**Background:** Optimal nutrition, particularly breastfeeding, is critical for infant health and development. The WHO recommends early initiation within one hour of birth, exclusive breastfeeding for six months, and continued breastfeeding to two years or beyond. However, global breastfeeding rates remain low, especially among displaced populations. South Sudan represents the largest refugee crisis in Africa, with over 2.3 million displaced, and Uganda hosts the majority. In Adjumani district, early initiation rates ranged from 58% to 84.4% across settlements in 2020, and exclusive breastfeeding was 42.3%—nearly 20 percentage points below the average across all settlements. This qualitative study aimed to identify facilitators and barriers to breastfeeding among South Sudanese refugees living in protracted settlements in Adjumani, Uganda.
**Methods:** The study was conducted in July 2019 in three randomly selected refugee settlements (Agojo, Ayilo-I, Nyumanzi) among 17 settlements in Adjumani district. Participants included mothers (n=63) and fathers (n=32) of children under 24 months, recruited via Village Health Teams from randomly selected household lists. Six focus group discussions (FGDs) were conducted—four with mothers and two with fathers—each comprising 15–16 participants. FGDs were conducted in Arabic, Dinka, or Madi, audio-recorded, transcribed verbatim, and back-translated into English. Thematic analysis was performed using NVivo v. 12. Ethics approval was obtained from Makerere University, Uganda National Council of Science and Technology, and Oklahoma State University.
**Key Results:** Mean maternal age was 27.1 years; paternal mean age was 39.7 years. Only 14.3% of mothers worked outside the home versus 50% of fathers. Maternal illiteracy was 36.5% compared to 18.8% among fathers. Four facilitator themes emerged: (1) Beliefs and knowledge about breastfeeding benefits—participants reported breastmilk protects from disease, promotes growth and strength, and enhances cognitive development. (2) Support from husband/father—fathers provided food, emotional support, and assistance with household chores. (3) Community support—grandmothers provided food, neighbors provided firewood and water. (4) NGO support—Plan International provided breastfeeding education, and both Plan International and Medical Teams International provided flour for porridge. Four barrier themes were identified: (1) Physical barriers—maternal illness (including HIV/AIDS and breast cancer), maternal death, perceived milk insufficiency, and breastfeeding difficulties (e.g., late initiation, infant refusal). (2) Socioeconomic barriers—maternal employment and higher education level were cited as reasons for using breastmilk substitutes. (3) Knowledge barriers—some participants believed infants under six months should receive powdered milk, cow's milk, juice, formula, or margarine; some believed weaning should occur at 3 months; others thought sick infants need more than breastmilk (e.g., porridge, soft drinks). (4) Psychosocial barriers—marital conflict, fear of pain during breastfeeding, and maternal mental health issues were reported by fathers but not by mothers.
**Clinical Implications:** The study highlights the multifactorial nature of breastfeeding barriers in protracted refugee settings. Interventions should address knowledge gaps about exclusive breastfeeding recommendations, particularly the misconception that infants under six months need supplemental feeds. Antenatal and postnatal care should include education on breastfeeding benefits, management of perceived low milk supply, and solutions to common lactation difficulties. Screening for intimate partner violence and maternal mental health issues during antenatal and postnatal visits is critical, though stigma reduction is needed first. Engaging fathers, grandmothers, and community support networks may be effective, though further research on gender norms and father influence in this context is warranted. Policies should regulate formula donations in refugee settlements to prevent undermining breastfeeding. NGO-led peer support programs may offer cost-effective, sustainable approaches to improve breastfeeding practices. The socioecological model is recommended as a framework for designing interventions that address barriers at individual, interpersonal, community, and organizational levels.