Infant feeding counselling in Uganda in a changing environment with focus on the general population and HIV-positive mothers - a mixed method approach

Lars T Fadnes, Ingunn Marie S Engebretsen, Karen Marie Moland, Jolly Nankunda, James K Tumwine, Thorkild Tylleskär, Lars T Fadnes, Ingunn Marie S Engebretsen, Karen Marie Moland, Jolly Nankunda, James K Tumwine, Thorkild Tylleskär

Abstract

Background: Health workers' counselling practices are essential to improve infant feeding practices. This paper will assess how infant feeding counselling was done and experienced by counsellors and mothers in Eastern Uganda in the context of previous guidelines. This has implications for implementation of the new infant feeding guidelines from 2009.

Methods: This paper combines qualitative and quantitative data from Mbale District in Eastern Uganda. Data was collected from 2003 to 2005 in a mixed methods approach. This includes: key-informant interviews among eighteen health workers in the public hospital, health clinics and non-governmental organisations working with people living with HIV, fifteen focus group discussions in the general population and among clients from an HIV clinic, two cross-sectional surveys including 727 mothers from the general population and 235 HIV-positive mothers.

Results: The counselling sessions were often improvised. Health workers frequently had pragmatic approaches to infant feeding as many clients struggled with poverty, stigma and non-disclosure of HIV. The feasibility of the infant feeding recommendations was perceived as challenging among health workers, both for HIV-positive mothers and in the general population. Group counselling with large groups was common in the public health service. Some extra infant feeding teaching capacities were mobilised for care-takers of undernourished children. A tendency to simplify messages giving one-sided information was seen. Different health workers presented contradicting simplified perspectives in some cases. Outdated training was a common concern with many health workers not being given courses or seminars on infant feeding since professional graduation. Other problems were minimal staffing, lack of resources, and programs being started and subsequently stopped abruptly. Many of the HIV-counsellors in the non-governmental organisations got extended training in counselling which seemed to be beneficial.

Conclusions: Health workers were faced with challenges related to workload, resources, scientific updating, and also a need to adjust to frequent changes in programs, recommendations and guidelines. The clients were faced with difficult choices, poverty, lack of education and stigma. Feasibility of the recommendations was a major concern. Systematic approaches to update health workers should be a priority.

