Formative Research to Better Understand Nutrition Practices
Both previous research and anecdotal evidence suggested that a primary reason for the high
prevalence of under-nutrition, anemia, and stunting among Kyrgyz children is a diet that may
be adequate in calories, but is very deficient in micronutrients. The complementary foods
given to young children in Kyrgyzstan often consist of potatoes, noodles, bread, cereals, and
other foods that are low in bioavailable iron and lack the nutrients necessary for proper
growth and development. Additionally, complementary foods are often not introduced at the
appropriate time, and not given in the proper quantity or frequency. Another major factor
contributing to the problem of under-nutrition among Kyrgyz children is improper
breastfeeding practices. The prevalence of exclusive breastfeeding until 6 months of age is
low (31.5%), and too few mothers continue breastfeeding into the second year of life. Lack
of knowledge of proper breastfeeding complementary feeding practices among mothers is a
significant factor in the nutritional deficiencies of young children.
However, while several of the causes of poor childhood nutrition in Kyrgyzstan had already
been identified, an important step in the development of the campaign strategy and
educational messages was to conduct additional research to better understand the knowledge,
attitudes, and practices pertaining to infant and young child feeding. To that end, three
formative studies were undertaken, the results of which are described below.
Qualitative Research on Infant and Young Child Feeding Practices
In November 2006, UNICEF and the Ministry of Health commissioned a qualitative study on
infant and young child feeding practices. The aim of the study was to develop a more
comprehensive understanding of the common feeding practices for children under three
years, so that practical and locally-relevant recommendations could be developed for a
nutrition education campaign. Researchers also sought to identify common feeding problems
and the obstacles mothers face in following health care provider recommendations for
improving their child’s nutrition. The study was conducted through individual interviews
with the mothers and caregivers of 53 children (3 to 36 months of age) in Talas oblast and
Bishkek city. Subjects were randomly selected using standard sampling methods. Structured
questionnaires were administered, and the survey methods were adapted using WHO
recommendations for nutritional assessments (within the context of IMCI programs). The
survey included an adapted 24-hour food recall instrument, a food frequency questionnaire,
and a standard breastfeeding questionnaire.
Two interviews were conducted with the mothers over a four day period. During the first
interview, problems were identified with the child’s feeding practices, and appropriate
recommendations (based on IMCI nutrition guidelines) were given to the mother to address
each of the identified problems. Researchers worked with the mother to select five feeding
recommendations that were realistic for her to follow. The researchers then returned two
days later and conducted an identical interview with the mother using the 24-hour food recall
instrument and breastfeeding questionnaire. The purpose of the second interview was to
determine if the mother had followed the recommendations and made any changes to her
child’s diet. If the mother did not follow the recommendations, the reasons and obstacles for
noncompliance were discussed.
Key findings from the study include:
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Among the mothers surveyed, there was a low prevalence of practicing exclusive
breastfeeding during the first six months of life; water, tea, and cow’s milk are introduced
early in life
Giving tea to young children is a widespread practice, and tea is usually introduced early
in life. Children consume tea frequently (usually 3-5 times a day).
Complementary foods are often introduced late and tend to be monotonous and low in
bioavailable iron (lack meat, fish, vegetables, beans). The most common complementary
food for young children seems to be bread and sweetened tea, and this meal is generally
given three times a day. Complementary foods often have a low energy density (thin,
watery soups are generally given once a day). Use of porridges was uncommon among
the children sampled.
Complementary foods are not given in the proper quantity or frequency. Children over
one year who were no longer being breastfed, were generally given 1-2 meals a day, in
addition to 1-2 small snacks. Over half of the children surveyed were being fed an
insufficient quantity of food in relation to the recommendations for their age.
Mothers are unaware of the risks of giving children under 9 months whole cow’s milk.
Only 36% of the children received dairy products on a daily basis. Even families with
their own cows responded that they do not give the child dairy products on a regular
basis.
All of the mothers indicated that they did not have financial constraints in purchasing
meat, eggs, beans, and other sources of protein for themselves and their children.
However, among most of the children surveyed, meat, fish, and beans were introduced
late and are consumed irregularly and in insufficient quantities.
In the rural areas surveyed, all families had their own land for growing fruits and
vegetables, and 80% of the mothers confirmed they have access to beans, basic
vegetables (potatoes, cabbage, carrots, onion, beets), and fruits (apples, pears). Most
mothers indicated they introduced vegetables into the child’s diet after 6 months of age,
but the use of vegetables in children’s diet seems to be quite limited.
