line. In addition, WFP conducts nutrition awareness projects to address the multiple burdens of malnutrition in the State of Palestine.
In 2019, as part of the collaboration between UNICEF and WFP to improve nutrition among the most vulnerable women and young children, the two United Nations agencies worked together to conduct a barrier analysis of maternal and child nutrition behaviours which aimed to better understand the facilitating factors as well as the barriers to practicing these behaviours in such a complex environment.
Barriers and motivators to improved complementary feeding
To gain an in-depth understanding of these behaviours in both the West Bank and Gaza Strip, a mixed-methods research approach was taken, including collecting quantitative data by using a barrier analysis questionnaire and a series of in-depth qualitative interviews.
The barrier analysis used a rapid assessment tool to identify the factors that were either preventing or motivating a target group to adopt specific behaviours so that more effective behaviour change communication messages, strategies, and supporting activities could be developed (Kittle, 2017). For the State of Palestine, the six maternal and child nutrition behaviours that were studied were: the rates of exclusive breastfeeding in children below six months of age, the rate of continued breastfeeding of children six to 24 months (in addition to giving complementary foods), the feeding frequency of children six to 24 months, the minimum dietary diversity of children aged nine to 23 months, the prevalence of pregnant and lactating women eating high iron-rich foods, and the prevalence of children two to five years old eating high iron-rich foods. Although different from the range of standard IYCF indicators (WHO and UNICEF, 2021), these six key behaviours were selected because they were promoted through the Ministry of Health, UNICEF, and WFP programmes but had not yet seen improvements according to assessments and programme data.
For each of the six behaviours of the barriers analysis, 45 ‘doers’ and 45 ‘non-doers’ across different communities in both the West Bank and the Gaza Strip were sampled. Purposive sampling was used based on criteria related to the identified behaviours, meaning they were selected because they possessed knowledge that was directly related to the identified behaviours. Sampling considered mother’s age, age of children, location, employment status, highest level of education achieved, and nationality (UNICEF and WFP, 2020). All responses were analysed to identify which determinants had significant differences between doers and non-doers.
In addition to the barrier analysis, a mix of individual, family and interviews in pairs (with two persons at the same time related and non-related) were conducted with 37 participants from the Gaza Strip and seven from the West Bank. Those included mothers, fathers, and mothers-in-law. Six interviews with key informants who were professionals working in Gaza were also conducted and grounded theory was used to guide sampling. These interviews were all qualitative in nature to gain a greater understanding of not just the barriers, but to understand why these barriers affected eating habits and choices and to identify possible change motivators.
The barrier analysis identified key factors that explained the differences between doer and non-doer caregivers for the six behaviours.
For behaviours related to the feeding frequency of children six to 24 months and the minimum dietary diversity of children aged nine to 23 months, the barriers identified included the difficulty of remembering the eight food groups, the lack of food/money for food, the difficulties in securing the food to feed children five solid meals a day, the fact that it was difficult to feed some children a diverse diet as they were refusing to eat specific types of foods or wanted to breastfeed instead of eating food, the lack of control on meal preparation, the complacency about current eating practices, the safety fears that prevented eating certain foods such as iron-rich plant foods, and the perceived risk and severity that were seen by parents as not enough to change behaviour, e.g., parents understood the benefits and sources of vitamins and minerals but often did not see brain development for babies and foetuses as a longer-term benefit.
The barrier analysis also revealed key behaviour differences among mothers in relation to exclusive breastfeeding, e.g., the lack of time, the child not accepting the breast, and the child not becoming ‘full’ from the breastmilk. For the continuation of breastfeeding of children six to 24 months, the key barriers found were the perception by mothers that there were no benefits for them, their child, or their family from continuing to breastfeed.
The barrier analysis also showed that the main barriers to feeding children two to five years-old iron-rich food groups were the family financial situation, the lack of knowledge of which foods are iron-rich, the availability and access to iron-rich foods.
Finally, the barriers identified for pregnant and lactating women to consume iron-rich foods included the accessibility and affordability of iron-rich food with non-doers feeling that they were more susceptible to anaemia while pregnant or breastfeeding.
Key actions taken as an outcome of the barriers analysis
The findings from the barrier analysis for both West Bank and Gaza encouraged all active partners in the nutrition sector to revisit their programmes and introduce improvements to programme implementation at community level, e.g., to include behavioural change of nutrition practices among high-risk women, children, and adolescents. Improvements were also made at policy level.
Actions taken at the policy level
Some of the improvements that were accomplished included the action taken by the Ministry of Health to review and update the maternal and child national nutrition protocol which dated from 2005. This update came as a response to the evidence and research conducted in this field including the results of the barrier analysis.
The update of the protocol aimed to cover the needs of service providers to have one comprehensive document that would guide the service provision in different settings. The protocol covers different areas of maternal and child nutrition including essentials on breastfeeding, complementary feeding, nutritional assessment and growth monitoring of infants and children, infant and young child feeding during emergencies, and the management of acute and chronic malnutrition. The protocol also encompasses the International Code of Marketing of Breastmilk Substitutes which was adopted in 2011.
The review and update of the protocol was coordinated among different stakeholders through the nutrition sub-cluster, reflecting the level of cooperation and engagement among ministries and all relevant nutrition partners including the Ministry of Health, the Ministry of Education, and the United Nations Relief and Works Agency for Palestine Refugees in the Near East.
Actions taken at the service delivery level
The barrier analysis informed the forthcoming nutrition awareness programming and the social behavioural change communication strategy with messages tailored to address the barriers identified by the analysis (See Table 1 for details of future actions).
