When knowledge is not enough: barriers to recommended cassava processing in resource-constrained Kwango, Democratic Republic of Congo.

Background: Despite interventions to provide knowledge and improve bitter cassava processing in the Democratic Republic of Congo (DRC), cassava processing is sub-optimal. Consumption of insufficiently processed bitter cassava is associated with konzo, a neurological paralytic disease. Objective: This study aimed to explore barriers to appropriate cassava processing carried out by women in one deep rural, economically deprived area of DRC. Methods: A qualitative design used focus group discussions (FGDs) and participant observation to collect data among purposively selected women aged 15-61 years in Kwango, DRC. Data were analyzed using thematic analysis. Results: 15 FGDs with 131 women and 12 observations of cassava processing were undertaken. Observations indicated women did not follow recommended cassava processing methods. Although women were knowledgeable about cassava processing, two main barriers emerged: access to water and lack of money. Accessing water from the river to process cassava was burdensome, and the cassava was at risk of being stolen by soaking it in the river; therefore, women shortened the processing time. Cassava was not only used as a staple food but also as a cash crop, which led to households shortening the processing time to reach the market quickly. Conclusion: Knowledge about the risks of insufficient cassava processing and about safe processing methods alone is insufficient to change practices in a context of severe resource constraints. When planning nutrition interventions, it is critical to view the intervention in light of the socio-economic context in which the intervention will take place to improve its outcomes.

Challenges of using e-health technologies to support clinical care in rural Africa: a longitudinal mixed methods study exploring primary health care nurses' experiences of using an electronic clinical decision support system (CDSS) in South Africa.

BACKGROUND: Electronic decision-making support systems (CDSSs) can support clinicians to make evidence-based, rational clinical decisions about patient management and have been effectively implemented in high-income settings. Integrated Management of Childhood Illness (IMCI) uses clinical algorithms to provide guidelines for management of sick children in primary health care clinics and is widely implemented in low income countries. A CDSS based on IMCI (eIMCI) was developed in South Africa. METHODS: We undertook a mixed methods study to prospectively explore experiences of implementation from the perspective of newly-trained eIMCI practitioners. eIMCI uptake was monitored throughout implementation. In-depth interviews (IDIs) were conducted with selected participants before and after training, after mentoring, and after 6 months implementation. Participants were then invited to participate in focus group discussions (FGDs) to provide further insights into barriers to eIMCI implementation. RESULTS: We conducted 36 IDIs with 9 participants between October 2020 and May 2021, and three FGDs with 11 participants in October 2021. Most participants spoke positively about eIMCI reporting that it was well received in the clinics, was simple to use, and improved the quality of clinical assessments. However, uptake of eIMCI across participating clinics was poor. Challenges reported included lack of computer skills which made simple tasks, like logging in or entering patient details, time consuming. Technical support was provided, but was time consuming to access so that eIMCI was sometimes unavailable. Other challenges included heavy workloads, and the perception that eIMCI took longer and disrupted participant's work. Poor alignment between recording requirements of eIMCI and other clinic programmes increased participant's administrative workload. All these factors were a disincentive to eIMCI uptake, frequently leading participants to revert to paper IMCI which was quicker and where they felt more confident. CONCLUSION: Despite the potential of CDSSs to increase adherence to guidelines and improve clinical management and prescribing practices in resource constrained settings where clinical support is scarce, they have not been widely implemented. Careful attention should be paid to the work environment, work flow and skills of health workers prior to implementation, and ongoing health system support is required if health workers are to adopt these approaches (350).

A qualitative study to explore dietary knowledge, beliefs, and practices among pregnant women in a rural health zone in the Democratic Republic of Congo.

