Translating global recommendations on HIV and infant feeding to the local context: The development of culturally sensitive counselling tools in the Kilimanjaro Region, Tanzania

University of Bergen, Center for International Health, Norway.
Implementation Science (Impact Factor: 4.12). 02/2006; 1(1):22. DOI: 10.1186/1748-5908-1-22
Source: PubMed


This paper describes the process used to develop an integrated set of culturally sensitive, evidence-based counselling tools (job aids) by using qualitative participatory research. The aim of the intervention was to contribute to improving infant feeding counselling services for HIV positive women in the Kilimanjaro Region of Tanzania.
Formative research using a combination of qualitative methods preceded the development of the intervention and mapped existing practices, perceptions and attitudes towards HIV and infant feeding (HIV/IF) among mothers, counsellors and community members. Intervention Mapping (IM) protocol guided the development of the overall intervention strategy. Theories of behaviour change, a review of the international HIV/IF guidelines and formative research findings contributed to the definition of performance and learning objectives. Key communication messages and colourful graphic illustrations related to infant feeding in the context of HIV were then developed and/or adapted from existing generic materials. Draft materials were field tested with intended audiences and subjected to stakeholder technical review.
An integrated set of infant feeding counselling tools, referred to as 'job aids', was developed and included brochures on feeding methods that were found to be socially and culturally acceptable, a Question and Answer Guide for counsellors, a counselling card on the risk of transmission of HIV, and an infant feeding toolbox for demonstration. Each brochure describes the steps to ensure safer infant feeding using simple language and images based on local ideas and resources. The brochures are meant to serve as both a reference material during infant feeding counselling in the ongoing prevention of mother to child transmission (pMTCT) of HIV programme and as take home material for the mother.
The study underscores the importance of formative research and a systematic theory based approach to developing an intervention aimed at improving counselling and changing customary feeding practices. The identification of perceived barriers and facilitators for change contributed to developing the key counselling messages and graphics, reflecting the socio-economic reality, cultural beliefs and norms of mothers and their significant others.