Most mothers attempted to follow the feeding recommendations provided by the
researchers. Even the poorest families were able to improve the diversity and richness of
the foods given to their child. The most difficult recommendation to follow was the
cessation of giving tea. Mothers found it difficult to replace tea with another liquid, and
commented that the child asked for tea.
It was concluded that common problems with feeding practices for young children are caused
not by lack of access to nutritious foods, but mainly by low awareness among mothers of
optimal nutrition and feeding practices. The research also found that inappropriate dietary
advice from health care professionals was a major factor in the low public awareness of
proper infant and young child feeding practices. The conclusion from this phase of research
was that it is essential to ensure mother’s have access to accurate information on proper
infant and young child feeding practices, and to ensure the nutrition counseling provided by
medical workers is reliable and supportive of proper practices.
Quantitative Research on Maternal and Child Nutrition Practices
Qualitative research helped elucidate some of the nutrition and child feeding practices that
contribute to under-nutrition among young children in Kyrgyzstan. However, the working
group developing the pilot nutrition program did not have accurate data on the prevalence of
these child feeding practices. It was therefore decided that since the pilot program would
take place in Talas oblast, the next step in the formative research process was to conduct a
quantitative survey to gather data representative of Talas oblast on the diet of pregnant
women and infant and young child feeding practices. To that end, a quantitative maternal
and child nutrition KAP (Knowledge, Attitudes, and Practices) study was conducted in 2007
by the Ministry of Health with support from UNICEF. The objectives of the study were to:
 Gather data representative of Talas oblast on the diet of pregnant women and infant
and young child feeding practices (for children under 2 years)
 Assess women’s knowledge of proper dietary practices for pregnancy, exclusive
breastfeeding, and complementary feeding
 Identify problems with the diet of pregnant women and child feeding practices that
may be unique to Talas oblast
 Gain insights on maternal and child nutrition in Talas oblast that would enable the
working group to cater the campaign strategy and nutritional
recommendations/messages to the local situation
 Determine obstacles mothers may face in making recommended dietary changes for
themselves and their children
Study Methodology
The study was conducted through individual interviews using a structured questionnaire (see
Appendix B). There were three target groups for the interviews: pregnant women,
grandmothers and mothers-in-law, and mothers of children 6-24 months. Standard sampling
methods were used to ensure the data would be representative of Talas oblast. Sampling was
conducted using two-stage cluster sampling and the Probability Proportionate to Size method
(which would result in self-weighted data). Using the Probability Proportionate to Size
method, thirty clusters were selected from a complete list of the 90 villages and their
associated populations in Talas oblast. Using census data and lists of pregnant women kept
by the FGP/FAP, complete lists of eligible women in each cluster were created. From these
lists, participants were randomly selected using standard methods. A total of 920 people were
randomly selected to be interviewed from the three target groups (~300 per group). 10-12
people from each of the three groups were interviewed in each of the 30 clusters (10 people
per group x 3 groups x 30 clusters = ~900 total respondents).
Key Findings
Infant and Young Child Feeding Practices
Breastfeeding
 91.3% of the mothers continued breastfeeding their baby for the first 12 months or longer.
However, there is a low prevalence (15%) of exclusive breastfeeding during the first six
months of a child’s life.
o One explanation for this finding is a lack of appropriate advice and counseling by
health care providers in hospitals/medical institutions, as the survey found that
12.3% of the mothers gave their baby foods and liquids (other than breast milk)
while in the maternity ward.
o Only 16.9% of the mothers thought that women should exclusively breastfeed
(without giving any other liquids or food) until the child is 6 months old
 Half (50.8%) of the mothers reported that they breastfed the baby within the first hour
after birth, and 35.3% during the first 2-6 hours. The majority of mothers (74.6%) knew
that a newborn should be breastfed during the first few hours after birth.
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50% of mothers reported that they stop breastfeeding when their child is sick. However,
93.2% of mothers said they believe it is important to continue breastfeeding when the
child is sick.
 In terms of the duration of exclusive breastfeeding and timing of introducing
complementary foods, the grandmothers interviewed tended to be more knowledgeable
than mothers
Tea Giving
 Giving tea to babies is very common, and by the age of 10 months, all children are given
tea. A majority of mothers (65.4%) believe that children should drink tea (most common
reason given was that tea alleviates thirst after breastfeeding or eating other foods).
29.1% of mothers believe that children should not drink tea. While most mothers prefer
to give their babies tea, a majority of mothers (84.3%) reported that they family has juice,
stewed fruit juice (compote) and other national drinks available.
