1 SUBMITTED 28 DEC 21 1 REVISION REQ. 13 FEB 22; REVISION RECD. 13 MAR 22 2 ACCEPTED 27 APR 22 3 ONLINE-FIRST: MAY 2022 4 DOI: https://doi.org/10.18295/squmj.5.2022.038 5 6 Exclusive Breastfeeding 7 Barrier analysis among Omani mothers 8 Samia Al-Ghannami,1 Salima Al-Mamari,1 Danielle Chekaraou,2 Caroline 9 Abla,3 Ibtisam Al-Ghmmari,1 Amna Al-Ajmi,1 Saleh Al-Shammkhi,1 10 Ruqaiya M. Al-Balushi,4 Fatma Al-Mamari,1 *Ruth M. Mabry5 11 12 1Department of Nutrition, Ministry of Health, Muscat, Oman; 2RDC International Public 13 Health Solutions, Phoenix, Arizona, USA; 3Independent Public Health Consultant, Arlington, 14 Texas, USA; 4Department of Food Science and Nutrition, College of Agricultural and Marine 15 Sciences, Sultan Qaboos University, Muscat, Oman; 5Independent Public Health Consultant, 16 Muscat, Oman. 17 *Corresponding author: rmmabry@gmail.com 18 19 Abstract 20 Objectives: Less than a quarter of Omani infants < 6 months are exclusively breastfed. 21 Therefore, this study aimed to examine individual barriers and supports to exclusive 22 breastfeeding and identify potential policy and programmatic interventions in Oman. 23 Methods: A cross-sectional Barrier Analysis was carried out among a purposive sample of 24 Omani women - 45 “Doers” (who exclusively breastfed their infants) and 52 “Non-Doers” 25 (who do not) – who were selected and interviewed by trained enumerators in health clinics in 26 various parts of the country. A barrier analysis tool, adapted for the Omani context, covered 27 12 common determinants of behavior adoption using open-ended questions regarding 28 participants’ perceptions about exclusive breastfeeding including positive and negative 29 consequences, self-efficacy and social norms. Qualitative analysis involved coding and 30 tabulating as well as thematic analysis. Results: Mothers report that motivation for exclusive 31 breastfeeding include the perception that it leads to healthier children, is easy, readily 32 available and therefore convenient and that mothers report an elevated level of family support 33 mailto:rmmabry@gmail.com 2 for breastfeeding. Barriers included perceived milk insufficiency and mother’s employment. 34 Conclusion: To achieve the 2025 exclusive breastfeeding target of 50%, public health action 35 should focus on emphasizing the benefits and convenience of exclusive breastfeeding and 36 building women’s confidence in their ability to produce sufficient milk. These efforts will 37 require increasing the knowledge and skills of community and health care workers and 38 establishing monitoring mechanisms. Expanding paid maternity leave and supportive 39 workplace policies are necessary to encourage working women to exclusively breastfeed. 40 Keywords: Breastfeeding, Breastfeeding barriers, Breastfeeding support, Exclusive 41 breastfeeding, Nutrition policy, Oman, Health Promotion. 42 43 Advances in Knowledge 44  Incentives to exclusively breastfeed for Omani women include the perception that it leads 45 to healthier children, that it is easy to do, readily available and therefore convenient. 46  Barriers to exclusively breastfeeding include perceived mother’s milk insufficiency, 47 mother’s employment, and limited familial support. 48  Creating an enabling environment for exclusively breastfeeding in Oman involves scaling 49 up existing programs that vigilantly seek to remove the identified barriers and shaping 50 messages that emphasize the benefits of breastfeeding to both infant and mother, the 51 convenience, and the ability of women to produce sufficient mother’s milk for their 52 infants. 53 54 Application to Patient Care 55  Key messages for promoting exclusive breastfeed include that it is easy to do, readily 56 available and convenient, affirm women’s ability to produce sufficient milk for their 57 infants and should target both mothers of young infants as well as their families. 58  Existing programmes such as the Community Support Group and the WHO Baby 59 Friendly Hospital initiatives should continue to engage in individual and group 60 counseling, immediate breastfeeding support following delivery, and lactation 61 management; renewed efforts to increase knowledge and skills of health professionals 62 and community volunteers would ensure their sustainability. 63 64 Introduction 65 3 Exclusive breastfeeding, where infants are given only mother’s milk during the first 6 months 66 of life and no other food or water, is a key intervention that has a major impact on child 67 mortality and morbidity.1 Mother’s milk contains all the needed nutrients for an infant’s first 68 6 months of life, provides immunity to disease through maternal antibodies, increases 69 intelligence and likely reduces overweight and diabetes.1 For women, breastfeeding protects 70 against breast cancer, improves birth spacing and may protect against ovarian cancer and type 71 2 diabetes.1-2 An estimated 823,000 child deaths and 20 000 deaths due to breast cancer could 72 be averted annually if all infants were breastfed, including initiation within one-hour of birth, 73 exclusively breastfeed for the full 6-month period and continued breastfeeding.1 74 75 Less than a quarter of Omani infants < 6 months are exclusively breastfed,3 markedly less 76 than the World Health Organization (WHO)/United Nations Children Fund (UNICEF) global 77 target for 2025 of at least 50%.4 The low