BACKGROUND: A nutritious and healthy diet during pregnancy is essential for the health of both mother and baby. Inadequate dietary intake during pregnancy contributes to maternal malnutrition and can have lifelong effects on the health of the child. Maternal malnutrition is common in many low-income countries, including the Democratic Republic of Congo (DRC). Kwango province, DRC, has a high prevalence of malnutrition among all population groups, including macro and micronutrient deficiencies among pregnant women. The study aimed to explore the dietary knowledge and practices of a pregnant woman in this area. METHODS: This study adopted a qualitative approach using in-depth interviews (IDIs) with pregnant women and key informants, and focus group discussions (FGDs) with fathers and grandmothers in the community, to explore women's knowledge and practice about diet during pregnancy. Data were collected between January and April 2018. IDIs were conducted with pregnant women who were recruited at antenatal clinics during their second and third trimesters. IDIs were undertaken with selected key informants, who were health workers providing care to pregnant women, and included doctors, nurses, nutritionists, and community health workers. All IDIs and FGDs were audio-recorded, transcribed verbatim, and translated to English. The triangulation method and thematic analyses were used. RESULTS: Overall, women showed good general knowledge about nutrition and the need for increased and varied foods during pregnancy, but little technical knowledge about nutrients and sources of nutrition. Healthcare facilities, media, NGOs, and family members were the main sources of nutritional information. However, women were unable to put this knowledge into practice, primarily due to poverty and poor access to a variety of foods. The Popokabaka community accessed food from farming, fishing, and the market, although purchasing food was frequently unaffordable. Cassava flour was the most common daily food. Food taboos, traditional practices, and late ANC attendance were identified as factors that influenced dietary practices. CONCLUSIONS: Various social, economic, and environmental factors within the local community influenced dietary practices among pregnant women in rural DRC. A comprehensive approach is required to improve nutrition, and address food insecurity, cultural practices and improve the health outcomes of both mother and child.

Exploring women's exposure to marketing of commercial formula products: a qualitative marketing study from two sites in South Africa.

BACKGROUND: Regulating the marketing of commercial formula products is a long-term commitment required to protect breastfeeding. Marketing strategies of formula manufacturers, retailers and distributors evolve at a rapid rate. OBJECTIVE: The aim of this research was to describe exposure of pregnant women and mothers of young children in South Africa to marketing of commercial formula products, compared to international recommendations and national legislation. METHODS: Using mobile phone marketing diaries twenty participants in Cape Town and Johannesburg documented the formula marketing they were exposed to for one week. Ten mothers were interviewed to explore their perceptions towards marketing exposure in more depth. RESULTS: Women reported limited infant formula advertising, but an abundance of strategies used to market growing-up formula and powdered drinks for children over 36 months. Strategies included product packaging, in-store displays, online distribution channels and educational material about product ranges. Online strategies were reported, namely social media marketing (sponsored adverts and support groups), websites and mobile phone applications providing infant and young child feeding information and price discounts, print and TV advertisements, and competitions. Products for children over 36 months are cross-promoted with products prohibited to be advertised by national legislation. CONCLUSIONS: South African women are being exposed to covert marketing of infant, follow-up, and growing-up formula. Explicit marketing of products for children over 36 months of age allows formula companies to provide messages about branding and use of commercial formula products to mothers. National legislation should be updated and effectively implemented to address changing marketing strategies.

They push their products through me: health professionals' perspectives on and exposure to marketing of commercial milk formula in Cape Town and Johannesburg, South Africa - a qualitative study.

OBJECTIVE: To understand the views of public and private sector health professionals on commercial milk formula, to describe their exposure to companies that market commercial milk formula within their workplaces and to describe their awareness of South African (SA) regulations. DESIGN: A qualitative study consisting of semistructured interviews. SETTING: The study was conducted in Cape Town and Johannesburg, SA. PARTICIPANTS: Forty health professionals who had regular contact with pregnant or postnatal women were interviewed between February 2020 and February 2021. RESULTS: Analysis of the interviews revealed six themes. Health professionals in the private sector reported frequent contact with industry representatives with over two-thirds reporting exposure to industry representatives to present products, provide training or sponsor educational activities. Participants held strong opinions regarding the equivalency of breastfeeding to commercial milk formula citing information from industry representatives and product packaging. Health professionals were very knowledgeable on so-called formulas for special medical purposes and these were valued as solutions to infant feeding challenges. Of the 40 health professionals interviewed, less than half (19) had ever heard of the SA regulation related to marketing of breast milk substitutes (R991). CONCLUSIONS: This study demonstrates clearly that health professionals, particularly in the private sector, are exposed to and promote the use of commercial milk formula among SA women. The findings of this study should be used to catalyse policy responses, social movements, consumer and professional association action to strengthen monitoring and enforcement of the Code regulations in order to protect breastfeeding and support the optimal health and well-being of the population.