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    • "While the Tanzania Demographic and Health Surveys (TDHS) collects data on national prevalence of EBF, it does not generate regional rates, nor does it provide detailed information on predictors of EBF. Further many studies on breastfeeding in Tanzania have only been concentrated in HIV positive women or prevention of mother to child transmission (PMTCT) of HIV [18,19]. Among few studies on predictors of EBF conducted on general population of women, were either done in the late 90s or based in the urban settings [14,17,20]. "
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    ABSTRACT: Exclusive breastfeeding (EBF) is a simple and cost-effective intervention to improve child health and survival. Effective EBF has been estimated to avert 13% - 15% of under-five mortality and contribute to reduce mother to child transmission of HIV. The prevalence of EBF for infant less than six months is low in most developing countries, including Tanzania (50%). While the Tanzania Demographic Health Survey collects information on overall EBF prevalence, it does not evaluate factors influencing EBF. The aim of this paper was to determine the prevalence and predictors of exclusive breastfeeding in urban and rural areas in Kilimanjaro region. A population-based cross-sectional study was conducted between June 2010 to March 2011 among women with infants aged 6--12 months in Kilimanjaro. Multi-stage proportionate to size sampling was used to select participants from all the seven districts of the region. A standardized questionnaire was used to collect socio-demographic, reproductive, alcohol intake, breastfeeding patterns and nutritional data during the interviews. Estimation on EBF was based on recall since birth. Multivariable logistic regression was used to obtain independent predictors of EBF. A total of 624 women participated, 77% (483) from rural areas. The prevalence of EBF up to six months in Kilimanjaro region was 20.7%, without significant differences in the prevalence of EBF up to six months between urban (22.7%) and rural areas (20.1%); (OR = 0.7, 95% CI 0.5,1.4).In multivariable analysis, advice on breastfeeding after delivery (Adjusted odds ratio, AOR = 2.6, 95% CI 1.5, 4.6) was positively associated with EBF up to six months. Compared to married/cohabiting and those who do not take alcohol, single mothers (AOR = 0.4, 95% CI 0.2, 0.9) and mothers who drank alcohol (AOR = 0.4, 95% CI 0.3, 0.7) had less odds to practice EBF up to six months. Prevalence of EBF up to six months is still low in Kilimanjaro, lower than the national coverage of 50%. Strengthening of EBF counseling in all reproductive and child health clinics especially during antenatal and postnatal periods may help to improve EBF rates.
    Full-text · Article · Oct 2013 · International Breastfeeding Journal
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    • "Mothers2mothers is a non-profit facility-based and community-based education and support project wherein HIV-positive Mentor Mothers provide comprehensive peer education and support to pregnant women and new mothers (Teasdale and Besser, 2008). Providing peer-counseling services ensures education is delivered in a culturally sensitive manner, whereas the Mentors' disclosed positive HIV status helps to diminish the stigma many HIV-positive mothers feel when interacting with regular health professionals (Lshabari et al., 2006; Evans and Ndirangu, 2009). This program was designed to improve PVT care and outcomes, and its service model has been shown in several contexts to be " cost effective, easily replicable and scalable, and adaptable to serve diverse cultures and communities " (Teasdale and Besser, 2008). "
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    ABSTRACT: The vertical transmission of HIV occurs when an HIV-positive woman passes the virus to her baby during pregnancy, delivery or breastfeeding. The World Health Organization's (WHO) Guidelines on HIV and infant feeding 2010 recommends exclusive breastfeeding for HIV-positive mothers in resource-limited settings. Although evidence shows that following this strategy will dramatically reduce vertical transmission of HIV, full implementation of the WHO Guidelines has been severely limited in sub-Saharan Africa. This paper provides an analysis of the role of ideas, interests and institutions in establishing barriers to the effective implementation of these guidelines by reviewing efforts to implement prevention of vertical transmission programs in various sub-Saharan countries. Findings suggest that WHO Guidelines on preventing vertical transmission of HIV through exclusive breastfeeding in resource-limited settings are not being translated into action by governments and front-line workers because of a variety of structural and ideological barriers. Identifying and understanding the role played by ideas, interests and institutions is essential to overcoming barriers to guideline implementation. Copyright © 2012 John Wiley & Sons, Ltd.
    Full-text · Article · Jul 2013 · International Journal of Health Planning and Management
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    • "Other authors suggest that perceived breast milk inadequacy is underpinned by a complex and synergistic interaction among socio- cultural influences, feeding management such as positioning of babies and attachment while breastfeeding [32], the baby’s behavior, lactation physiology, and the mother’s psychological state [26]. Apart from perceived hunger or thirst, the observed notions of “the baby needs water” and “the baby has other needs apart from milk to grow well and faster” are also supported in the literature [29]. Furthermore, it may be the perceived ill health of the babies that makes caregivers use a variety of food and drink, other than breast milk, for feeding the infants. "
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    ABSTRACT: Background Despite the significant positive effect of exclusive breast-feeding on child health, only 32% of children under 6 months old were exclusively breast-fed in Kenya in 2008. The aim of this study was to explore perceptions and feeding practices of caregivers of children under 6 months old with special attention to the caregivers’ indigenous knowledge, perceptions about the health and nutritional problems of their infants, and care-seeking behaviors that affect feeding practices. Methods The study was exploratory and used an inductive approach. In all, 32 key informants, including mothers, mothers-in-law, and traditional healers, were interviewed in-depth. The number of participants in free-listing of perceived health problems of babies, in ranking of the perceived severity of these health problems, and in free-listing of food and drink given to children under 6 months old were 29, 28, and 32, respectively. Additionally, 28 babies under 6 months old were observed at home with regard to feeding practices. Data obtained using these methods were triangulated to formulate an ethnomedical explanatory model for mothers who do not practice exclusive breast-feeding. Results The informants stated that various types of food, drink, and medicine were given to infants under 6 months old. Direct observation also confirmed that 2- to 3-month-old babies were given porridge, water, juice, herbal medicine, and over-the-counter medicine. Mothers’ perceptions of insufficient breast milk production and a lack of proper knowledge about the value of breast milk were identified in key informant interviews, free-listing, and ranking as important factors associating with the use of food and drink other than breast milk; in addition, perceived ill health of babies appears to be associated with suboptimal practice of exclusive breast-feeding. Caregivers used various folk and popular medicines from the drugstore, their own backyard or garden, and traditional healers so that the mother or child would not be exposed to perceived risks during the vulnerable period after birth. Conclusions Mothers should be advised during their antenatal and postnatal care about exclusive breast-feeding. This should be done not as a single vertical message, but in relation to their concerns about the health and nutritional problems of their babies.
    Full-text · Article · May 2013 · BMC Public Health
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