Complementary Feeding
 There is a problem with both early and late introduction of complementary foods (12.5%
of mothers reported that they introduced foods at 1-2 months; 32.1% introduced food at
3-5 months; 43.2% introduced after 6 months).
 Young children receive an inadequate number of meals each day, especially babies 6-12
months of age; 54.4% of children 6-12 months received complementary foods only 1-2
times a day, and 29.3% received 3-4 times/day. Lack of knowledge seems to be the key
issue, as 55.9% of mothers thought a child 6-12 months should only be given
complementary foods 1-2 times per day. The complementary food often consists of thin
soups, cow’s milk, or other fermented milk products.
 The main problem seems to be a lack of knowledge of proper complementary feeding
practices, as the majority of families interviewed had consistent access to nutritious foods
that could be used to prepare appropriate meals for the baby
 48% of the mothers use a bottle to give their baby liquid food
 In the 24 hours prior to the survey, 53.3% of the children received breast milk; 84.3%
received water, juice, stewed fruit and national drinks; 78.4% - fresh fruit; 85.6% - tea;
56.2% - meat; 64.4% cheese, cottage cheese, yogurt, kefir, and airan; 63.1% - whole
milk; 29.4% - eggs.
 The complementary foods that were less commonly provided included cereal porridges
(37.7%), buckwheat/rice/millet/oat (23.2%), bylamyk (24.5%), vegetables (pumpkin,
beets, carrots, green peppers, tomatoes, and cabbage) (39.2%), fish (5.9%), formula
(17.7%), and beans (4.9%). While vegetables are not a substantial part of young
children’s diets, a variety of vegetables are grown in Talas oblast, and many families have
vegetable gardens. Therefore, it is important to provide families with information on the
importance of giving children vegetables, and simple recipes for preparing vegetable
dishes for young children.
 The majority of mothers thought that complementary food should include: milk and milk
products (97.1%), carrots (91.8%), meat (87.6%), fruit (89.8%), potatoes (85.3%),
tomatoes (74.1%), beets (69.6%), and fish (60.1%). Half of the mothers thought a baby’s
diet should not include greens (51.6%), pumpkin (52.3%), cucumbers (50.3%), and beans
(60.8%).
 97.1% of the mothers believed that milk and milk products can be given to a child daily
as a substantive complementary food. The use of whole cow’s milk to feed babies during
the first 9 months of life is very common. Evidently, the overreliance on cow’s milk for
complementary feeding is a result of decades of health care provider propaganda
regarding the benefits of fermented milk products.
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44.1% of mothers think that a child should not be given complementary foods when he is
sick.
77.9% of the respondents had sufficiently iodized salt in the household; 86.4% of the
mothers interviewed were not aware of the availability of fortified flour
The main sources of nutritional information for mothers are medical workers (68.2%),
friends, relatives and neighbors (17.8%), and the mass media (5.2%).
Mother’s Diet During Pregnancy and Breastfeeding
 Only 55% of the mothers reported that they changed their diet during pregnancy or while
breastfeeding (27.5% increased their daily intake, 33.4% ate fruit and vegetables every
day, 22.9% ate meat as often as possible, 0.7% did not drink tea before or after the meal,
5.9% took iron tablets daily, and 6.9% used only iodized salt). 87.5% of the women
knew that it is important for a woman to improve her diet during pregnancy and while
breastfeeding. Reasons women gave for not changing their diet included a lack of money,
insufficient food products, and no support from the family. It was concluded that families
are generally unaware that it is important for a pregnant woman to improve her diet and
this is the primary reason for their lack of support, as most families surveyed had access
to a variety of food products (flour, meat, potatoes, milk products, vegetables, beans,
etc.).
 In the 24 hours prior to the interview, 74.4% of the pregnant women ate meat
 Tea is consumed widely among pregnant women; 44.7% of the women drank 11-20 cups
of tea a day. Only 20% of the women surveyed were aware that drinking tea during
meals can lead to the development of anemia. Results of previous focus groups showed
that women will not stop drinking tea, even though they are aware of the health risks.
Tea is the primary beverage in women’s diets, and most women drink as much as two
liters of tea each day. Therefore, when developing the campaign messages, it was
important to keep in mind the pervasiveness of tea in the Kyrgyz diet, and develop
realistic recommendations (ie, drinking tea 1 ½ - 2 hours after a meal).
 Among the women surveyed, there was low awareness of and little demand for fortified
flour. 50.5% of the women knew that an insufficient diet during pregnancy can lead to
anemia. However, only 6.2% of the women believed that pregnant and breastfeeding
women should take iron and folic acid supplements daily. These results indicated that
women may not fully understand the health consequences of anemia for themselves and
their children.
