Scaling-up in KZN:Outcomes & Recommendations

Infant & Young Child Feeding

CONTEXT• SA DoH revised PMTCT guidelines from 1st

April 2010– All HIV exposed infants receive daily NVP from

birth – 6 weeks and continued daily for those who are BF where mother is not taking lifelong ARVs

– Mothers not taking lifelong ARVs are encouraged to BF for up to 12 months

• Integrating ARVs to BF is expected to reduce HIV transmission rate to <2% (UNICEF, 2010)

CONTEXT• KZN DoH (as of 1 January 2011) decided to cease

provision of free infant formula to HIV infected mothers (except where clear medical indications)

• Mothers will choose desired feeding method but will no longer be issued with free infant formula if she chooses replacement feeding

• Extra support for BF is required to enable mothers make informed decisions and sustain exclusive BF

CONTEXTObjectives of IYCF in the context of HIV training (as

per TOR):1. To adapt or develop advocacy messages on the

new provincial guidelines on BF and infant feeding to be shared with political leaders, health practitioners, and communities

2. To develop training materials for health facility based professional teams and lay counsellors on IYCF in the context of HIV and conduct training for these teams

CONTEXT• Zoe-Life is a purpose-driven organisation based in

SA, working towards societal transformation through direct service interventions, capacity-building, technical support and skills training for organisations and communities

• In 2010, Zoe-Life was commissioned by KZN DoH: Nutrition Directorate and UNICEF to provide IYCF training for District Trainers and 1850 Lay Counsellors throughout KZN. The training was to be rolled out between October 2010 and April 2011.

CONTEXT

CONTEXT

Tshwane Declaration (Aug 2011)• SA to declare itself as a country that actively promotes,

protects and supports exclusive breastfeeding, and takes actions to demonstrate this commitment. This includes further mainstreaming of breastfeeding in all relevant policies, legislation, strategies and protocols;

• SA to adopt the 2010 WHO guidelines on HIV and Infant feeding and to recommend that all HIV infected mothers should breastfeed their infants and receive ARV drugs to prevent HIV transmission. ARV drugs to prevent HIV through breastfeeding and to improve the health and survival of HIV infected mothers should be scaled up and sustained;

Tshwane Declaration (Aug 2011)• Generally this was a welcomed decision:– Unanimous decision from the top– PMTCT experience revealed consistent practical,

implementation issues• Overall reflections from the field = decision

positively welcomed

Tshwane Declaration (Aug 2011)• Going forward:– Not enough to simply welcome the declaration– Need to act

• Discovered on the ground:– Misconceptions from health workers and public– Require uniform training with same messages– Messages on IYCF have not saturated HCWs or

public• Vital time has passed

STAKEHOLDERS– KZN DOH Nutrition Directorate– UNICEF– Researchers – supporting policy change– KZN Government – HOD– Advocacy groups (TAC, Yezingane Network,

Children’s Rights Centre)– 20 000+, UKZN (Quality Improvement)– Zoe-Life (Resource Development, Training)– MCDI (Community based response)

STRATEGY

Advocacy and Preparation

Media and Political support

Inter-programme advocacy

Process documentation and lessons shared for National response

Development of Messaging, Training and

Tools

Training of Multidisciplinary

teamsMentorship, QI, QA

Integration of Implementation

Clinical, Psychosocial, Community

Linkages, development of

tools to link C,P,CQA/ QI at each level

AIMS OF THE TRAINING

DEVELOPMENT OF MESSAGES, TRAINING AND TOOLS

• Unique opportunity to re-establish BRAND IDENTITY of Exclusive Breastfeeding as a public health intervention

• Other opportunities for key messaging– Role of the male– Attractiveness of breastfeeding as a choice for

families

BRAND IDENTITY as part of COMMUNICATION STRATEGY

– Needed to speak to all target audiences• Clinical HCWs• Psychosocial and Community HCWs• Patients in predominantly semi-urban culture groups

– Program branding• Needed to establish some continuity with previous

PMTCT work done• BUT needed to establish clear change.

Continuity• Used basic format from 2008 IYCF training: – Participants manual– Breastfeeding flipchart– Pre- & post-course assessments– Post-course evaluation

• For 2010 IYCF provincial scale-up:– Facilitators’ manual– Participant workbook– Pocket tool– IYCF flow path– Project planning board– CDs of training materials

Change

– Refreshed and modernised colours– Added partner graphics– Format of Breastfeeding flipchart– Added tools – pocket tool, Flow path

Developing the IYCF ProjectTraining materials:• For the 5 day TOT, participants

were given a facilitator’s manual, participant’s manual, workbook, flip chart and pocket tool.

• For the lay counsellor 3 day training, participants were given a manual, workbook and pocket tool. One flip chart was given to the participants per health facility and mobile clinic.

