A study evaluating the social and cultural context of a counselling booklet containing infant feeding and caring messages - a component of a community-based health package in Umlazi, KwaZulu-Natal
Exclusive breastfeeding (mother's milk only, with the exclusion of all other food or drink) reduces breast milk transmission of HIV compared with mixed feeding. This study was part of formative work for a community-based un-blinded randomised controlled trial (RCT) in an urban township with high antenatal HIV prevalence in KwaZulu-Natal (KZN), South Africa. The RCT sought to determine whether an integrated package of home-based care delivered by community health workers (CHWs) increases uptake of prevention of mother-to-child-transmission (PMTCT) interventions and improves neonatal outcomes. One example of where counselling is used is in Behaviour Change Communication (BCC) approaches. A counselling booklet, used by CHWs during home visits, was part of the integrated package. The primary objective of this study was to document the socio-cultural context in which infant feeding and caring decisions were made. The secondary objective was to field test the draft counselling booklet for the RCT. Methods This qualitative study used focus groups (n=8 groups) and individual interviews (n=6). All participants, of unknown HIV status, were purposively sampled from the study site. The focus group participants included, in separate groups, eight MRC researchers; 14 pregnant women (two separate groups of seven each); six non-pregnant women; eight older women; five men and 15 CHWs (separated into two groups). Results Data showed that socio-cultural factors, like the lack of social support systems; uncertainty regarding the role of men in infant feeding and caring issues; local beliefs and practices that encouraged risky infant caring practices; the lack of supply of formula and CHWs' lack of breastfeeding knowledge and experience; and HIV-related stigma may directly or indirectly, drive mothers to practice non-exclusive infant feeding. BCC principles acknowledge that people are affected greatly by social pressures exerted not only by their peers, but also by their larger communities (Bentley et al., 1999). For vi example, with regard to the support systems, both pregnant as well as younger women felt that feeding and caring decisions regarding their infants were mostly made by older women ' their husbands were seldom involved in such decisions. In relation to HIV-related stigma, many pregnant women felt that some clinics were not very supportive regarding HIV disclosure. In terms of health system factors, CHWs said that they were sometimes ill-equipped to deal with issues of disclosure due to a lack of training and confusion around the key feeding and caring messages. With regard to infant caring practices, the data revealed risky practices (using soap enemas and inappropriate hand washing practices), even amongst CHWs. Participants said they would share the booklet with others in the community as it taught them important lessons regarding infant feeding and caring practices. For some, the pictures in the booklet enhanced their understanding of 'old' messages. Participants identified several weaknesses in the booklet and suggested that it be less repetitive; that voluntary counselling and testing (VCT) be given priority in earlier rather than later visits; that unfamiliar terms is explained; more pictures included; and the general tone of messages improved. Literacy rates were low among older women and some men in the study. Conclusion and Recommendations Socio-cultural factors drive mothers to practice non-exclusive feeding and care for their infants in ways that may unwittingly increase the risk of HIV transmission. There is a need for CHWs to include family members in discussions about feeding so that they can change their thinking around infant-feeding and caring issues. The data suggests that VCT is not given priority in the counselling booklet and support is lacking in some clinics, therefore policy makers should ensure that support for VCT becomes a priority in the future. Furthermore, some CHWs were confused about the messages they are disseminating, therefore, the training that facility managers give to CHWs should be adapted to suit socio-cultural contexts so that CHWs are better equipped to communicate messages pertaining to infant feeding and caring appropriately to mothers. With the data revealing general acceptability of risky infant caring practices, even amongst CHWs, the vii health system needs to look at how it will effectively change health-related practices among health professionals. With literacy rates being low among older women and some men in the study, it was therefore recommended that gaining skills in materials design and improving CHWs' understanding of the BCC process, booklets such as this one needs to be designed together with the primary user in mind.
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Department of Public Health and Family Medicine