An exploration of pregnant women and mothers' attitudes, perceptions and experiences of formula feeding and formula marketing, and the factors that influence decision-making about infant feeding in South Africa.

BACKGROUND: Despite strong evidence showing the lifelong benefits of breastfeeding for mothers and children, global breastfeeding practices remain poor. The International Code of Marketing of Breastmilk Substitutes is an internationally agreed code of practice, adopted by the World Health Assembly in 1981, to regulate promotion of commercial formula, and is supported by legislation in many countries. However, marketing of formula remains widespread and contributes to mother's decisions to formula feed. We present South African data from a multi-country, mixed-methods study exploring women's decision-making about infant feeding and how this was influenced by exposure to formula marketing. METHODS: Using a consumer-based marketing approach, focus group discussions (FGDs) were conducted with pregnant women and mothers of children aged between 0 and 18 months in two urban sites in South Africa. Participants were purposively selected according to their child's age, infant feeding practices and socioeconomic status. Ten FGDs were conducted during February 2020 with a total of 69 participants. Thematic analysis was used to analyse the data with NVivo v.12 software. RESULTS: Despite being encouraged by health professionals to breastfeed and intending to do so, many mothers chose to give formula in the early weeks and months of their child's life. Mothers reported breastfeeding challenges as the most frequent reason for initiating infant formula, stating that family members and health professionals recommended formula to solve these challenges. Although participants described few advertisements for infant formula, advertisements for 'growing-up' formulas for older children were widespread and promoted brand recognition. Mothers experienced other marketing approaches including attractive packaging and shop displays of infant formula, and obtained information from social media and online mothers' groups, which influenced their choice of formula brand. Mothers reported strong brand loyalty derived from previous experiences and recommendations. Health professionals frequently recommended formula, including recommending specific formula brands and specialist formulas. CONCLUSION: Global formula companies use multifaceted marketing methods to promote a strong narrative portraying formula feeding as a positive lifestyle choice. Positive, coordinated efforts are required to counter pro-formula messaging and change the narrative to support breastfeeding as an aspirational choice. In particular, health professionals must stop supporting the formula industry.

Does the unconditional cash transfer program in South Africa provide support for women after child birth? Barriers to accessing the child support grant among women in informal work in Durban, South Africa.

BACKGROUND: The child support grant (CSG) is the largest unconditional cash transfer program in Africa and aims to alleviate poverty and improve child health and nutrition in low-income families in South Africa. Among informal working women, the CSG is an important source of income after childbirth when informal workers are unable to work, but reports suggest that women experience delays in accessing the CSG. We explore experiences and challenges of accessing the CSG among informal workers in Durban, South Africa. METHODS: We undertook a longitudinal mixed-methods cohort study. Women informal workers were recruited during pregnancy and followed-up for up to one year after the baby was born. Quantitative questionnaires and semi-structured in-depth interviews were used to collect data about women's plans for applying for the CSG, the application process, use of the CSG in the household, and household food insecurity. Interviews were conducted in IsiZulu by experienced researchers. Descriptive analysis of quantitative data used SPSS v26, and framework analysis using NVIVO v12.3 was used for qualitative analysis. RESULTS: Twenty-four informal working women were enrolled. The CSG received for older children was reported as an important and reliable source of income for mothers after childbirth. However, delays receiving the CSG for the new baby meant this support was unavailable to first-time mothers. The complex application process for the CSG required mothers to travel to various government departments to complete the required documentation, often taking the baby with them. This was costly and time-consuming for mothers who were already vulnerable, and led to delays in obtaining CSG funds. Many women experienced moderate or severe food insecurity before and after the baby was born. As a result, some mothers had to return to work earlier than planned, disrupting childcare and breastfeeding. CONCLUSIONS: Cash transfer programmes can effectively support low income households and improve outcomes for mothers and children. In South Africa there is a need for innovative approaches to streamline CSG applications, so women can access the funds immediately post-delivery to fill a resource gap and provide support at a vulnerable time for mothers and their children.