prevalence of exclusive breastfeeding during the 78 first four months of life (31.9%) in Oman has not changed in the past 20 years; however, the 79 prevalence of continued breastfeeding beyond 12 months increased from 66.8% in 2000 to 80 80.0% in 2017. However, the decline in early initiation (within one hour of birth) - 87.1% and 81 82.0% - and the current low rate of exclusive breastfeeding for the first six months (23.2%) 82 is concerning3 not only in Oman but also in the region as a whole.5-6 83 84 A wide range of factors, including social and cultural attitudes, marketing of infant formula, 85 health systems and workplace, community settings and individual attitudes affect whether or 86 not women initiate breastfeeding early, and maintain exclusive and continued breastfeeding 87 for up to 2 years.2 Barrier analysis, based on the Health Belief Model7 and the Theory of 88 Reasoned Action8 has identified 12 determinants of behavior: perceived self-efficacy, 89 perceived social norms, perceived positive consequences, perceived negative consequences, 90 perceived action efficacy, access, perceived susceptibility/risk, perceived severity, cues for 91 action, policy, culture and perceived divine will.9 High self-efficacy is a strong predictor of 92 breastfeeding.10 Social norms and positive or negative consequences, like support and advice 93 from family and the health system, influence mothers’ confidence in breastfeeding.2 While, 94 marketing of infant formula, working status including short maternity leaves, and inadequate 95 support to mothers of young infants influence mothers’ perceptions of sufficiency of maternal 96 milk for breastfeeding and their ability to breastfeed and are some of the numerous reasons 97 for low levels of exclusive breastfeeding around the world.2 Although similar evidence is 98 emerging from several countries of the Arabian Gulf,11-14 greater understanding is needed to 99 4 better guide policy-makers in addressing the low prevalence of exclusive breastfeeding.3 100 Thus, this study aimed to examine individual barriers and supports to exclusive breastfeeding 101 and identify potential policy and programmatic interventions in Oman. 102 103 Methods 104 Research Design 105 Descriptive qualitative study design was used to identify the factors that prevent and facilitate 106 a target group from adopting a preferred behavior,15 in this case exclusively breastfeed 107 infants aged 0 – 6 months. Using the Barrier Analysis (BA) methodology, this study explores 108 twelve determinants of behavior which influence a desired behavior: perceived self-efficacy, 109 perceived social norms, perceived positive consequences, perceived negative consequences, 110 perceived action efficacy, access, perceived susceptibility/risk, perceived severity, cues for 111 action, policy, culture and perceived divine will.9 Since defining the behavior to be assessed 112 is an essential step in a BA study, the behavior defined was Mothers of children 0 to 6 113 months feed them only mother’s milk. 114 115 Setting and Relevant Context 116 Despite a socio-cultural environment supportive of breastfeeding, exclusive breastfeeding 117 remains low in Oman.16 Employment, marketing of breastmilk substitutes, inadequate health 118 care support and insufficient mother’s milk are some of the key barriers identified by women 119 in the Arabian Gulf.11-14 Although policies and strategies are in place to encourage 120 exclusively breastfeeding, further work is needed if Oman is to achievement the 121 UNICEF/WHO global target of 50% exclusive breastfeeding. Face-to-face interviews, based 122 on a barrier analysis assessment tool, were conducted in Ministry of Health primary health 123 care clinics in five governorates from 10 – 14 March 2019. A 5-day training covered change 124 theory, effective interviewing techniques, a thorough review of the data collection tool, a pre-125 test, and data entry was completed prior to the field work to ensure high quality results. 126 127 Sampling Strategy 128 To assess exclusive breastfeeding, purposive sampling methods were used to recruit Omani 129 mothers with infants aged 4 to 9 months to participate; 4-months was identified as the lower 130 age limit to capture as many ‘Doers’ as possible; the 9-months upper limit was identified to 131 minimize recall bias. In order to identify a sufficient number of Doers, the BA methodology 132 allows for researchers to ‘relax a behavior’; thus, the tool defined “Doers” as mothers who 133 5 exclusively breastfed their infants for the first 4 months of life rather than the recommended 6 134 months of exclusive breastfeeding.4 Recruitment was monitored using an excel sheet until the 135 recommended number of respondents was reached. 