Actions taken at community and household levels
Ongoing activities such as cooking demonstrations, community mobilisation and parents’ education, and counselling services have the potential to be strengthened and made more specific by using the results of the barrier analysis.
The ‘complementary feeding bowl and spoon’ was identified as an initiative with potential to address some of the findings of the barrier analysis, including caregivers’ difficulty in remembering the eight food groups, within the overall programme to improve the complementary feeding practices for children six to 24 months. The feeding bowl depicts images to support key messaging around young children’s diets and the slotted spoon aims to emphasise the right food consistency. Further details can be found here. The initiative is being implemented as a pilot test in partnership with WFP and two local non-government organisations that each cover different geographical areas in Gaza and West Bank. The initiative targets 20,000 children aged between six to 24 months (10,000 in Gaza and 10,000 in the West Bank) who each receive one feeding bowl and spoon.
The pilot started in Gaza in April 2022 and is due to be completed in December 2022. Activities included the training of 32 health and nutrition staff on complementary feeding and how to present the bowl and spoon to the mothers/caregivers. The trained staff then instructed mothers/caregivers on how best to use the bowl and spoon to improve feeding practices within an overall programme of integrated activities, including mothers/caregivers’ education sessions, cooking demonstration sessions, IYCF counselling sessions (individual and group), and as part of the nutrition and early childhood development assessments.
By the end of August 2022, 2,300 children six to 24 months in Gaza had already benefited from the initiative’s activities and received the bowl and spoon. Although activities to collect feedback and review the initiative are ongoing, initial feedback received indicated both positive and negative reactions. On the one hand, the initiative was perceived as a way to raise the knowledge of mothers about complementary feeding, in which the bowl and spoon have helped them to provide their children with nutritious meals. On the other hand, the design, colour and durability of the bowl and spoon were found to have room for improvements. All feedback received will be documented and shared with the relevant counterparts for the purpose of learning and informing possible future scale up.
Learning from the barrier analysis and from the feedback on ongoing programme implementation, UNICEF will continue supporting local authorities and other partners to strengthen and develop child nutrition service provision.
Strategic actions will be taken at policy, institutional and community/household levels and cover the areas of health and nutrition services, water, sanitation and hygiene, and social protection, as described in Table 1.
Table 1: Priority strategic actions to be implemented in the State of Palestine
Health and nutrition services
Endorsement and implementation of the maternal and child national nutrition protocol.
Train service providers (health facility and community based) on the provision of IYCF practices and counselling.
Develop and implement innovative approaches and tools for complementary feeding counselling, including scaling up the implementation of complementary feeding bowl intervention.
Engage and support selected health facilities offering maternity services in practicing the Baby Friendly Hospital Initiative standards.
Invest in behavioural change and community engagement approaches to improve healthy diets for young children.
Support the creation of a community-based system (mother support groups and/or care groups) aimed at strengthening the peer support system on IYCF practices.
Facilitate and support community-based activities aiming at promoting good complementary feeding practices using local and indigenous products, including community cooking demonstrations.
Support a social behaviour change communication campaign on optimal IYCF practices with key messages appropriate for the context and using multimedia channels
Water, sanitation, and hygiene
Endorsement and implementation of WASH in health standards
Explore opportunities of intersectoral work with WASH for improving complementary feeding through improved access of poor households’ access to clean water and sanitation services.
Support local authorities to develop and adopt innovative WASH nutrition-sensitive and climate-resilient) interventions.
Support a social behaviour change communication campaign with key messages to deliver joint nutrition and WASH messages.
Social protection services
Support local authorities in the integration of nutrition in the social protection policies and programmes.
Intersectoral work with the social protection sector through cash transfer programmes for improving complementary feeding through improved access of poor households to nutritious food.
Support local authorities to develop social behaviour change communication strategies as a component of the social protection programme.
The barrier analysis that was conducted in 2019 in West Bank and Gaza has helped to identify and understand the key barriers to optimum maternal and child nutrition behaviours. The results of the barrier analysis had a strong positive impact on implementing partners, encouraging them to adapt their programmes accordingly and guided the implementation of key interventions at both the community and policy levels.
For more information, please contact Amani Jouda at firstname.lastname@example.org
Kittle B (2017) A Practical Guide to Conducting a Barrier Analysis (2nd ed.). New York, NY: Helen Keller International. https://www.fsnnetwork.org/sites/default/files/final_second_edition_practical_guide_to_conducting_barrier_analysis.pdf
OCHA (2022) Multi-Sectoral Needs Assessment (MSNA)
PCBS (2021) Palestinian Multiple Indicator Cluster Survey 2019-2020, Survey Findings Report. Palestinian Central Bureau of Statistics: Ramallah, Palestine.
PCBS and FSS (2020) Socio-Economic & Food Security Survey 2020, State of Palestine. Palestinian Central Bureau of Statistics and Food Security Sector partners.
UNICEF and WFP (2020) Barrier Analysis and In-depth Qualitative Interviews Report, West Bank and Gaza Strip.
WHO and UNICEF (2021) Indicators for assessing infant and young child feeding practices: definitions and measurement methods. https://www.who.int/publications/i/item/9789240018389
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Amani Jouda, Fairooz Abuwarda, Rana Awad, Adriana Zarrelli and Kanar Qadi (). State of Palestine: Investing in assessment positively impacted programming for complementary feeding. Field Exchange 68 , November 2022. www.ennonline.net/fex/68/cfepalastine