1. S URANGANI A BEYESEKERA, C OMMUNICATION FOR D EVELOPMENT S PECIALIST UNICEF G HANA Identifying and addressing norms to improve Exclusive Breastfeeding practices in Ghana

2. T HE C HALLENGE Exclusive Breastfeeding (EBF) continues to be a challenge in Ghana. 87% of respondents in a KAP study says that breast milk is the best food for children But less than 50% actually practice EBF Many new born children are given water, gripe-water and honey and sometimes even pap These practices are steeped in many factual beliefs

3. F ACTUAL B ELIEFS Colostrum is toxic and can poison the baby If a baby boy is breastfed with the first 7days the woman will not conceive again Infants need to be given water or else they become mean when they grow up and will not take care of the parents Exclusive breastfeeding is difficult and unrealistic Breast milk alone will not satisfy the baby. Baby will sleep better if given other foods. Children who are exclusively breastfed have difficulty in accepting complimentary food

4. O N E XCLUSIVE BREAST FEEDING & COLOSTRUM New mothers would like to EBF But, the action is interdependent Huge influence by the MIL Empirical expectations on the new mother All new mothers Obey their MIL Normative Expectations on the NM The NM believes that every one thinks she should obey the MIL

5. T HE MOTHER - IN - LAW New Mothers deliver at home Then it is both an empirical and normative expectation MIL makes decisions about the child

6. W HAT A FATHER SAYS “ We live with our parents and wives in the same compound and according to our tradition the elderly of the family is the care taker of our children and family health issues. These care takers are the barrier to practicing Exclusive Breastfeeding.’’ A father in Gburumani in the Tolan District of Northern Ghana who has observed the influence of family on his wife and the infant feeding practices.

7. W HO IS SHE ?

8. Q UEEN MOTHER The Queen Mother (QM) plays a pivotal role in Ghanaian communities Is usually the Chiefs mother or sister She is the custodian of the stool (throne) and all customs and traditions related to births, puberty, marriage, funerals, widowhood, “enstoolment”, “destoolment” etc. She has the first say in choosing a new Chief She is the main advisor to the Chief and sits on the right hand of the Chief She is consulted on important decisions concerning to community or the kingdom A hierarchy of QMs exists based on the traditional groups they belong to;

9. QUEEN MOTHER Traditional Leader New Mother Mother in law Grand mother Husband Religious leader New mothers peer Health worker B ROAD SOCIAL NETWORK OF A NEW MOTHER

10. W HAT ARE THE RELATIONSHIPS Queen Mother The Most Central and Highest degree node/ individual in the communit y Mother-in-law Strongest influence on the NM as she has the strongest tie Husband and the Grandmother Ties are strong but less than the MIL, but exerts influenc e Many other individuals Ties not so strong but influence still exists with TL, RL, HW, Peers

11. W HAT HAS BEEN DONE SO FAR AND SOME ? The work been done has resulted in high levels of awareness …. but does not translate to practice (or not enough) We may have not worked with the most central or highest degree nodes (working with the HW) Did we try to change one of the scripts of the NM? Without considering the interdependence of the action of EBF – did we not consider the possible emotional and physical sanctions against the NM? Did we not look at the need for the new mother to conform to her MILs expectations – her need to be liked (normative influence of the MIL). Did we miss the issue of social proof – the need to conform to what others are doing – “if it is good for everyone else then why should I not do so too?”

12. W HAT WILL WE DO DIFFERENT ? Move from focusing on individual behaviour to collective behaviour – while keeping in mind the interdependence of the behaviour (Social convention theory) By looking at the individuals / nodes that have most influence on the NM and then see who we need to engage with to create a dialogue. Who influences the new mother? Who influences the MIL or the Grand mother? Can we then through this discourse / dialogue address the pluralistic ignorance that exist? “I don’t think that colostrum is bad for the baby, but as I believe that everyone else does then I will do so too”

13. W HAT WILL WE DO DIFFERENT ? We need to address the factual beliefs By providing them with alternatives and by providing the MIL or the grandmother with correct information from a credible source (to the MIL) Start working with the Queen Mother in a concerted way (to reduce suspicion of the new information) As the MIL/ grandmother would want to seek social proof from the QM for their behaviour and thereby conform the to expectation of the QM

14. W HAT WILL WE DO DIFFERENT ? Look at power expressions in relation to the new mother. “Power within” and “Power to” – to empower the new mother and help her build her self esteem and self efficacy. Provide her with the necessary information, tools and supportive mechanisms so that she can influence decisions particularly in relation to the health or on what’s good for their baby

15. W HAT WILL WE CONTINUE TO DO ? We will continue to work with the Ghana Community Radio Network to continue to engage different types of individuals in the deliberations. Due to the format used by Community Radio it is hoped that organised diffusion will happen. Will also continue the IPC work being done by Ghana Health Services and the NGOs. Will also continue to work with national and regional media

16. I N CONCLUSION Much information is available on KAP related to Infant and Young Child Feeding There is a need for more detailed understanding on relationships and expectations and norms that exists in Ghanaian culture. The study is also expected to provide us with a baseline for future measurement of changes of norms. Through this knowledge we hope to target better our interventions and start converting this high levels of knowledge to practice.

17. O VER TO YOU FOR QUESTIONS OR CLARIFICATIONS …..