136 137 Research Team 138 The enumerators, identified by the health management team in each region, were health care 139 workers with qualitative research experience. Prior to conducting the survey, 22 enumerators 140 including 19 women and three men from five governorates (Muscat, Al Dakhilyah, Dhofar, 141 North Ash Sharqiya, South Al Batinah) and the MoH nutrition team (six people) were trained 142 in Muscat for five days on the BA methodology and interviewing skills. The training took 143 place from 3 to 7 March 2019. All enumerators were required to exhibit key qualifications 144 with a 90% or greater on the Quality Improvement Verification Checklist average scores 145 during training prior to the field work. 146 147 Tool 148 The BA questionnaire contained two sections: items to screen/classify respondents as Doers 149 or Non-Doers and items to assess barriers and supports based on their classification. The 150 barrier analysis included six open-ended questions, one question for perceived positive and 151 negative consequences and two questions each for perceived self-efficacy and perceived 152 social norms (Table 1). Questions on perceived access, cues for action, susceptibility/risk, 153 severity, efficacy, perception of Divine Will, culture and policy had discrete responses; 154 respondents were encouraged to provide details for the last two areas (culture and policy). 155 Questions varied slightly between Doers and Non-Doers. A question addressing universal 156 motivators, looking at what mothers want more than anything in life, was included since this 157 information is useful when designing promotional campaigns. 158 159 The questionnaire was developed and contextualized to the Omani context in English 160 following the standard BA questionnaire design guidelines and translated into Arabic. It was 161 then validated by the Ministry of Health (MoH) nutrition team and enumerators during 162 training by pilot testing with 27 doers and non-doers to ensure clarity for each question in the 163 local Arabic dialect. The research protocol was approved by the UNICEF Ethical Review 164 Board. 165 166 Data collection 167 6 22 trained enumerators approached each potential participant at a health clinic, found a semi-168 private place to conduct a face-to-face interview, introduced the study and obtained informed 169 consent. Eligible women who consented to be part of the study were then screened to 170 determine their status as Doer or Non-Doer before proceeding with the survey interview. 171 During the interview, enumerators were encouraged to probe participants to prompt them for 172 further details, if needed (Table 1). 173 174 Data Analysis 175 Completed questionnaires were scanned and sent via email to the MoH nutrition team in 176 Muscat. Qualitative analysis involved coding, tabulating, and thematic analysis of the data by 177 the central nutrition team. Once responses were coded and tabulated, they were entered into a 178 barrier analysis tabulation sheet 9 to calculate estimated relative risk and odds ratios to 179 identify significant differences between Doers and Non-Doers. For barrier analysis, an 180 estimated relative risk (RR) is the preferred approach to presenting findings as it provides 181 more accurate estimates of association.9 Significance was determined by p-value of less than 182 0.05, with a confidence interval of 95%. 183 184 Results 185 The team interviewed 97 women (45 Doers and 52 Non-Doers) in the five governorates. As 186 shown in Table 2, the thematic determinants that emerged during the interviews varied 187 significant between Doers and Non-Doers across six areas studied: perceived self-efficacy, 188 perceived social norms, perceived positive and negative consequences, perceived action 189 efficacy, universal motivator. 190 191 Perceived Self-Efficacy (What makes it easy or difficult) 192 The reasons about the importance of exclusive breastfeeding were statistically similar 193 between Doer and Non-Doer mothers. Mother’s availability to breastfeed, not having 194 difficulties breastfeeding and the benefits to a child’s health including the immune system 195 and growth and development were the most common reasons. To examine belief in ability to 196 do a particular behavior respondents were asked, “What makes it (or what would make it) 197 easier or more difficult” for you to exclusively breastfeed your baby for the first 6 months of 198 life. Doers were 5.4 times (P=0.018) more likely than Non-Doers to say, “It is easy because I 199 think it is important” and 2.8 times (P=0.011) more likely to say, “It is easy because it is 200 available and ready for the child and it requires no preparation” than Non-Doers. Non-Doers 201 7 were significantly 4.2 times (P=0.014) more likely to say, “It is difficult (to exclusively 202 breastfeed) because I work outside the home” than Doers. In addition, Non-Doers were 3.5 203 times (P=0.010) more likely than Doers to say, “It is difficult when there is not enough milk, 204 especially in the beginning”. 205 206 Perceived Consequences (positive and negative) 207 The most common perceived positive consequence of exclusive breastfeeding among all 208 respondents was related to the child’s health and well-being. Other common responses among 209 both groups included delays in pregnancy and mother’s health. Doers were 10.8 times 210 (P=0.043) more likely to say, “I can save money and time because it is free, easy, and takes 211 no time to prepare” than Non-Doers and 3.1 times (P=0.023) more likely to say, “It helps the 212 mother lose the weight gained with the pregnancy” than Non-doers. Nearly 20% of Non-213 doers mentioned “The baby does not get enough milk and is not satisfied and then loses 214 weight”; a concern not expressed by Doers. 