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 w...
CONTEXT
• KZN DoH (as of 1 January 2011) decided to cease
provision of free infant formula to HIV infected
mothers (except...
CONTEXT
Objectives of IYCF in the context of HIV training (as
per TOR):
1. To adapt or develop advocacy messages on the
ne...
CONTEXT
• Zoe-Life is a purpose-driven organisation based in
SA, working towards societal transformation
through direct se...
CONTEXT
CONTEXT
Tshwane Declaration (Aug 2011)
• SA to declare itself as a country that actively
promotes, protects and supports exclusive...
Tshwane Declaration (Aug 2011)
• Generally this was a welcomed decision:
– Unanimous decision from the top
– PMTCT experie...
Tshwane Declaration (Aug 2011)
• Going forward:
– Not enough to simply welcome the declaration
– Need to act
• Discovered ...
STAKEHOLDERS
– KZN DOH Nutrition Directorate
– UNICEF
– Researchers – supporting policy change
– KZN Government – HOD
– Ad...
STRATEGY
Advocacy and
Preparation
Media and Political
support
Inter-programme
advocacy
Process
documentation and
lessons s...
AIMS OF THE TRAINING
DEVELOPMENT OF MESSAGES, TRAINING
AND TOOLS
• Unique opportunity to re-establish BRAND
IDENTITY of Exclusive Breastfeeding...
BRAND IDENTITY as part of
COMMUNICATION STRATEGY
– Needed to speak to all target audiences
• Clinical HCWs
• Psychosocial ...
Continuity
• Used basic format from 2008 IYCF training:
– Participants manual
– Breastfeeding flipchart
– Pre- & post-cour...
Change
– Refreshed and modernised colours
– Added partner graphics
– Format of Breastfeeding flipchart
– Added tools – poc...
Developing the IYCF Project
Training materials:
• For the 5 day TOT, participants
were given a facilitator’s manual,
parti...
MATERIAL CONTENT AND METHODOLOGY
• Used WHO 2010 guidelines as base,
• Added Values clarification
• Facilitators Manual:
•...
Developing the IYCF Project
Training Modules for the TOT programme
1. Reasons why children are dying
2. Knowledge, Attitud...
Developing the IYCF Project
Training Modules for the lay counsellor programme
1. Reasons why children are dying
2. Knowled...
FLOW PATH SIMPLIFIED
s
INFANT AND YOUNG CHILD FEEDING FLOW PATH
NOTE: These are the messages that should be communicated a...
Training
• Zoë-Life Facilitators
– Selected because of previous health and
nutrition-related training experience
– 4 teams...
Training
• Trainer of Trainers
– 2 from each District – District Trainer (Clinical)
with Mentor coordinator (Psychosocial)...
TARGETS & DEMOGRAPHIC ANALYSIS
34 TOTs representing all
Districts
District Scale Up for LCs:
• Target 1850
• Attended 1706...
TRAINING EVALUATION
• Numbers attended all sessions
• Discipline type
• Facility/ District/ Demographics
• Years of experi...
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 trans...
VALUES CLARIFICATIONS
Whilst feedback has been both negative and positive, it must be clearly
stated that the overwhelming response was positive...
Brand identity and user acceptability of tools
• Pocket tool most used
• Flip chart second
• Used by nurses and lay counse...
• Efficient and rapid scale up of Back to back
training requires logisitics and communication
SOP
– Detail the specific ro...
• Facility management reluctance to release staff
for training: Formulate a strategy for
uninterrupted services during rap...
LESSONS LEARNED
• IYCF training standardised and provided to all
HCWs regularly with onsite focussed follow up
• Counsello...
• AFASS poorly understood –may need to
rethink tools and terminologies
• Multidisciplinary team dynamics and
advantages
• ...
• Follow up support:
– To reinforce the PMTCT and IYCF policies (ART
during BF)
– To ensure all misinformation is correcte...
• Cross border alignment of policy
• Labour law regulations to support
breastfeeding mothers
• Integration of training int...
• This is a great opportunity to come alongside
government
• It is one of the most impressive policy changes with the
pote...
Thank you !Demonstrating the
lying down position
Group work
Practice positioning a baby
at the breast
MRC/info4africa KZN Community Forum | June 2012
MRC/info4africa KZN Community Forum | June 2012
MRC/info4africa KZN Community Forum | June 2012
MRC/info4africa KZN Community Forum | June 2012
MRC/info4africa KZN Community Forum | June 2012
MRC/info4africa KZN Community Forum | June 2012
MRC/info4africa KZN Community Forum | June 2012
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MRC/info4africa KZN Community Forum | June 2012

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Ms Philippa Barnard, a Nutritionist at Zoe-Life outlined the Tshwane Declaration of 2011, which advocated breastfeeding as the best infant feeding choice for all babies, regardless of HIV status. This great change in policy created massive potential for decreasing infant and child mortality. Ms Barnard also highlighted some of Zoe-Life's practical insights gained whilst training lay counsellors in infant and young child feeding.

