A proof of concept feasibility study of an outreach mentorship approach for disseminating the updated 2016 WHO HIV and infant feeding guidelines

Despite many training courses to update health workers about infant feeding guidelines for young children, breastfeeding guidelines are poorly implemented. Often, this results in sub-optimal infant feeding practices. In July 2016, the World Health Organisation (WHO) and United National Children’s Fund (UNICEF) released important updated global infant feeding recommendations. These recommendations support exclusive breastfeeding for six months and continued breastfeeding for up to two years amongst HIV positive women on triple antiretroviral therapy and HIV negative women.

Given that standard methods to update health workers on HIV and infant feeding guidelines had not achieved the desired outcomes, a new approach was needed to update health workers.

Working in close collaboration with the South African Medical Research Council and the KwaZulu-Natal Department of Health, the team developed a novel participatory, theoretically grounded, team-based approach to the dissemination of the new HIV and infant feeding guidelines to address attitudes, increase infant feeding knowledge, improve self-efficacy and skills of health workers.

The training and mentoring was designed in such a manner that it would be replicable in low-resource settings without the use of modern technologies that are not always available in outlying areas or rural settings (Horwood C, Haskins L, Goga A, Doherty T,  John V, Engebretsen IMS, Feucht U,  Rollins N, Kroon M, Sanders D,  Tylleskar T.    An educational intervention to update health workers about HIV and infant feeding. Maternal and Child Nutrition. 2019;e12922. https://doi.org/10.1111/mcn.12922)

A quasi-experimental before-after study with intervention (received training) and comparison (received normal DOH updates) sites was undertaken to compare health workers’ knowledge, attitudes, skills and self-efficacy.

The participatory training approach to updating the HIV and infant feeding guidelines was associated with an improvement in health worker attitudes and a mean knowledge score. This approach was not successful in shifting knowledge and attitudes about mixed feeding (breast milk and formula milk) and, by the end of the study, health workers were not confident in advising that a shorter duration of breast feeding is better than no breast feeding at all. (Goga A, Doherty T, Manda S, Nkwenika T, Haskins L, John V, Engebretsen IMS, Feucht U, Dhansay A, Rollins N, Kroon M, Sanders D, Kauchali S, Tylleskar T, Horwood C. Translating new evidence into clinical practice: a quasi-experimental controlled before–after study evaluating the effect of a novel outreach mentoring approach on knowledge, attitudes and confidence of health workers providing HIV and infant feeding counselling in South Africa. BMJ Open 2020;10: e034770.  https://doi:10.1136/bmjopen-2019-034770)

A qualitative study explored mother narratives of how they experienced infant feeding and breastfeeding messages during this intervention. Mothers described receiving some practical support with initiation of breastfeeding after delivery, but support for common breastfeeding challenges in the early post‐natal period appeared to range from supportive and correct messages to incorrect or absent advice by health workers.

The early post‐natal period is a critical time to establish and support breastfeeding, and these findings form this study underscore the need for continued, home‐based and clinic‐based support for mothers when they experience common challenges. (Doherty T, Horwood C, Haskins L, Magasana V, Goga A, Feucht U, Sanders D, Tylleskar T, Kauchali S, Dhansay MA, Rollins N, Kroon M, Engebretsen IMS. Breastfeeding advice for reality: Women’s perspectives on primary care support in South Africa. Maternal and Child Nutrition. 2019;e12877. https://doi.org/10.1111/mcn.12877)