215 216 Social Norms/Access 217 The social norms determinant refers to an individual’s perception of the approval or 218 disapproval of exclusively breastfeeding by people considered to be important in an 219 individual’s life. Respondents were asked who approves or disapproves of them exclusively 220 breastfeeding their child for the first six months of life Doers were 2.7 times (P=0.034) more 221 likely to say, “My husband approves of me only giving breastmilk to my baby for the first 6 222 months” and 2 times (P=0.065) more likely to say, “My mother approves of me only giving 223 breastmilk to my baby for the first 6 months” than Non-Doers. On the other hand, the access 224 determinant has many different facets, it includes the degree of availability of the needed 225 products or services required to adopt a behavior. Respondents were asked how difficult is it 226 (or would it be) to get the support needed to exclusively breastfeed? Non-Doers were 2.6 227 times (P=0.034) more likely to say, “It is somewhat difficult to get the support I need to give 228 only breast milk to my baby for the first 6 months” than Doers. 229 230 Perceived Action Efficacy 231 To examine the belief that a behavior will avoid a certain problem, respondents were asked 232 about the likelihood of an infant becoming malnourished if exclusively breastfeed. Non-233 Doers were 2.6 times (P=0.027) more likely to say, “It is somewhat likely that my child will 234 become malnourished if I give him only breastmilk to 6 months of age” than Doers 235 8 demonstrating that Non-doers express doubt of the benefit of exclusive breastfeeding to 236 protect children from malnourishment. 237 238 Universal Motivators 239 Respondents were asked what they wanted more than anything in life to identify key factors 240 motivate most people, irrespective of other variables. Family health and children’s education 241 were common universal motivators among both doers and non-doers. Non-doers were 2.9 242 times (P=0.027) more likely to say, “I want happiness and peace more than anything from 243 life” than Doers. 244 245 Discussion 246 This study identified barriers and supports for exclusive breastfeeding in Oman. Incentives to 247 exclusively breastfeed include the perception that exclusive breastfeeding leads to healthier 248 children, is easy, readily available and therefore convenient. Support from husbands and 249 mothers is also noted as necessary for successful breastfeeding. Barriers to exclusive 250 breastfeeding included perceived milk insufficiency, mother’s employment, and limited 251 family support. Despite high knowledge about the benefits of breastfeeding to both the 252 mother and child, the barriers identify reasons for the low exclusive breastfeeding rates in 253 Oman. Similar barriers have been described globally17-18 and in neighboring countries.11-14 254 255 Individual experiences play a major role in determining whether or not a mother exclusively 256 breastfeeds her infant. The perception of insufficient milk supply mentioned by participants 257 in this study as well as research in this region. is an important reason why women stopped 258 exclusively breastfeeding during their infant’s first six months and/or introduce formula or 259 weaning food.12-14, 18-19 For example, more than half of study participants in Saudi Arabia and 260 one-in-three study participants in Qatar discontinued breastfeeding due to their perception of 261 lack of sufficiency mother’s milk.14, 19 Breastfeeding difficulties and perceptions that infant 262 crying is perceived hunger in the early weeks undermine mothers’ confidence making her 263 assume that she has insufficient milk and thus, introduce infant formula.2 Encouraging new 264 mothers to exclusively breastfeed requires building confidence in their ability to produce 265 sufficient milk for their infants. 266 267 The participants from this barrier analysis study highlighted the importance of family support 268 in promoting infant feeding practices: Doers were almost four times as likely to believe that it 269 9 was not difficult to get support compared to the Non-doers Although traditional culture is 270 supportive of breastfeeding, older women family members have a great influence on mothers’ 271 breastfeeding practices, especially new mothers unfamiliar with breastfeeding.12-13 272 Researchers from the region have shown that some grandmothers and fathers are supportive 273 of exclusive breastfeeding, while others may advise introducing water, formula, or other 274 food.11-13 Although infant formula were not frequently mentioned in our study, their 275 marketing is ubiquitous in the region and are undermining efforts to improve breastfeeding 276 including women’s own ability to breastfeed.2, 13-14, 19-21 Although stronger regulations were 277 enacted in May 202122 and includes stronger regulations aligned to the Code for marketing 278 infant formula23-24 further research would be useful to examine their influence on exclusive 279 breastfeeding in Oman, especially on new mothers and their circle of family support. 