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Promotion of Exclusive Infant Feeding in South Africa: Community-Based Peer Counselling in high HIV Prevalent Area
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Despite global efforts, exclusive breastfeeding is rarely practiced in South Africa where infants are at risk of diarrheal infections, malnutrition and HIV transmission. The present study was conceptualized within the context of a multi-country, cluster randomized community-based behavioural intervention known as PROMISE-EBF in South Africa, Burkina Faso, Zambia and Uganda (www.clinicaltrials.gov, no: NCT00397150). The aim of this thesis was to identify and describe contextual factors that are important for the effectiveness of community-based peer counselling with a special focus on the promotion of exclusive breast and formula feeding. This thesis identifies the paradoxes and discrepancies embedded in the notion of community-based “peer” counselling approach, especially in the South African context of poverty, HIV and social distrust. Peer counselling, while perceived useful, was associated with social distrust which might have resulted in reduced effectiveness of the intervention. The thesis further illustrates that, while there is strong support for breast feeding, there was a general openness for early introduction of commercial foods and liquids. Mothers’ perceptions on infant feeding and peer counselling varied substantially according to HIV-status and geographical area. Nevertheless, the infant feeding peer counselling approach neither modified the mothers’ perceptions on feeding nor its associated barriers. Thus, several important barriers to exclusive breastfeeding including the risk for HIV stigmatization still remain. The results of this thesis highlight the need to rethink current approaches to the promotion of exclusive breastfeeding. It further draws attention to the gap between theoretical assumptions inherent in health interventions and the actual dynamic processes and realties of women in low-income high HIV settings.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2010. , p. 72
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 619
Keywords [en]
Promotion, Exclusive Breastfeeding, Formula Feeding, Peer Counselling, HIV, South Africa
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
URN: urn:nbn:se:uu:diva-133199ISBN: 978-91-554-7939-8 (print)OAI: oai:DiVA.org:uu-133199DiVA, id: diva2:360322
Public defence
2010-12-15, Universitetshuset, Sal IX, Biskopsgatan 3, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2010-11-24 Created: 2010-11-02 Last updated: 2011-01-13Bibliographically approved
List of papers
1. "Peer but not peer": considering the context of infant feeding peer counseling in a high HIV prevalence area
Open this publication in new window or tab >>"Peer but not peer": considering the context of infant feeding peer counseling in a high HIV prevalence area
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2009 (English)In: Journal of Human Lactation, ISSN 0890-3344, E-ISSN 1552-5732, Vol. 25, no 4, p. 427-434Article in journal (Refereed) Published
Abstract [en]

Postnatal transmission of HIV through breastfeeding remains an unsolved problem in resource poor settings, where refraining from breastfeeding is neither feasible nor safe. This study describes how women experienced infant-feeding peer counseling within a community-based intervention trial in 3 settings in South Africa. In total, 17 interviews and 10 observations were done with HIV-infected and uninfected women. The findings raise questions on the concept of "peer." Some women feared the peer counselor visits and questioned their intentions. Others, especially HIV-infected women, valued peer counseling for the emotional support provided. Being HIV infected with limited or no network of support appeared stressful for most women. The effects of data collection on the delivery and uptake of peer counseling are discussed. The findings underline the contextual barriers facing peer counselors and show that these challenges could have important implications for the effectiveness of infant-feeding counseling in high HIV prevalence countries.

Keywords
HIV, exclusive breastfeeding, exclusive formula feeding, peer counseling, interventions, South Africa
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-124187 (URN)10.1177/0890334409341050 (DOI)000271223200009 ()19622755 (PubMedID)
Available from: 2010-05-03 Created: 2010-05-03 Last updated: 2017-12-12Bibliographically approved
2. Mother's perceptions and experiences of infant feeding within a community-based peer counselling intervention in South Africa
Open this publication in new window or tab >>Mother's perceptions and experiences of infant feeding within a community-based peer counselling intervention in South Africa
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2012 (English)In: Maternal and Child Nutrition, ISSN 1740-8695, E-ISSN 1740-8709, Vol. 8, no 4, p. 448-458Article in journal (Refereed) Published
Abstract [en]