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MRC/info4africa KZN Community Forum | June 2012

  1. 1. Scaling-up in KZN: Outcomes & Recommendations Infant & Young Child Feeding
  2. 2. 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)
  3. 3. 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
  4. 4. CONTEXT Objectives 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
  5. 5. 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.
  6. 6. CONTEXT
  7. 7. CONTEXT
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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)
  12. 12. 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 teams Mentorship, QI, QA Integration of Implementation Clinical, Psychosocial, Community Linkages, development of tools to link C,P,C QA/ QI at each level
  13. 13. AIMS OF THE TRAINING
  14. 14. 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
  15. 15. 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.
  16. 16. 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
  17. 17. Change – Refreshed and modernised colours – Added partner graphics – Format of Breastfeeding flipchart – Added tools – pocket tool, Flow path
  18. 18. Developing the IYCF Project Training 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.
  19. 19. 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
  20. 20. Developing the IYCF Project Training Modules for the TOT programme 1. Reasons why children are dying 2. Knowledge, Attitudes & Practice 3. Importance of breastfeeding 4. How breastfeeding works 5. Assessing a breastfeed 6. Positioning a baby at the breast 7. Expressing and storing breast milk 8. Breastfeeding challenges (incl GMP) 9. Breast conditions 10. IYCF in the context of HIV 11. Breastfeeding & ARVs 12. Cost of formula (activity) 13. Counselling process 14. Preparation of formula 15. Heat treating EBM 16. Complementary feeding 17. Quality Assurance (QA) and Quality Improvement (QI) 18. IYCF flow path 19. Project planning board (action plan) 20. Presentation of training tools 21. Discussion on facilitator’s manual & its application
  21. 21. Developing the IYCF Project Training Modules for the lay counsellor programme 1. Reasons why children are dying 2. Knowledge, Attitudes & Practice 3. Importance of breastfeeding 4. How breastfeeding works 5. Assessing a breastfeed 6. Positioning a baby at the breast 7. Expressing and storing breast milk 8. Breastfeeding challenges (incl GMP) 9. Breast conditions 10. IYCF in the context of HIV 11. Breastfeeding & ARVs 12. Cost of Formula (activity) 13. Counselling process 14. Preparation of formula 15. Heat treating EBM 16. Complementary feeding 17. IYCF flow path
  22. 22. FLOW PATH SIMPLIFIED s INFANT AND YOUNG CHILD FEEDING FLOW PATH NOTE: These are the messages that should be communicated and practices that support mothers in feeding their infants and young children. Antenatal Clinic Mothers who will be breastfeeding • Definition of breastfeeding • Benefits and risks of not breastfeeding • Immature gut of the infant Labour & Delivery Breastfeeding Mothers • Breastfeeding in the first hour • Skin to skin contact • ARVS for the baby (HIV positive Post Delivery Reinforce these messages • Definition of breastfeeding • Composition of breast milk • Benefits and risks of not breastfeeding • Immature gut of the infant • Dangers of mixed feeding • Good positioning and attachment (demonstrate) • Breastfeeding challenges • Expressing and storing breast milk • Breastfeeding in the first hour • ARVs and breastfeeding (HIV positive mothers only) mother only) Formula Feeding Mothers (HIV positive mother): • Skin to skin contact • ARVS for the baby • Dangers of mixed feeding • Good positioning and attachment (demonstrate) • Breastfeeding challenges • Expressing and storing breast milk Breastfeeding Mothers • ARVs for the baby • Adherence to ARVs • PCR testing for baby at 6 week Mothers who choose to formula feed (HIV positive mother) • Dangers of mixed feeding • Skin to skin contact • Preparation of formula (demonstrate) • Disclosure • Feeding on demand • Introducing complementary feeds at 6 months • Vitamin A • Stopping breastfeeding Formula Feeding Mothers (HIV positive mother): • Exclusive formula feeding • Demonstration of safe preparation of formula • Introducing complementary feeds at 6 months • Vitamin A Designed and Produced by SMT Health Solutions cc T/A Zoë-Life 2010
  23. 23. 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
  24. 24. 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
  25. 25. TARGETS & DEMOGRAPHIC ANALYSIS 34 TOTs representing all Districts District Scale Up for LCs: • Target 1850 • Attended 1706 • LCs trained 1496
  26. 26. 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
  27. 27. PRE- AND POST COURSE QUESTIONNAIRE
  28. 28. PRE- AND POST COURSE QUESTIONNAIRE
  29. 29. 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
  30. 30. VALUES CLARIFICATIONS
  31. 31. 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.
  32. 32. 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
  33. 33. • 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
  34. 34. • 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
  35. 35. 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
  36. 36. • 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
  37. 37. • 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
  38. 38. • 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
  39. 39. • 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
  40. 40. Thank you !Demonstrating the lying down position Group work Practice positioning a baby at the breast

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