'I am not only beneficial to the community but to the entire country, I am trained as a researcher now': Developing health research skills in low-income countries.

ABSTRACTPartnerships between Higher Education Institutions in the global South and North have potential for building capacity in public health research in low-resource countries. We present experiences of partners involved in a North-South-South partnership between universities in Norway, the Democratic Republic of Congo (DRC) and South Africa. The partnership aimed to establish a postgraduate programme in nutritional epidemiology at the University of Kinshasa, DRC, and develop a cadre of researchers and academic leaders to provide locally generated health research to inform policy. In-depth interviews were conducted with 31 purposively selected stakeholders, facilitators, and students from partner institutions. All participants expressed positive experiences, indicating that the partnership provided excellent opportunities to network, enriched participants' learning and enhanced academic growth, with benefits at individual, institutional, and country levels. Participants suggested that maintaining a common vision was important for success, facilitated by joint planning of project activities, focussing strongly on building research and academic capacity at Kinshasa School of Public Health and addressing local nutrition problems. Important challenges highlighted for future partnerships included failures of co-facilitation and co-supervision, poor research dissemination and policy impact, and concerns about sustainability. Notwithstanding, North-South-South partnerships can address skills shortages in public health research with significant benefits to all partner institutions.

Infant feeding, growth monitoring and the double burden of malnutrition among children aged 6 months and their mothers in KwaZulu-Natal, South Africa.

South Africa has a documented high prevalence of stunting and increasing obesity in children as well as obesity in adults. The double burden of malnutrition, which can be on an individual-, household- or population level, has implications for both health and the economic development of a community and country. This paper describes a large-scale survey (N = 774) of infant feeding, growth monitoring and anthropometry among mother and child pairs aged 6 months of age in KwaZulu-Natal (KZN), South Africa, conducted between January and August 2017. Among children, a large increase in the prevalence of stunting and obesity was seen between birth and 6 months of age increasing from 9.3% to 21.7% and 4.0% to 21.0%, respectively. 32.1% of the mothers were overweight [body mass index (BMI): 25.0-29.9] and 28.4% had obesity grade 1 (BMI: 30-<40). Although most mothers (93%; 563/605) initiated breastfeeding, the introduction of other foods started early with 17.6% (56/319) of the mothers having started giving other fluids or food to their child within the first month. At 6 months 70.6% (427/605) children were still breastfed and 23.5% were exclusively breastfed. In addition, we found that length measurements were done less frequently than weight measurements between birth and 6 months, on average 2.2 (SD: 1.3) versus 5.8 (SD: 1.5) times. Moreover, there is a need for improvement of health worker training and understanding regarding anthropometric measurements when assessing malnutrition in children in the clinics. Early detection and improved infant feeding practices are key in preventing both stunting and obesity in children.

Health workers' disrespectful and abusive behaviour towards women during labour and delivery: A qualitative study in Durban, South Africa.