280 281 Oman has introduced several interventions to promote breastfeeding including the 282 Community Support Group Program,25 lactation counselors for the WHO Multicentre Growth 283 Reference Study26 and the WHO Baby Friendly Hospital Initiative.20 Strengthening these 284 programs through the inclusion of individual and group counseling, immediate breastfeeding 285 support following delivery, and lactation management, will require renewed efforts to 286 increase knowledge and skills of health professionals and community volunteers, 287 strengthening monitoring and ensuring their sustainability.2, 5 These programs should address 288 the key barriers identified in this barrier analysis by emphasizing the benefits and 289 convenience of exclusive breastfeeding to both the infant and mother and building women’s 290 confidence in producing sufficient milk for their infants and how exclusive breastfeeding can 291 contribute to a happy and peaceful life. 292 293 Mother’s employment is major barrier to exclusive breastfeeding in Oman. Globally, it a 294 critical factor that influences women’s decisions to initiate breastfeeding, exclusively 295 breastfeed, and continue breastfeeding into the second year.2 About one quarter of the Omani 296 workforce are women and it is expected in increase.27-28 Although Oman has maternity leave 297 protection,28 it does not meet the International Labor Organization’s 14-week minimal 298 standard.29 Mothers are unable to adhere to exclusive breastfeeding due to the short leave, the 299 lack of child care and the challenges of expressing milk2 and is widely reported in the region 300 Two-thirds of the participants in a study in the United Arab Emirates did not exclusively 301 breastfeed their infants for six months due to short maternity leave.13 Al Nuaimi, et al20 302 highlights employment as a key factor for low breastfeeding rates in the Arabian Gulf. 303 10 Reducing barriers for working mothers by expanding maternity leave, providing lactation 304 rooms and nursing breaks can improve breastfeeding rates and improve workforce 305 performance.2, 11, 13, 20 306 307 The results of this research is being used to strengthen the breastfeeding promotion 308 programme within the Ministry of Health including determining the key messages for a 309 nation-wide exclusive breast feeding campaign, sharing findings with staff working in the 310 maternal and child health and health education programmes so that they can strengthen EBF 311 promotion within their own programmes and using the findings as part of the training of 312 lactation consultants currently working in secondary hospitals. The findings are also being 313 used to advocate for strengthening family-friendly policies to be more supportive of exclusive 314 breastfeeding, a key barrier identified in this study. 315 316 This study used a verified methodology9 and included respondents from the governorates 317 where a majority of the Omani population reside. More Non-doers were recruited from the 318 southern-most governorate due to the extremely low level of breastfeeding in one governorate 319 while additional Doers were recruited from the other four governorates. It provides a broad 320 overview of the most common determinants of breastfeeding in the country. However, a more 321 focused study on the southern province would be useful to identify more focused 322 interventions. Although the enumerators were rigorously trained and conducted the field 323 work, coding was carried out by the Nutrition Core Team which may have led to some 324 margin of error of interpretation. Although the sample size is small and participants were 325 from various regions of the country, the results may not be generable to the whole population. 326 327 Conclusion 328 Women in Oman experience similar barriers to breastfeeding as women around the world. 329 Scaling up existing interventions, policies and programs requires not only continuing to 330 emphasize the benefits and convenience of exclusive breastfeeding but also building 331 women’s confidence in their ability to produce sufficient milk. These expansions will require 332 increasing the knowledge and skills of community and health care workers. National 333 campaigns could highlight how exclusive breastfeeding contributes to a happy and peaceful 334 life and encourage support from family members. Expanding paid maternity leave and other 335 policies that encourage working women to exclusively breastfeed is also needed. 336 337 11 Conflict of Interest 338 The authors declare no conflicts of interest. 339 340 Funding 341 UNICEF 342 343 Acknowledgements 344 Thanks to the women who participated in this study. This manuscript is based on UNICEF 345 funded research conducted by the authors. The views expressed in this paper are those of the 346 authors and do not necessarily reflect those of the Ministry of Health of Oman. 347 348 Authors’ Contribution 349 SA-G, SA-M, DC and CA conceptualized the study. SA-G, DC and CA worked on the 350 methodology utilized in the study. DC and CA authored the research tools. IA-G, AA-A, SA-351 S, RMA-B and FA-M collected the data. All authors were involved in data analysis. SA-M, 352 DC, CA and RMM interpreted the results. SA-M and RMM drafted the manuscript. All 353 authors approved the final version of the manuscript. 354 355 References 356 1. Victora, C. G.; Bahl, R.; Barros, A. J. D.; França, G. V. A.; Horton, S.; Krasevec, J., 357 et al., Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The 358 Lancet 2016, 387 (10017), 475-490. doi: https://doi.org/10.1016/S0140-6736(15)01024-7 359 2. Rollins, N. C.; Bhandari, N.; Hajeebhoy, N.; Horton, S.; Lutter, C. K.; Martines, J. C., 360 et al., Why invest, and what it will take to improve breastfeeding practices? The Lancet 2016, 361 387 (10017), 491-504. doi: 362 3. Ministry of Health Oman, Oman National Nutrition Survey 2017. Ministry of Health, 363 O., Ed. Ministry of Health: Muscat, Oman, 2017. 