References

    1. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M. What works? Interventions for maternal and child undernutrition and survival. Lancet. 2008;371(9610):417–440.
    1. Bryce J, Daelmans B, Dwivedi A, Fauveau V, Lawn JE, Mason E, Newby H, Shankar A, Starrs A, Wardlaw T. Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions. Lancet. 2008;371(9620):1247–1258.
    1. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year? Lancet. 2003;362(9377):65–71.
    1. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2002. p. CD003517.
    1. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera J. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371(9608):243–260.
    1. Edmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics. 2006;117(3):e380–386.
    1. Lazzerini M, Ronfani L. Oral zinc for treating diarrhoea in children. Cochrane Database Syst Rev. 2008. p. CD005436.
    1. The Baby-Friendly Hospital Initiative (BFHI)
    1. Integrated Management of Childhood Illness (IMCI)
    1. Multicountry evaluation of the integrated management of childhood illness.
    1. Engebretsen IM, Wamani H, Karamagi C, Semiyaga N, Tumwine J, Tylleskar T. Low adherence to exclusive breastfeeding in Eastern Uganda: a community-based cross-sectional study comparing dietary recall since birth with 24-hour recall. BMC Pediatr. 2007;7:10.
    1. Macro O, editor. Uganda Ministry of Health. Uganda HIV/AIDS Sero-Behavioral Survey 2004-2005. 2006.
    1. Ziegler JB, Cooper DA, Johnson RO, Gold J. Postnatal transmission of AIDS-associated retrovirus from mother to infant. Lancet. 1985;1(8434):896–898.
    1. Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T. Effect of the HIV epidemic on infant feeding in South Africa: "When they see me coming with the tins they laugh at me". Bull World Health Organ. 2006;84(2):90–96.
    1. Leshabari SC, Blystad A, de Paoli M, Moland KM. HIV and infant feeding counselling: challenges faced by nurse-counsellors in northern Tanzania. Hum Resour Health. 2007;5:18.
    1. Luo C. Evaluation of a pilot programme and a follow up study of infant feeding practices during the scaled-up programme in Botswana. Eval Program Plann. 2002;25:421–431.
    1. Coutsoudis A, Goga AE, Rollins N, Coovadia HM. Free formula milk for infants of HIV-infected women: blessing or curse? Health Policy Plan. 2002;17(2):154–160.
    1. Prevention of mother to child transmission of HIV/AIDS - PMTCT program.
    1. Chopra M, Rollins N. Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes. Arch Dis Child. 2008;93(4):288–291.
    1. Coovadia HM, Rollins NC, Bland RM, Little K, Coutsoudis A, Bennish ML, Newell ML. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet. 2007;369(9567):1107–1116.
    1. Iliff PJ, Piwoz EG, Tavengwa NV, Zunguza CD, Marinda ET, Nathoo KJ, Moulton LH, Ward BJ, Humphrey JH. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. Aids. 2005;19(7):699–708.
    1. Kagaayi J, Gray RH, Brahmbhatt H, Kigozi G, Nalugoda F, Wabwire-Mangen F, Serwadda D, Sewankambo N, Ddungu V, Ssebagala D, Sekasanvu J, Kigozi G, Makumbi F, Kiwanuka N, Lutalo T, Reynolds SJ, Wawer MJ. Survival of infants born to HIV-positive mothers, by feeding modality, in Rakai, Uganda. PLoS ONE. 2008;3(12):e3877.
    1. Kuhn L, Aldrovandi GM, Sinkala M, Kankasa C, Semrau K, Mwiya M, Kasonde P, Scott N, Vwalika C, Walter J, Bulterys M, Tsai WY, Thea DM. Effects of early, abrupt weaning on HIV-free survival of children in Zambia. N Engl J Med. 2008;359(2):130–141.
    1. Kumwenda NI, Hoover DR, Mofenson LM, Thigpen MC, Kafulafula G, Li Q, Mipando L, Nkanaunena K, Mebrahtu T, Bulterys M, Fowler MG, Taha TE. Extended antiretroviral prophylaxis to reduce breast-milk HIV-1 transmission. N Engl J Med. 2008;359(2):119–129.
    1. Horvath T, Madi BC, Iuppa IM, Kennedy GE, Rutherford G, Read JS. Interventions for preventing late postnatal mother-to-child transmission of HIV. Cochrane Database of Systematic Reviews. 2009. p. CD006734.
    1. Shapiro RL, Hughes MD, Ogwu A, Kitch D, Lockman S, Moffat C, Makhema J, Moyo S, Thior I, McIntosh K, van Widenfelt E, Leidner J, Powis K, Asmelash A, Tumbare E, Zwerski S, Sharma U, Handelsman E, Mburu K, Jayeoba O, Moko E, Souda S, Lubega E, Akhtar M, Wester C, Tuomola R, Snowden W, Martinez-Tristani M, Mazhani L, Essex M. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. N Engl J Med. 2010;362(24):2282–2294.
    1. Chasela CS, Hudgens MG, Jamieson DJ, Kayira D, Hosseinipour MC, Kourtis AP, Martinson F, Tegha G, Knight RJ, Ahmed YI, Kamwendo DD, Hoffman IF, Ellington SR, Kacheche Z, Soko A, Wiener JB, Fiscus SA, Kazembe P, Mofolo IA, Chigwenembe M, Sichali DS, van der Horst CM. Maternal or infant antiretroviral drugs to reduce HIV-1 transmission. N Engl J Med. 2010;362(24):2271–2281.
    1. World Health Organisation. Rapid advice: infant feeding in the context of HIV. 2009.