BACKGROUND: A high prevalence of disrespectful and abusive behaviour by health workers towards women during labour and delivery has been widely described in health facilities, particularly in Africa, and is a worldwide public health concern. Such behaviours are barriers to care-seeking, and are associated with adverse outcomes for mothers and newborns. This paper reports experiences of disrespectful care among informal working women in three public health facilities in Durban, South Africa. METHODS: A qualitative longitudinal study was conducted among a cohort of informal working women recruited during pregnancy in two clinics in Durban. The study comprised a series of in-depth interviews conducted at different time points from pregnancy until mothers had returned to work, followed by focus group discussions (FGDs) with cohort participants. We present data from participatory FGDs, known as 'Journey with my Baby', conducted at the end of the study, during which women's experiences from pregnancy until returning to work were reviewed and explored. Thematic analysis was used with NVIVO v12.4. RESULTS: Three 'Journey with my Baby' FGDs were conducted with a total of 15 participants between March and October 2019. Many participants narrated experiences of disrespectful behavior from nurses during labour and childbirth, with several women becoming very distressed as a result. Women described experiencing rudeness and verbal abuse from nurses, lack of privacy and confidentiality, nurses refusing to provide care, being denied companionship and being left unattended for long periods during labour. Women described feeling anxious and unsafe while in the labour ward because of the behaviour they experienced directly and observed other patients experiencing. Such experiences created bad reputations for health facilities, so that women in the local community were reluctant to attend some facilities. CONCLUSION: Disrespect and abuse continues to be a serious concern in public health facilities in South Africa. We challenge the health system to effectively address the underlying causes of disrespectful behavior among health workers, initiate robust monitoring to identify abusive behavior when it occurs, and take appropriate actions to ensure accountability so that women receive the high-quality maternity care they deserve.

'I can no longer do my work like how I used to': a mixed methods longitudinal cohort study exploring how informal working mothers balance the requirements of livelihood and safe childcare in South Africa.

BACKGROUND: Returning to work after childbirth is challenging for working mothers. Childcare quality may have lifelong effects on children's health, development and cognitive function. Over 60% of working women globally are informal workers without employment or maternity protection, but little is known about how these women care for their children. METHODS: We conducted a mixed-methods longitudinal cohort study among informal women workers in Kwazulu-Natal, South Africa between July 2018 and August 2019. Participants were followed up from late pregnancy until they had returned to work. We conducted structured quantitative interviews and in-depth qualitative interviews at different time points: before and after the baby was born, and after returning to work. Subsequently, a photovoice activity was conducted with groups of participants to explore the childcare environment. We employed narrative thematic analysis for qualitative data and descriptive analysis for quantitative data. RESULTS: 24 women were recruited to participate. Women returned to work soon after the baby was born, often earlier than planned, because of financial responsibilities to provide for the household and new baby. Women had limited childcare choices and most preferred to leave their babies with family members at home, as the most convenient, low cost option. Otherwise, mothers chose paid carers or formal childcare. However, formal childcare was reported to be poor quality, unaffordable and not suited to needs of informal workers. Mothers expressed concern about carers' reliability and the safety of the childcare environment. Flexibility of informal work allowed some mothers to adapt their work to care for their child themselves, but others were unable to arrange consistent childcare, sometimes leaving the child with unsuitable carers to avoid losing paid work. Mothers were frequently anxious about leaving the child but felt they had no choice as they needed to work. CONCLUSION: Mothers in informal work had limited childcare options and children were exposed to unsafe, poor-quality care. Maternity protection for informal workers would support these mothers to stay home longer to care for themselves, their family and their baby. Provision of good quality, affordable childcare would provide stability for mothers and give these vulnerable children the opportunity to thrive.

A North-South-South partnership in higher education to develop health research capacity in the Democratic Republic of the Congo: the challenge of finding a common language.