MATERIAL CONTENT AND METHODOLOGY

• Used WHO 2010 guidelines as base,• Added Values clarification• Facilitators Manual:

• Facilitation skills• How to use the tools• QA QI principles• Project planning

• Content and methodology workshoped with technical team and facilitators

Developing the IYCF ProjectTraining Modules for the TOT programme

1. Reasons why children are dying2. Knowledge, Attitudes & Practice3. Importance of breastfeeding4. How breastfeeding works5. Assessing a breastfeed6. Positioning a baby at the breast7. Expressing and storing breast milk8. Breastfeeding challenges (incl GMP)9. Breast conditions10. IYCF in the context of HIV11. Breastfeeding & ARVs12. Cost of formula (activity)

13. Counselling process14. Preparation of formula15. Heat treating EBM16. Complementary feeding17. Quality Assurance (QA) and Quality Improvement (QI) 18. IYCF flow path19. Project planning board (action plan)20. Presentation of training tools21. Discussion on facilitator’s manual & its application

Developing the IYCF Project

Training Modules for the lay counsellor programme

1. Reasons why children are dying2. Knowledge, Attitudes & Practice3. Importance of breastfeeding4. How breastfeeding works5. Assessing a breastfeed6. Positioning a baby at the breast7. Expressing and storing breast milk8. Breastfeeding challenges (incl GMP)9. Breast conditions

10. IYCF in the context of HIV11. Breastfeeding & ARVs12. Cost of Formula (activity)13. Counselling process14. Preparation of formula15. Heat treating EBM16. Complementary feeding17. IYCF flow path

FLOW PATH SIMPLIFIED

Training

• Zoë-Life Facilitators – Selected because of previous health and

nutrition-related training experience– 4 teams: 1 clinical and 1 psychosocial

• Pre-testing of training materials and methodology– 23 Community Caregivers (Masisizane) – KZN DOH and UNICEF

DEVELOPMENT OF TRAINERS

Training

• Trainer of Trainers – 2 from each District – District Trainer (Clinical)

with Mentor coordinator (Psychosocial)– Aim: Provide ongoing training and support of both

clinical and psychosocial staff.

• Lay Counsellor and nurse training– Recognizing role of LC as first point of contact and

follow up support

TRAINING COURSES

TARGETS & DEMOGRAPHIC ANALYSIS

34 TOTs representing all

Districts

District Scale Up for LCs:

• Target 1850

• Attended 1706

• LCs trained 1496

TRAINING EVALUATION

• Numbers attended all sessions• Discipline type• Facility/ District/ Demographics• Years of experience• Pre and Post course questionnaires• Values clarification• Qualitative data- FAQs, comments, concerns,

beliefs of participants

PRE- AND POST COURSE QUESTIONNAIRE

PRE- AND POST COURSE QUESTIONNAIRE

TRAINING EXPERIENCE

• 43% of participants indicated that they had previous IYCF training

• Previous training did not translate to competence on IYCF principles and on self-reported quality of IYCF counselling

VALUES CLARIFICATIONS

Whilst feedback has been both negative and positive, it must be clearly stated that the overwhelming response was positive and

the districts are supportive of the new guidelines.

Communications and logistics challenges, whilst dominating much of the feedback, are expected in a project of this size.

Improvements will reduce frustrations and cost. However, participants and trainers should be commended for rising above

the challenges.

Knowledge transference was successful and participants are eager to implement the new guidelines.

Brand identity and user acceptability of tools• Pocket tool most used• Flip chart second• Used by nurses and lay counsellors, with

recommendations for use in community

• Communication strengthens with standardization of messages – both words and graphics

LESSONS LEARNED

• Efficient and rapid scale up of Back to back training requires logisitics and communication SOP– Detail the specific roles and responsibilities of

stakeholders– Detail a communication flow

• This will minimise disruptions and improve cost efficiencies

LESSONS LEARNED

• Facility management reluctance to release staff for training: Formulate a strategy for uninterrupted services during rapid scale up– LCs offered more than one opportunity to attend

training• Combine training for Nurses and LCs

LESSONS LEARNED

LESSONS LEARNED

• IYCF training standardised and provided to all HCWs regularly with onsite focussed follow up

• Counsellors may need more training time to build foundational sciences knowledge

• More time allocated to unpack values on IYCF in the context of HIV

• IMCI training needed for LCs

• AFASS poorly understood –may need to rethink tools and terminologies

• Multidisciplinary team dynamics and advantages

• Call for professionalisation of counsellors• Training props are essential for effective group

health education• Strong call for rapid community training to

ensure standardisation of messaging

LESSONS LEARNED

• Follow up support:– To reinforce the PMTCT and IYCF policies (ART

during BF)– To ensure all misinformation is corrected– Use pre and post questionnaire results to direct

support–Mentorship and QA tools with clear guidance

LESSONS LEARNED

• Cross border alignment of policy• Labour law regulations to support

breastfeeding mothers• Integration of training into Education Life

orientation, Department of Social Development

• Code of Marketting violations – mechanisms for reporting

• Professionalisation of LCs

ADVOCACY ISSUES ARISING

• This is a great opportunity to come alongside government• It is one of the most impressive policy changes with the

potential to impact on child mortality• Ask ourselves:

– How best can we come alongside government?– How does the Tshwane Declaration fit in with maternity leave?– What can our organisations do to maintain the positive

momentum?– Vital time has passed– Advocate for well constructed, strong, mass-media movement– Bridge the public-private divide

Tshwane Declaration

Thank you !Demonstrating the lying down position

Group work

Practice positioning a baby at the breast