364 4. World Health Organization; UNICEF, Global Nutrition Targets 2025, Breastfeeding 365 Policy Brief (WHO/NMH/NHD/14.7). World Health Organization: Geneva, 2014. 366 5. Al-Jawaldeh, A.; Abul-Fadl, A., Assessment of the baby friendly hospital initiative 367 implementation in the eastern Mediterranean region. Children 2018, 5 (3), 41. doi: 368 https://doi.org/10.1016/S0140-6736(15)01024-7 12 6. Al-Jawaldeh, A.; Abul-Fadl, A.; Tawfik, A., In-depth Analysis of Mortality in 369 Relation to Malnutrition in Children Under-five of Age in the Eastern Mediterranean Region. 370 J Nutr Weight Loss 2018, 2 (112), 2. doi: 371 7. Parsa, P.; Masoumi, Z.; Parsa, N.; Parsa, B., Parents' Health Beliefs Influence 372 Breastfeeding Patterns among Iranian Women. Oman Med J 2015, 30 (3), 187-92. doi: 373 10.5001/omj.2015.40 374 8. Humphreys, A. S.; Thompson, N. J.; Miner, K. R., Assessment of breastfeeding 375 intention using the transtheoretical model and the theory of reasoned action. Health 376 Education Research 1998, 13 (3), 331-341. doi: 377 9. Kittle, B., A practical guide to conducting a barrier analysis. 2nd ed.; 2017. 378 10. Brockway, M.; Benzies, K.; Hayden, K. A., Interventions to improve breastfeeding 379 self-efficacy and resultant breastfeeding rates: a systematic review and meta-analysis. 380 Journal of Human Lactation 2017, 33 (3), 486-499. doi: 381 11. Nasser, A.; Omer, F.; Al-Lenqawi, F.; Al-Awwa, R.; Khan, T.; El-Heneidy, A., et al., 382 Predictors of continued breastfeeding at one year among women attending primary healthcare 383 centers in Qatar: A cross-sectional study. Nutrients 2018, 10 (8), 983. doi: 384 12. Radwan, H.; Sapsford, R., Maternal perceptions and views about breastfeeding 385 practices among Emirati mothers. Food and nutrition bulletin 2016, 37 (1), 73-84. doi: 386 13. Al Ketbi, M. I.; Al Noman, S.; Al Ali, A.; Darwish, E.; Al Fahim, M.; Rajah, J., 387 Knowledge, attitudes, and practices of breastfeeding among women visiting primary 388 healthcare clinics on the island of Abu Dhabi, United Arab Emirates. International 389 breastfeeding journal 2018, 13 (1), 26. doi: 390 14. Elmougy, A.; Matter, M.; Shalaby, N.; El-Regal, M.; Abu Ali, W.; Aldossary, S., et 391 al., Knowledge, attitude and practice of breastfeeding among working and non-working 392 mothers in Saudi Arabia Egyptian Journal of Occupational Medicine 2018, 42 (1), 133-150. 393 doi: 394 15. Davis Jr., T. P. Barrier Analysis Facilitator Guide: A Tool for Improving Behavior 395 Change Communication in Child Survival and Community Development Programs; Food for 396 the Hungry: Washington, DC, 2004. 397 16. Ministry of Health, O., Oman National Nutrition Survey. Ministry of Health, O., Ed. 398 Ministry of Health: Muscat, 2018. 399 17. Pérez-Escamilla, R.; Curry, L.; Minhas, D.; Taylor, L.; Bradley, E., Scaling Up of 400 Breastfeeding Promotion Programs in Low- and Middle-Income Countries: the 401 13 “Breastfeeding Gear” Model. Advances in Nutrition 2012, 3 (6), 790-800. doi: 402 10.3945/an.112.002873 403 18. Brown, C. R.; Dodds, L.; Legge, A.; Bryanton, J.; Semenic, S., Factors influencing 404 the reasons why mothers stop breastfeeding. Canadian Journal of Public Health 2014, 105 405 (3), e179-e185. doi: 406 19. Hendaus, M. A.; Alhammadi, A. H.; Khan, S.; Osman, S.; Hamad, A., Breastfeeding 407 rates and barriers: a report from the state of Qatar. International journal of women's health 408 2018, 10, 467. doi: 409 20. Al-Nuaimi, N.; Katende, G.; Arulappan, J., Breastfeeding Trends and Determinants: 410 Implications and recommendations for Gulf Cooperation Council countries. Sultan Qaboos 411 Univ Med J 2017, 17 (2), e155-e161. doi: 10.18295/squmj.2016.17.02.004 412 21. Al-Ghannami, S. S.; Al-Shammakhi, S. M.; Al-Jawaldeh, A.; Al-Mamari, F. A.; Al-413 Gammaria, I. K.; Al-Aamry, J. A., et al., Rapid assessment of marketing of unhealthy foods 414 to children in mass media, schools and retail stores in Oman. East Mediterr Health J 2019, 415 25. doi: 416 22. Ministry of Commerce, I. a. I. P. O., Marketing Regulation of Designated Products for 417 Infants and Young Children (OS 1649/2021). Standards, D. G. o. S. a., Ed. Ministry of 418 Commerce, Industry and Investment Promotion: Muscat, Oman, 2021. 419 23. Ministry of Health Oman, The Omani Code for Marketing of Breast Milk Substitutes. 420 Ministry of Health, Oman: Muscat, Oman, 1998. 421 24. World Health Organization, Marketing of breast-milk substitutes: national 422 implementation of the international code: status report 2016. World Health Organization: 423 Geneva, Switzerland, 2016. 424 25. Ministry of Health Oman, Community-based Initiative Strategy. Ministry of Health: 425 Muscat, Oman, 2017. 426 26. Prakash, N. S.; Mabry, R. M.; Mohamed, A. J.; Alasfoor, D., Implementation of the 427 WHO Multicentre Growth Reference Study in Oman. Food and nutrition bulletin 2004, 25 428 (1_suppl_1), S78-S83. doi: 429 27. Al-Hasani, M. Women's employement in Oman. The University of Queensland, The 430 University of Queensland, 2015. 