Conclusions
From the study, it was concluded that there is a low awareness and practice of proper infant
and young child feeding practices, which is resulting in children receiving an insufficient
duration of breastfeeding and exclusive breastfeeding, and inadequate types and quantities of
complementary foods. Additionally, too few women make appropriate changes in their diet
during pregnancy and while breastfeeding. The main source of information for women on
maternal and child nutrition is village-level medical workers. As results of the study found
that women’s knowledge of maternal and child nutrition is poor, it was concluded that local
medical workers are likely giving inaccurate information and counseling to mothers.
Therefore, it was recommended that before implementing the component of the pilot program
on training local medical workers, a qualitative study should be conducted to determine
knowledge and counseling practices of local health care providers. Additionally, results of
the research were evaluated and the following recommendations were proposed for the
development of the campaign messages for the population:
Following Should be the Focus for Messages on Infant and Young Child Feeding
1. Importance of early initiation of breastfeeding
2. Importance of exclusive breastfeeding, and potential consequences of not exclusively
breastfeeding
3. Abstaining completely from giving tea to young children
4. Proper quantity and frequency of daily complementary feeding
5. Risks of bottle feeding
6. Food products that are nutritious complementary foods (cereals, vegetables)
7. Continuation of complementary feeding and breastfeeding during illness
8. Monitoring growth and development of babies
Following Should be the Focus for Messages on Diet During Pregnancy and Breastfeeding
1. Importance of a nutritious and adequate diet during pregnancy and breastfeeding
2. Food products that should be used as a part of a nutritious diet during pregnancy and
breastfeeding
3. Combinations of food products to improve absorption of nutrients; methods of cooking
certain foods to ensure preservation of nutrients
4. Consequences of developing anemia during pregnancy and breastfeeding. Methods of
preventing anemia through a healthy diet and daily iron supplementation
5. Avoiding tea consumption during pregnancy
6. Use of fortified flour and iodized salt
Qualitative Research to Explore Factors Contributing to Dietary Practices
Following the quantitative research on maternal and child nutrition in Talas oblast, it was
decided that additional qualitative research was necessary to better understand why mothers
engage in certain dietary practices for themselves and their children. Previous research had
elucidated the main dietary practices that contribute to poor maternal and child nutrition,
however, the cultural beliefs, common attitudes, and social factors affecting these dietary
practices were still not well understood. Therefore, to better understand the factors affecting
mothers’ nutrition decisions, 9 focus groups were conducted in November 2007 with mothers
and grandmothers in Talas oblast. There were three target groups who participated in the
focus group discussions: 1) pregnant women and women with children under 6 months of
age, 2) women with children 6-24 months of age, and 3) grandmothers. To ensure focus
groups would be representative, researchers selected women from various age groups,
occupations, levels of education, levels of income, family sizes, and geographic locations
within Talas. The focus groups (consisting of 8-12 women) were conducted in Bakai-Ata,
Ak-Dobo, Kok-Oi, and Kara-Suu villages. Facilitators from SIAR Research and Consulting
conducted the focus groups using structured interview guides developed for each of the three
target groups.
Following are the main results by target group and discussion topic:
Pregnant Women and Women with Children Under 6 Months of Age
Daily Dietary Intake for Pregnant and Breastfeeding Women
 Pregnant and breastfeeding women generally do not change their daily diet in terms of the
quantity of food they eat and the diversity and nutrient content of their food
 The diet of pregnant and breastfeeding women usually consists of flour-based foods, fried
potatoes, fried macaroni, apples, and airan
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Women generally have a low level of knowledge regarding how to improve nutrition
during pregnancy and breastfeeding. They know they should eat well and take vitamins,
but don’t know how to improve their diet or what vitamins they should take. Women also
lack knowledge regarding how their diet affects the health of their child.
Traditional Kyrgyz dietary habits strongly influence women’s food choices. It is difficult
to change eating habits from the traditional diet based on meat and flour-products.
Women think that eating “dense” foods is more important than worrying about the
nutrient content of the foods
Women commented that living with their mother-in-law makes it more difficult to change
their diet during pregnancy and while breastfeeding
Most women commented that they are not interested in learning new ways to prepare
foods that will diversify and enrich the diet
Women commented that local health care providers are not qualified to provide proper
counseling on maternal and child nutrition, and women don’t seek advice on nutrition
from them
Most of the women have financial constraints that prevent them from diversifying and
improving their diet
It was mentioned that families that grow beans often do not eat them, but simply sell the
beans. Health education messages should, therefore, encourage families to eat the beans
they grow.