    1. World Health Organisation. Rapid advice: use of antiretroviral drugs for treating pregnant women and preventing HIV Infection in infants. 2009.
    1. World Health Organisation. Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents. 2009.
    1. Fadnes LT, Engebretsen IM, Wamani H, Wangisi J, Tumwine JK, Tylleskar T. Need to optimise infant feeding counselling: A cross-sectional survey among HIV-positive mothers in Eastern Uganda. BMC Pediatr. 2009;9(1):2.
    1. Engebretsen IMS, Tylleskär T, Wamani H, Karamagi C, Tumwine JK. Determinants of infant growth in Eastern Uganda: a community-based cross-sectional study. BMC Public Health. 2008;8:418.
    1. Fadnes LT, Engebretsen IM, Wamani H, Semiyaga NB, Tylleskar T, Tumwine JK. Infant feeding among HIV-positive mothers and the general population mothers: comparison of two cross-sectional surveys in Eastern Uganda. BMC Public Health. 2009;9:124.
    1. Creswell JW, Clark VLP, Gutmann ML, Hanson WE. In: Handbook of mixed methods in social and behavioral research. Tashakkori A, Teddlie C, editor. California: Sage Publications; 2003. Advanced mixed methods research designs; pp. 209–240.
    1. Tashakkori A, Teddlie C. In: Handbook of mixed methods in social and behavioral research. Tashakkori A, Teddlie C, editor. Sage Publications; 2003. The past and future of mixed methods research: from data triangulation to mixed model designs; pp. 671–701.
    1. Fadnes LT, Engebretsen IM, Wamani H, Semiyaga NB, Tylleskar T, Tumwine JK. Infant feeding among HIV-positive mothers and the general population mothers: comparison of two cross-sectional surveys in Eastern Uganda. BMC Public Health. 2009;9(1):124.
    1. Uganda Bureau of Statistics.
    1. Macro O, editor. Health; UMo. Uganda HIV/AIDS Sero-Behavioral Survey 2004-2005. 2006.
    1. Wanyenze RK, Nawavvu C, Namale AS, Mayanja B, Bunnell R, Abang B, Amanyire G, Sewankambo NK, Kamya MR. Acceptability of routine HIV counselling and testing, and HIV seroprevalence in Ugandan hospitals. Bull World Health Organ. 2008;86(4):302–309.
    1. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 2004;24(2):105–112.
    1. Pope C, Mays N. Qualitative Research in Health Care. 3. WileyBlackwell; 2006.
    1. Krueger RA. Analyzing & reporting focus group results. 1998.
    1. Pool R, Nyanzi S, Whitworth JA. Breastfeeding practices and attitudes relevant to the vertical transmission of HIV in rural south-west Uganda. Ann Trop Paediatr. 2001;21(2):119–125.
    1. Sibeko L, Coutsoudis A, Nzuza Sp, Gray-Donald K. Mothers' infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutrition. 2009;12(11):1983–1990.
    1. Visser MJ, Neufeld S, de Villiers A, Makin JD, Forsyth BWC. To tell or not to tell: South African women's disclosure of HIV status during pregnancy. AIDS Care. 2008;20(9):1138–1145.
    1. Varga CA, Sherman GG, Jones SA. HIV-disclosure in the context of vertical transmission: HIV-positive mothers in Johannesburg, South Africa. AIDS Care. 2006;18(8):952–960.
    1. Medley A, Garcia-Moreno C, McGill S, Maman S. Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: implications for prevention of mother-to-child transmission programmes. Bulletin of the World Health Organization. 2004;82:299–307.
    1. Blystad A, Moland KM. Technologies of hope? Motherhood, HIV - and infant feeding in eastern Africa. Anthropology & Medicine. 2009;16(2):105.
    1. Quinn VJ, Guyon ASB, Schubert JW, Stone-Jimenez M, Hainsworth MD, Martin LH. Improving breastfeeding practices on a broad scale at the community level: success stories from Africa and Latin America. Journal of human lactation. 2005;21(3):345–354.
    1. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane Effective Practice and Organization of Care Review Group. BMJ. 1998;317(7156):465–468.
    1. Awad AI, Eltayeb IB, Baraka OZ. Changing antibiotics prescribing practices in health centers of Khartoum State, Sudan. Eur J Clin Pharmacol. 2006;62(2):135–142.
    1. van Roosmalen J, van Roosmalen-Wiebenga MW. Effectiveness of seminars in training rural health workers. Tropical doctor. 1986;16(2):90–92.
    1. Evaluation: the top priority for global health. Lancet. 2010;375(9714):526.
    1. Bryce J, Gilroy K, Jones G, Hazel E, Black RE, Victora CG. The Accelerated Child Survival and Development programme in west Africa: a retrospective evaluation. Lancet. 2010;375(9714):572–582.
    1. Tylleskar T. International Congress of Nutrition 2009. Vol. 1181. Bangkok, Thailand; 2009. Preliminary results from the multi-centre cluster-randomised behaviour intervention trial Promise-EBF: exclusive breastfeeding promotion in Sub-Saharan Africa.
    1. Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers. Cochrane Database Syst Rev. 2007. p. CD001141.

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