FORM4: COMMUNITY LEADERS QUESTIONNAIRE

PART 1: IDENTIFICATION / No
A / B / C / D

A: 1. Guntur, 2. Gajah B. Form number, C. Visit number ..? D. Participant number..

1.  Name / : / 4.1.1. 
2.  Address / : / 4.1.2. 
Dukuh/dusun
RT RW / 4.1.3. 
Village : / 4.1.4. 
Subsdistrict: 1. Guntur 2. Gajah / 4.1.5. 
Telephone number / 4.1.6. 
3.  Place and date of birth / : / Usia: tahun / 4.1.7. 
4.  Education / : / …………………………………………
…. tahun / 4.1.8. 
5.  Profession / : / 1.  Government employee
2.  Private
3.  Merchant-entrepreneur
4.  Farmers
5.  Housewife
6.  Other: please specify...... / 4.1.9. 
6.  Participant's type / 1. Village's Head, 2. Muslim scholar, 3. Voluntary health worker, 4. Non clinical staff of PHC. / 4.1.10. 

Interviewer's name: ______Sign ______

Date of interview……………………………………... / 2 / 0
Visit number / 2nd / 3rd / 4th / d / d / m / m / y / y / y / y

Supervisor's name …………………………………………. Sign ………………………….

Date of checked ……….…………………...... ……… / 2 / 0
d / d / m / m / y / y / y / y

PART 2: PRACTICE

I want to ask you a little bit about yourself and your activities related to breastfeeding

1.  / How long have you been a community leader (mentioned his/her role)? / ….… year / 4b.2.1. 
2.  / As a community leader, have you ever provide counseling/teaching about breastfeeding? / 1. Yes / 2. No, go to Part 2 / 4b.2.2. 
3.  / Do you feel confident in providing counseling/teaching on exclusive breastfeeding? / 1.  Feel confidence.
2.  Feel not confidence / 4b.2.3. 
4.  / When you educate a mother, what a given topic related to breastfeeding? / 4b.2.4. 
a.  Benefits of breastfeeding / 1. Yes / 2. No / 4b.2.5. 
b.  Early initiation of breastfeeding / 1. Yes / 2. No / 4b.2.6. 
c.  Giving colostrum, not giving prelacteal food / 1. Yes / 2. No / 4b.2.7. 
d.  Exclusive breastfeeding, only breast milk until the age of 6 months / 1. Yes / 2. No / 4b.2.8. 
e.  Breastfeed often and as long as possible, at least 8 times a day / 1. Yes / 2. No / 4b.2.9. 
f.  the mother should let her baby finish one breast before she offers the other breast / 1. Yes / 2. No / 4b.2.10. 
g.  Good position and attachment / 1. Yes / 2. No / 4b.2.11. 
h.  Breastfeeding difficulties: mbangkaki (engorgement), cracked nipples, sore nipple, etc. / 1. Yes / 2. No / 4b.2.12. 
i.  Food portions for mothers / 1. Yes / 2. No / 4b.2.13. 
j.  Other: / 1. Yes / 2. No / 4b.2.14. 
k.  / 1. Yes / 2. No / 4b.2.15. 

PART 3: KNOWLEDGE

Now, I will say a few things related to breastfeeding. Please, give your statement what I say True or False. (Put a check mark √ in the column: true or false)

No / Statement / True / False /
1.  / If within 1-2 days after birth, breast milk comes a little, th baby needs to be given milk formula / 0 / 1 / 4b.3.1. 
2.  / Babies born will decrease their weight, and it will be back to the birth weight in 2 weeks-3 weeks / 1 / 0 / 4b.3.2. 
3.  / Signs of poor attachment is when a baby feeds very short (less than 10 minutes) / 1 / 0 / 4b.3.3. 
4.  / Baby suckles at the breast rather than at the nipple / 0 / 1 / 4b.3.4. 
5.  / Mothers are more susceptible to anemia if not breastfeed her baby / 1 / 0 / 4b.3.5. 
6.  / If the mother has difficulties in breastfeeding, the baby can be given milk formula / 0 / 1 / 4b.3.6. 
7.  / Babies cry often is caused of hunger / 0 / 1 / 4b.3.7. 
8.  / Babies crying is a sign that breastfed babies are less / 0 / 1 / 4b.3.8. 
9.  / Breast milk provides all the nutrients which the baby needs / 1 / 0 / 4b.3.9. 
10.  / the mother should let her baby finish one breast before she offers the other breast / 1 / 0 / 4b.3.10. 
11.  / Breast care is important. Breasts need to be washed before breastfeeding / 0 / 1 / 4b.3.11. 
12.  / If the baby feeds, the baby's body should be straight with the baby's head / 1 / 0 / 4b.3.12. 
13.  / Breastfeeding often and long may increase the milk supply / 1 / 0 / 4b.3.13. 
Nipple pain caused by poor attachment / 1 / 0 / 4b.3.14. 
15.  / Large breasts will produce more breast milk / 0 / 1 / 4b.3.15. 
16.  / A thin milk is a sign of poor quality of beastmilk / 0 / 1 / 4b.3.16. 

SECTION 4: ATTITUDES

Give your opinion on the statement which I will read.

(please mark X in the bottom of the column strongly agree, agree, disagree or strongly disagree)

No / Statement / Strongly agree / agree / Disagree / Strongly disagree
1.  / Children who are breastfed (breast milk) is often thin and does not grow well / 1 / 2 / 3 / 4 / 4b.4.1. 
2.  / Breastfeeding at night is not necessary / 1 / 2 / 3 / 4 / 4b.4.2. 
3.  / Nipples sore or cracked nipples in breastfeeding is normal / 1 / 2 / 3 / 4 / 4b.4.3. 
4.  / One of the ways fathers can be near / dear to the baby is bottle feeding in infants / 1 / 2 / 3 / 4 / 4b.4.4. 
5.  / The baby's father feel ignored when Mother breastfeeding her baby / 1 / 2 / 3 / 4 / 4b.4.5. 
6.  / Breastfeeding is good, but it would be better if the children were given formula milk as well / 1 / 2 / 3 / 4 / 4b.4.6. 
7.  / Breastfeeding will make breasts sag / 1 / 2 / 3 / 4 / 4b.4.7. 
8.  / Kempengan good baby to soothe fussy babies / 1 / 2 / 3 / 4 / 4b.4.8. 
9.  / Breastfeeding is easy / 4 / 3 / 2 / 1 / 4b.4.9. 
10.  / Giving formula / bottle easier than breastfeeding / 1 / 2 / 3 / 4 / 4b.4.10. 
11.  / Breastfeeding is the ancient / modern less / 1 / 2 / 3 / 4 / 4b.4.11. 
12.  / It is very difficult to give only breast milk until the age of 6 months / 1 / 2 / 3 / 4 / 4b.4.12. 
13.  / Need to learn how to breastfeed / 4 / 3 / 2 / 1 / 4b.4.13. 
Please observe and note interesting things during the interview

Thank you for taking the time to participate in this study.