The Boosters, Barriers, Questions (BBQ) tool involves examining the collected data for Boosters (ie. anything which might act to support coverage) and Barriers (ie. anything which might act to undermine coverage) during a community assessment. The BBQ tool should be used by the survey team throughout the duration of Stage 1 and should take place as follows:

• After each interview or group discussion, each team should review their notes and list the main barriers and boosters cited during the interviews. Barrier and Booster Types (below) lists the most common barriers and boosters in CMAM programmes. The barriers and boosters should be similar to these although they should be adapted to the context.
• After each barrier and booster, teams should note which source mentioned the relevant booster or barrier, the collection method used and the ethnicity of the interviewee.
• At the end of each day of the Community Assessment, all of the teams come together and the survey leader facilitates a feedback session on the barriers and boosters. Each survey team contributes the barriers and booster from the interviews they did. The survey leader adds these to two flipcharts, one for Boosters and one for Barriers. After each booster or barrier, they should add the source, method used and any other relevant demographic information (eg. tribe) (see Images 1+2).

• Owing to the fact that certain barriers and boosters are likely to be cited numerous times, it is useful to use abbreviations or symbols for the different sources and methods. These can be summarised on another flipchart (see Image 3).

•  Every time a new booster or barrier is mentioned, it should added to the relevant flipchart. If a barrier or booster is mentioned which is already on the flipcharts, the survey leader should note the additional source and method next to the existing entry, or, if it is from the same source, keep a tally of the number of times the same source has cited it.
• If, at the end of the process, there are some boosters or barriers which have only been cited once, they should be added to a third flipchart entitled Questions (see Image 4). These are points which deserve further investigation and should be added to relevant interview guides for the next day's data collection.

• Over the course of the Community assessment, the BBQ tool should be redrafted constantly, with the survey team combining similar findings and removing invalidated findings. Once the final list of barriers and boosters is established and all sources, methods and demographic information noted, the sheets should be kept on display. They will be referred back to during the BBQ "weighting" process, which comes at the start of Stage 3.

Types of Barriers and Boosters:

In 2014, the CMN commissioned a study which provided an in-depth analysis of the barriers and boosters identified during the qualitative data collection phase of previous SQUEAC assessments (Becart E, 2014). The barriers and boosters identified in the study were grouped into five overarching categories: Geographic, Temporal, Socio-cultural, Financial and Quality of care.  Table 1 and 2 list the barriers and boosters under each category: Table 1: Barriers - anything which might undermine coverage

CATEGORY	BARRIER
Geographic	- Distance - Population movement - Seasonal barriers
Temporal	- Carer busy - Long waiting time - Carer sick
Socio-cultural	- Alternative health practitioners preferred - Lack of awareness about malnutrition - Lack of awareness about the program - Husband refusal - Stigma - Insecurity
Financial	- High opportunity cost - Lack of money - Cost of treatment - Transport cost
Quality of care	- Relapse - Poor delivery of service - Unsuitable treatment interface - Wrong admission and discharge criteria - Non respondent - Previous rejection of a known child - Previous rejection - Poor outreach activities - Poor program monitoring - RUTF stock breaks - Long waiting time

Table 2: Boosters - anything which might act to support coverage

CATEGORY	BOOSTER
Geographic	- Community access to nutrition services within the coverage area is facilitated through numerous OTP centres or mobile units.
Temporal	- Supply of RUTF - Short waiting times/ efficient patient flow at program sites - Regular active case finding activities with appropriate and timely referral.
Socio-cultural	- Awareness of the signs and symptoms of SAM - Awareness that the child was SAM - Awareness that SAM can be treated effectively - Awareness the service to treat SAM is available at the local clinic - Key community figures actively support the program by referring children and support CHW’s activities - Reduction of stigma associated with malnutrition by seeking early treatment behavior - RUTF well accepted - Caregivers have physical access to nutrition activities
Financial	- Awareness that the treatment is free of charge
Quality of care	- Delivery of results in terms of high proportion cured, low mortality, low defaulting, and short length of stay - Case follow up of high risk cases - Absentee follow up - Defaulter tracing and follow up - Motivation of CHW / volunteer - Good program decision making by proper data collection - Effective systems in place for referral and transfer - Supply of RUTF - Good client / staff relationship - Short waiting times/efficient patient flow at programs sites - Sensitisation of the community - Adequate support and supervision given to volunteers etc - High number of self referral and peer to peer referral - Good coordination between CMAM actors etc

Sources:

• Becart E, 2014, Meta-analysis of Barriers and Boosters from 78 coverage assessments supported by the CMN. Available to view online here.
• Prentice. A, Balegamire. J, McOyoo. E, Nzidka. F, Ahmed. H, Chege. J, Macharia. J, Musumba. K, Kaindi. L, Kiamba. L, Gathii. M, Brennan. M, Kirichu. S, Abubakar. S, Kimanzi. S and Myatt. M, May 2013, Boosters, Barriers, Questions: an approach to organising and analysing SQUEAC data, , Field Exchange, Issue 45. Available to view online here.