431 28. Zerovec, M.; Bontenbal, M., Labor nationalization policies in Oman: Implications for 432 Omani and migrant women workers. Asian and Pacific migration journal 2011, 20 (3-4), 433 365-387. doi: 434 14 29. Ahmed, S.; Fielding, D., Changes in maternity leave coverage: Implications for 435 fertility, labour force participation and child mortality. Social Science & Medicine 2019, 241, 436 112573. doi: 437 438 15 Table 1: Barrier analysis assessment tool 439 Doers Non-doers Perceived Self-Efficacy 1a. What makes it easy for you to give only breast milk to your baby from birth to 6 months? [Probe] 1b. What would make it easier for you to give only breast milk to your baby from birth to 6 months? [Probe] 2a. What makes it difficult for you to give only breast milk to your baby from birth to 6 months? [Probe] 2b. What would make it difficult for you to give only breast milk to your baby from birth to 6 months? [Probe] Perceived positive and negative consequences 3a. What are the advantages of only giving breast milk to your baby from birth to 6 months? [Probe] 3b. What would be the advantages of only giving breast milk to your baby from birth to 6 months? [Probe] 4a. What are the disadvantages of only giving breast milk to your baby from birth to 6 months? [Probe] 4b. What would be the disadvantages of only giving breast milk to your baby from birth to 6 months? [Probe] Perceived Social Norms 5a. Who are all of the people that approve of you only giving breast milk to your baby from birth to 6 months? [Probe] 5b. Who are all of the people that would approve of you only giving breast milk to your baby from birth to 6 months? [Probe] 6a. Who are all of the people that disapprove of you only giving breast milk to your baby from birth to 6 months? [Probe] 6b. Who are all of the people that would disapprove of you only giving breast milk to your baby from birth to 6 months? [Probe] Perceived Access 7a. How difficult is it for you to get the support you need to give only breastmilk to your baby from birth to six months old? Would 7b. How difficult would it be to get the support your need to give only breast milk to your baby from birth to 6 months? Would you 16 you say that it is very difficult, somewhat difficult, or not difficult at all? A. Very difficult B. Somewhat difficult C. Not difficult at all say that it would be very difficult, somewhat difficult, or not difficult at all? A. Very difficult B. Somewhat difficult C. Not difficult at all Perceived Cues for Action / Reminders 8a. How difficult is it to remember to give only breast milk to your baby from birth to 6 months? Would you say that it is very difficult, somewhat difficult, or not difficult at all? A. Very difficult B. Somewhat difficult C. Not difficult at all 8b. How difficult would it be to remember to give only breast milk to your baby from birth to 6 months? Would you say that it would be very difficult, somewhat difficult, or not difficult at all? A. Very difficult B. Somewhat difficult C. Not difficult at all Perceived Susceptibility / Risk 9. How likely is it that your baby will become malnourished in the next year? Would you say that is it very likely, somewhat likely, or not likely at all? A. Very difficult B. Somewhat difficult C. Not difficult at all Perceived Severity 17 10. How serious would it be if your baby became malnourished? Would you say that it would be a very serious, somewhat serious, or not serious at all? A. Very difficult B. Somewhat difficult C. Not difficult at all Action Efficacy 11. How likely is it that your baby will become malnourished if you give only breast milk to your baby for the first 6 months? Would you say that it is very likely, somewhat likely or not likely at all? A. Very difficult B. Somewhat difficult C. Not difficult at all Perception of Divine Will 12. Does Islam approve of mothers giving only breastmilk to their babies for the first six months? A. Very difficult B. Somewhat difficult C. Not difficult at all Culture 13. Are there any cultural rules or taboos against only giving breast milk to your baby from birth to 6 months? A. Yes B. Maybe / I don’t know C. No 18 If yes, briefly explain: Policy 14. Are there any teachings, recommendations, policies, laws or regulations that make it more likely that you give only breast milk to your baby from birth to 6 months? A. Yes B. Maybe / I don’t know C. No If yes, briefly explain: Universal Motivators 15. Now I’m going to ask you a question not at all related to what we have been discussing. What do you want more than anything from life? [Probe] 440 19 Table 2: Determinants of Exclusive Breastfeeding among Omani Women (N=97) 441 Emerging Thematic Determinants % Doers (#) n=45 % Non- doers (#) n=52 Difference between doers and non-doers (% points) Odds Ratio (Confidence Interval) Estimate Relative Risk p-value 1. Self-Efficacy: What makes it easier? Breastmilk is available, ready and requires no preparation 38 (17) 15 (8) 22 3.34 (1.27, 8.76) 2.84 0.011 I think it is important (not specified) 16 (7) 2 (1) 14 9.39 (1.11, 79.61) 5.42 0.018 If I deliver the baby easily and have good health 0 12 (6) 12 0.00 0.00 0.021 I do not have any problems with breastfeeding or positioning the baby for feeding. 13 (6) 21 (11) 8 0.57 (0.19, 1.70) 0.60 0.230 It helps with the baby's growth and development 13 (6) 12 (6) 2 1.18 (0.35, 3.95) 1.16 0.514 I know that it improves my baby's immune system, keeps him from getting illnesses. 16 (7) 15 (8) 1 1.01 (0.34, 3.05) 1.01 0.600 20 I am available and free to breastfeed my child any time. 27 (12) 27 (14) 0 0.99 (0.40, 2.43) 0.99 0.581 2. Self - Efficacy: What makes it difficult? It is not difficult 40 (18) 4 (2) 36 16.67 (3.59, 77.28) 8.27 <0.001 There is not enough milk, especially in the beginning. 