Consumption of Iron Supplements
 Almost half of the focus group participants commented that they have anemia, however,
most do not take appropriate measures to treat their anemia. Some of the women think
that it is not necessary to take iron supplements for anemia, and have refused a doctor’s
prescription for iron tablets.
Breastfeeding and Complementary Feeding
 Almost all the women knew that breast milk is the best nutrition for an infant, and that it
is necessary to breastfeed a child for a minimum of 6 months. All the mothers started
breastfeeding their child from birth, and a majority knew the health benefits of feeding
the child colostrum.
 Almost all the women breastfeed their child on demand, not on a schedule (ie, every 3
hours)
 A majority of mothers continue to breastfeed even when the child is ill
 Some of the mothers commented that they try to continue breastfeeding for at least one
year
 Some mothers commented that they introduced complementary foods before 6 months
due to lack of breast milk or because they felt breast milk was not enough for the baby.
Women think that breast milk is not enough for the child because the child cries after
feeding, the child does not gain weight, the mother has watery breast milk, or their breasts
become sore and they no longer produce milk
 The women commented that they do not seek the advice of medical workers, and doctors
do not provide consultations on proper breastfeeding
 Even before the age of 6 months, many mothers give as complementary nutrition
bylamyk, semolina, Nestle formula, airan with sugar, cow’s milk, and boiled water. After
the age of 6 months, mothers start giving the baby meat, bread, noodles, tea with milk,
biscuits with milk, rice, mashed potatoes with butter, and sheep fat.
Behavior and Practices of Pregnant Women
 Most of the pregnant women were not concerned about their own health. Pregnant women
tend to go to the local health clinic later in the pregnancy and do not pursue the proper
prenatal care. Most women do not change their daily life during pregnancy, and continue
to work in the fields throughout the pregnancy. They continue to do all the household
chores and receive little help or support from family members. Pregnant women do not
have time to rest during the day.
Sources of Information on Nutrition
 A majority of women learn about breastfeeding and nutrition from their own mothers (not
their mothers-in-law). Medical workers do not proactively offer advice and counseling.
 Television and radio are popular sources of information on health
Women with Children 6-24 Months of Age
Complementary Feeding Practices
 Mothers felt the following foods are healthy for young children: fish, meat, airan, cottage
cheese, carrots, apples, grapes, and pomegranate. They felt the following foods are
harmful for young children: tail fat, fatty, fried, or spicy foods, salted cucumbers and
tomatoes, eggplant, watermelon, and melons
 Almost all mothers recognized that there is a direct relationship between proper nutrition
and a child’s physical and cognitive development.
 Most mothers thought that if a child is thin, it means they have poor health, and if a child
is fat, then it means the parents fed him properly.
 Some mothers feed the child without talking to them, but others talk to the child or sing
songs while feeding them
 On average, the mothers started to introduce weaning foods at 4 months of age, and the
complementary foods they commonly give include: bylamyk, soup with meat and
noodles, semonlina, boiled rice, mashed potatoes, and boiled eggs.
 Only a few of the women commented that they buy commercial infant cereals or
formulas. The majority make porridges for the child out of rice, buckwheat and semolina.
 A majority of mothers use bottles daily for feeding the child
 Most mothers do not give their children vitamin or iron supplements. Again, some
mothers commented that a doctor prescribed an iron supplement for the child, but the
mother stopped giving the iron tablet because she thought it was healthier to just feed the
child meat.
Breastfeeding
 On average, the women continued to breastfeed their children until the age of 1 ½ years.
They stopped breastfeeding when they became pregnant again, stopped producing milk,
or the child refused to breastfeed.
Sources of Information on Nutrition
 This group of women commented that both television programs and local medical
workers are reliable sources of information on nutrition
Main Conclusions
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Mothers lack knowledge and information regarding proper breastfeeding and
complementary feeding practices. Women lack confidence in their ability to improve
their diet and the nutrition of their children.
Women do not have time and do not know how to prepare foods specially for a young
child
Medical workers and family are not supportive and do not encourage the woman to
improve nutrition. The quality of medical consultation during pregnancy is also poor.
There is little awareness of how pregnant women should change their behaviors and daily
life. They continue to do household chores and field work, and have no time to rest. The
family is generally not supportive in helping the pregnant woman change her diet and
work load.
Women were very enthusiastic about the idea of receiving brochures and information on
how to improve nutrition for themselves and their children
Findings from the three stages of formative research were used to formulate the overall
campaign approach, and also to guide the development of campaign messages and
communication and training materials.