Based on the information available, mixed feeding is a common behavioral problem in Indonesia. While there is a lot of quantitative data describing breastfeeding practices in Indonesia, there is a lack of qualitative information about the problem behavior, specifically in North Jakarta. Since mixed feeding is a behavioral problem, it is important to understand why women use these practices instead of exclusively breastfeeding their children. There is a lack of information about the clear definition of what mixed breastfeeding means to mothers, where women learn about breastfeeding practices, and who the influential family or community figures are. In order to obtain this information, more research should be conducted, using a variety of methods to better understand the determinants leading to this behavior. The following methods were chosen based on the need for detailed qualitative information to fill the gaps in literature.
Some methods we could use to obtain this information are:
- Focus groups involving women in the community (mothers, grandmothers)
- Follow-up in-depth interviews with some women in the community
- In-depth interviews with key informants (community and religious leaders, midwives/traditional birth attendants)
Focus groups involving women in the community would be useful in gaining information on what women believe the definition of mixed feeding practices are and their attitudes toward it. The focus group would take place in a neutral setting where women can feel a connection with others sharing similar situations that would aim to provide a more comfortable setting for women to share their beliefs and behavior choices. During the focus groups, facilitators should focus on these topics: the women’s description of mixed feeding, their current feeding practices, and the barriers they face concerning breastfeeding. Since little is known about the influences driving women to use mixed feeding, focus groups with the mothers should be held separately from others to allow the women to speak freely and without judgment in case their personal behavior is due to someone else’s choice (i.e. mother in law, husband). In addition, focus group discussions with mothers who are currently practicing exclusive breastfeeding should take place to determine factors driving their positive behavior.
Follow-up interviews should be held with any positive deviants who were identified in the focus groups or women who seem to have insight and knowledge about correct feeding practices. During the interviews, facilitators should focus on identifying key informants and specific cultural practices that influence behavior. These interviews can help tailor our questions for the in-depth interviews that will be held with the key informants.
In-depth interviews should be held with key informants in the community to gain an understanding of the influential factors leading to breastfeeding practices. By understanding who the influential people are in the community, we can establish relationships and a foundation for community mobilization. Key informants already identified for interviews would be members of the district health office, midwives and birth attendants located in the community, religious leaders from the Muslim community, and village leaders also known as ‘kepala kampung’. In addition, snowball sampling will be used to identify any additional key informants during the follow-up and in-depth interviews. Facilitators should focus on gaining information about feeding practices and cultural influences/barriers to breastfeeding. A questionnaire of predetermined topics should be used to conduct the interviews.
Appropriate facilitators should be chosen based on cultural practices and on who is being interviewed. For example, females should conduct the focus groups with the mothers and facilitators of the same gender as the interviewee should be used to conduct interviews. Also, local facilitators should be used, ideally with research backgrounds, who are fluent in both Indonesian and English. Interviews and focus groups should be recorded and transcribed at a later date and detailed note taking should be used to supplement questionnaires to possibly prompt further questions. Cultural and religious practices should be considered to decide how the interviews are conducted and to decide an appropriate time and place to conduct interviews and focus groups. For example, appropriate skin coverage is essential in the Muslim community, as well as interacting only with the right hand and addressing elders with respect. Previous research shows that working and family income is important in the Indonesian society; therefore, interviews should be timed appropriately as to not during working hours.
Some key factors should be considered when trying to implement behavior change with mothers in North Jakarta. These include:
- Increasing awareness and knowledge of benefits of exclusive breastfeeding and risks of mixed feeding
- Improving education on proper breastfeeding techniques and latching for mothers
- Increasing perceptions of feasibility and value of breastfeeding for employers and mothers
- Increasing awareness of the breastfeeding law
- Increasing access to breast pumping resources
Key factors of the behavior change can be addressed through:
- Social marketing campaigns and increasing education on prevention of childhood diarrhea through exclusive breastfeeding
- Training community health workers and midwives in teaching proper latching techniques and importance of exclusive breastfeeding
- Social media campaigns using PSA ads to increase awareness of exclusive breastfeeding
- Providing inexpensive breast pumps and breastfeeding locations in community and work places
- Community support groups for women
Along with the community action cycle previously mentioned, identifying any positive deviance can be useful in encouraging mothers in North Jakarta to adopt exclusive breastfeeding and increasing social acceptance of the behavior. Changes in behavior can be expedited through enforcement of the breastfeeding law.
This paper identifies mixed feeding as a problem behavior associated with diarrheal morbidity and mortality in children under five. Exclusive breastfeeding is a way of combating this problem and is supported by Indonesia’s breastfeeding law. This paper explains community level intervention using an integrative theoretical framework, determinants analysis, and behavior framework. This systematic approach will ensure that behavior change is sustainable, leading to a successful reduction in childhood diarrhea in Indonesia.
 Sample questions for focus groups and interviews can be found in the Annex