11 (5) 33 (17) 22 0.26 (0.09, 0.77) 0.28 0.010 I work outside of the home. 7 (3) 25 (13) 18 0.21 (0.06, 0.81) 0.24 0.014 I have to be away from home and there is no place to breastfeed. 24 (11) 8 (4) 17 3.88 (1.14, 13.23) 3.13 0.023 Sometimes the baby does not want to nurse or take my breastmilk from a bottle. 16 (7) 27 (14) 11 0.50 (0.18, 1.38) 0.53 0.134 I have problems with my breasts or nipples (painful, swollen, cracked or inverted nipples) 22 (10) 27 (14) 5 0.78 (0.31, 1.97) 0.79 0.384 I have too many things to do so I get busy and tired. 16 (7) 12 (6) 4 1.41 (0.44, 4.56) 1.36 0.388 3. Perceived positive consequences: What are the advantages? 21 Helps the mother lose the weight gained with the pregnancy. 24 (11) 8 (4) 17 3.88 (1.14, 13.23) 3.13 0.023 Safe for the child to drink and doesn't cause side effects or allergies. 20 (9) 8 (4) 12 3.00 (0.86, 10.52) 2.55 0.070 It helps with brain development of the child and makes him intelligent. 13 (6) 21 (11) 8 0.57 (0.19, 1.70) 0.60 0.230 Improves the health of the mother and protects from illnesses. 20 (9) 13 (7) 7 1.61 (0.55, 4.74) 1.52 0.277 Decreases the chance that the mother will get cancer. 9 (4) 13 (7) 5 0.63 (0.17, 2.30) 0.65 0.352 Delays pregnancy; good for birth spacing. 20 (9) 17 (9) 3 1.19 (0.43, 3.33) 1.17 0.467 It improves weight and the immunity of the baby and keeps him healthy. 96 (43) 94 (49) 1 1.32 (0.21, 8.25) 1.28 0.569 Increases the bonding between mother and child. 16 (7) 15 (8) 0 1.01 (0.34, 3.05) 1.01 0.600 4. Perceived negative consequences: What are the disadvantages? The baby does not get enough milk and is not satisfied and then loses weight. 0 17 (9) 17 0.00 0.00 0.003 There are no disadvantages / I don't know. 64 (29) 58 (3) 7 1.33 (0.58, 3.02) 1.29 0.319 22 The child becomes too attached to me and then I cannot leave him to go do other things I need to do. 13 (6) 10 (5) 4 1.45 (0.41, 5.10) 1.39 0.398 5. Perceived social norms: Who approves? Husband 87 (39) 69 (36) 17 2.89 1.02, 8.19) 2.66 0.034 Mother 78 (35) 62 (32) 16 2.19 (0.89, 5.37) 2.04 0.065 Sister 42 (19) 56 (29) 14 0.58 (0.26, 1.30) 0.61 0.130 Mother-in-law 31 (14) 23 (12) 8 1.51 (0.61, 3.71) 1.44 0.254 Sisters-in-law 16 (7) 21 (11) 6 0.69 (0.24, 1.95) 0.71 0.330 Doctors, nurses and health workers 13 (6) 17 (9) 4 0.74 (0.24, 2.25) 0.76 0.400 6. Perceived social norms: Who disapproves? My mother 7 (3) 13 (7) 7 0.46 (0.11, 1.89) 0.49 0.225 My sisters 16 (7) 10 (5) 6 1.73 (0.51, 5.89) 1.62 0.281 23 No one 44 (20) 38 (20) 6 1.28 (0.57, 2.88) 1.25 0.348 My sisters-in-law 13 (6) 17 (9) 4 0.74 (0.24, 2.25) 0.76 0.400 My friends 11 (5) 15 (8) 4 0.69 (0.21, 2.27) 0.71 0.378 7. Perceived access: How difficult is it to get the support you need to EBF? Very Difficult 0 8 (4) 8 0.00 0.00 0.078 Somewhat difficult 13 (6) 31 (16) 17 0.35 (0.12, 0.98) 0.38 0.034 Not difficult at all 87 (39) 62 (32) 25 4.06 (1.46, 11.32) 3.65 0.005 8. Perceived cues for action: How difficult is it to remember to give your baby only breastmilk? Very difficult 2 (1) 2 (1) 0 1.16 (0.07, 19.08) 1.14 0.715 Somewhat difficult 9 (4) 17 (9) 8 0.47 (0.13, 1.63) 0.49 0.181 Not difficult at all 89 (40) 81 (42) 8 1.90 (0.60, 6.06) 1.81 0.207 9. Perceived susceptibility/risk: How likely is it that your baby will become malnourished in the coming year? Very likely 7 (3) 0 7 10.64 0.096 24 Somewhat likely 24 (11) 40 (21) 16 0.48 (0.20, 1.15) 0.51 0.073 Not likely at all 69 (31) 58 (30) 11 1.62 (0.70, 3.75) 1.55 0.177 10. Perceived severity: How serious would it be if your child became malnourished? Very serious 40 (18) 48 (25) 8 0.72 (0.32, 1.61) 0.74 0.277 Somewhat serious 49 (22) 42 (22) 7 1.30 (0.58, 2.91) 1.27 0.328 Not serious at all 11 (5) 10 (5) 1 1.18 (0.32, 4.35) 1.16 0.534 11. Action Efficacy: How likely is it that your child will become malnourished if you feed him only breastmilk to 6 months? A. Very likely 2 (1) 8 (4) 5 0.27 (0.03, 2.53) 0.30 0.229 B. Somewhat likely 16 (7) 35 (18) 19 0.35 (0.13, 0.93) 0.38 0.027 C. Not likely at all 82 (37) 58 (30) 25 3.39 (1.32, 8.70) 3.06 0.008 12. Perception of Divine Will: Does Islam approve of giving only breastmilk? A. Yes 89 (40) 83 (43) 6 1.67 (0.52, 5.42) 1.60 0.284 25 B. Maybe 2 (1) 8 (4) 5 0.27 (0.03, 2.53) 0.30 0.229 C No 9 (4) 10 (5) 1 0.92 (0.23, 3.64) 0.92 0.592 13. Culture: Are there any taboos or myths that prevent women from practicing the behaviour? A. Yes 18 (8) 13 (7) 4 1.39 (0.46, 4.19) 1.34 0.379 B. Maybe 0 0 0 1.000 C. No 82 (37) 87 (45) 4 0.72 (0.24, 2.17) 0.75 0.379 14. Policy: Are there any laws or regulations that make it more likely women will exclusively breastfeed? A. Yes 67 (30) 58 (30) 9 1.47 (0.64, 3.36) 1.41 0.243 B. Maybe 7 (3) 6 (3) 1 1.17 (0.22, 6.09) 1.15 0.590 C. No 27 (12) 37 (19) 10 0.63 (0.26, 1.51) 0.66 0.206 15. Universal Motivators Happiness and peace 11 (5) 29 (15) 18 0.31 (0.10, 0.93) 0.34 0.027 26 To be a good mother and raise good children. 27 (12) 10 (5) 17 3.42 (1.10, 10.63) 2.85 0.026 To please God 16 (7) 12 (6) 4 1.41 (0.44, 4.56) 1.36 0.388 Money and financial stability / a good job or source of income 24 (11) 21 (11) 3 1.21 (0.47, 3.12) 1.18 0.442 Health for myself and my family 64 (29) 65 (34) 1 0.96 (0.42, 2.21) 0.96 0.546 A good education and future for my children 24 (11) 25 (13) 1 0.97 (0.38, 2.45) 0.97 0.570 A house 13 (6) 13 (7) 0 0.99 (0.31, 3.19) 0.99 0.612 442