Exclusive breastfeeding (EBF) has the potential to significantly reduce infant mortality, but is frequently not practiced in low-income settings where infants are vulnerable to malnutrition and infections including human immunodeficiency virus (HIV). This study explores mothers' experiences of infant feeding after receiving peer counselling promoting exclusive breast or formula feeding. This qualitative study was embedded in a cluster randomized peer counselling intervention trial in South Africa that aimed to evaluate the effect of peer counselling on EBF. Participants were selected from the three districts that were part of the trial reflecting different socio-economic conditions, rural–urban locations and HIV prevalence rates. Seventeen HIV-positive and -negative mothers allocated to intervention clusters were recruited. Despite perceived health and economic benefits of breastfeeding, several barriers to EBF remained, which contributed to a preference for mixed feeding. The understanding of the promotional message of ‘exclusive’ feeding was limited to ‘not mixing two milks’: breast or formula and did not address early introduction of foods and other liquids. Further, a crying infant or an infant who did not sleep at night were given as strong reasons for introducing semi-solid foods as early as 1 month. In addition, the need to adhere to the cultural practice of ‘cleansing’ and the knowledge that this practice is not compatible with EBF appeared to promote the decision to formula feed in HIV-positive mothers. Efforts to reduce barriers to EBF need to be intensified and further take into account the strong cultural beliefs that promote mixed feeding.

Keywords
HIV, Exclusive Breastfeeding, Formula Feeding, Peer Counselling, South Africa
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:uu:diva-133193 (URN)10.1111/j.1740-8709.2011.00332.x (DOI)000308287400004 ()
Available from: 2010-11-02 Created: 2010-11-02 Last updated: 2017-12-12Bibliographically approved
3. Exclusive infant feeding promotion in a high HIV prevalence area: A cross-sectional community-based study in South Africa
Open this publication in new window or tab >>Exclusive infant feeding promotion in a high HIV prevalence area: A cross-sectional community-based study in South Africa
(English)Manuscript (preprint) (Other academic)
Keywords
Promotion, Exclusive Breastfeeding, Peer Counselling, HIV, South Africa
Research subject
Medicine
Identifiers
urn:nbn:se:uu:diva-133191 (URN)
Available from: 2010-11-02 Created: 2010-11-02 Last updated: 2011-01-13
4. Supervision of community peer counsellors for infant feeding in South Africa: an exploratory qualitative study
Open this publication in new window or tab >>Supervision of community peer counsellors for infant feeding in South Africa: an exploratory qualitative study
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2010 (English)In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 8, p. 6-Article in journal (Refereed) Published
Abstract [en]

Background: Recent years have seen a re-emergence of community health worker (CHW) interventions, especially in relation to HIV care, and in increasing coverage of child health interventions. Such programmes can be particularly appealing in the face of human resource shortages and fragmented health systems. However, do we know enough about how these interventions function in order to support the investment? While research based on strong quantitative study designs such as randomised controlled trials increasingly document their impact, there has been less empirical analysis of the internal mechanisms through which CHW interventions succeed or fail. Qualitative process evaluations can help fill this gap. Methods: This qualitative paper reports on the experience of three CHW supervisors who were responsible for supporting infant feeding peer counsellors. The intervention took place in three diverse settings in South Africa. Each setting employed one CHW supervisor, each of whom was individually interviewed for this study. The study forms part of the process evaluation of a large-scale randomized controlled trial of infant feeding peer counselling support. Results: Our findings highlight the complexities of supervising and supporting CHWs. In order to facilitate effective infant feeding peer counselling, supervisors in this study had to move beyond mere technical management of the intervention to broader people management. While their capacity to achieve this was based on their own prior experience, it was enhanced through being supported themselves. In turn, resource limitations and concerns over safety and being in a rural setting were raised as some of the challenges to supervision. Adding to the complexity was the issue of HIV. Supervisors not only had to support CHWs in their attempts to offer peer counselling to mothers who were potentially HIV positive, but they also had to deal with supporting HIV-positive peer counsellors. Conclusions: This study highlights the need to pay attention to the experiences of supervisors so as to better understand the components of supervision in the field. Such understanding can enhance future policy making, planning and implementation of peer community health worker programmes.

National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
urn:nbn:se:uu:diva-133194 (URN)10.1186/1478-4491-8-6 (DOI)000277618500001 ()
Available from: 2010-11-02 Created: 2010-11-02 Last updated: 2017-12-12Bibliographically approved

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