BACKGROUND: Globally, increasing numbers of higher education institutions (HEIs) in non-English-speaking countries have adopted English as a medium of instruction (EMI), because of the perception that this provides opportunities to attract high-calibre students and academic staff, and engage with the international research community. We report an evaluation of a North-South-South collaboration to develop health research capacity in the Democratic Republic of the Congo (DRC) by establishing a postgraduate programme in nutritional epidemiology at the Kinshasa School of Public Health (KSPH), where EMI was adopted. We report experiences and perceptions of stakeholders, facilitators and students about using EMI. METHODS: In-depth qualitative interviews were conducted between October and December 2019 among convenience sampled stakeholders (8), facilitators (11) and students (12) involved in the programme from all three partner institutions (University of Kinshasa; University of KwaZulu-Natal, South Africa; University of Bergen, Norway). Interviews were conducted in participants' language of preference (English or French), audio-recorded, transcribed verbatim and translated into English when required. Analysis employed a thematic approach. RESULTS: Most participants viewed EMI positively, reporting that studying in English created opportunities to access relevant literature, improve interactions with the scientific community and advance their careers. As a result of adopting EMI, some students had opportunities to present research findings at international conferences and publish their research in English. English-speaking researchers from partner institutions were able to participate in supervision of students' research. However, inadequate English competency, particularly among students, was challenging, with some students reporting being unable to understand or interact in class, which negatively affected their academic performance. Further, EMI created barriers at KSPH among academic staff who were not proficient in English, leading to poor participation among non-English-speaking staff and lack of integration with other postgraduate programmes. Participants suggested additional English language support for EMI. CONCLUSION: Partnerships between HEIs could be a powerful tool to develop research capacity in low-income countries in line with United Nations Sustainable Development Goals. EMI could be a solution to language barriers faced by many such partnerships, but wide-ranging support to develop English proficiency among staff and students is essential to ensure that the challenges do not outweigh the benefits.

Establishing a postgraduate programme in nutritional epidemiology to strengthen resource capacity, academic leadership and research in the democratic republic of Congo.

BACKGROUND: Low- and Middle-income countries (LMIC) face considerable health and nutrition challenges, many of which can be addressed through strong academic leadership and robust research translated into evidence-based practice. A North-South-South partnership between three universities was established to implement a master's programme in nutritional epidemiology at the Kinshasa School of Public Health (KSPH), Democratic Republic of Congo (DRC). The partnership aimed to develop academic leadership and research capacity in the field of nutrition in the DRC. In this article we describe the educational approach and processes used, and discuss successes, challenges, and lessons learned. METHODS: Self-administered questionnaires, which included both open and closed questions, were sent to all graduates and students on the master's programme to explore students' experiences and perceptions of all aspects of the educational programme. Quantitative data was analysed using frequencies, and a thematic approach was used to analyse responses to open-ended questions. RESULTS: A two-year master's programme in Nutritional Epidemiology was established in 2014, and 40 students had graduated by 2020. Key elements included using principles of authentic learning, deployment of students for an internship at a rural residential research site, and support of selected students with bursaries. Academic staff from all partner universities participated in teaching and research supervision. The curriculum and teaching approach were well received by most students, although a number of challenges were identified. Most students reported benefits from the rural internship experience but were challenged by the isolation of the rural site, and felt unsupported by their supervisors, undermining students' experiences and potentially the quality of the research. Financial barriers were also reported as challenges by students, even among those who received bursaries. CONCLUSION: The partnership was successful in establishing a Master Programme in Nutritional Epidemiology increasing the number of nutrition researchers in the DRC. This approach could be used in other LMIC settings to address health and nutrition challenges.

Addressing the interaction between food insecurity, depression risk and informal work: findings of a cross-sectional survey among informal women workers with young children in South Africa.

BACKGROUND: There is a high burden of depression globally, including in South Africa. Maternal depression is associated with poverty, unstable income, food insecurity, and lack of partner support, and may lead to poor outcomes for mothers and children. In South Africa one-third of working women are in informal work, which is associated with socioeconomic vulnerability. METHODS: A cross sectional survey explored work setting and conditions, food security and risk of depression among informal working women with young children (0-3 years). Depression risk was assessed using the Edinburgh Postnatal Depression Score (EPDS) and Whooley score. Food insecurity was evaluated using Household Food Insecurity Access Scale. Data was analysed using SPSS and Stata. RESULTS: Interviews were conducted with 265 informal women workers. Types of work included domestic work, home-based work, informal employees and own account workers, most of whom were informal traders. Most participants (149/265; 56.2%) earned between US$70-200 per month, but some participants (79/265; 29.8%) earned < US$70 per month, and few earned > US$200 per month (37/265; 14.0%). Many participants experienced mild (38/267; 14.3%), moderate (72/265; 27.2%) or severe (43/265; 16%) food insecurity. Severe food insecurity was significantly higher among participants with the lowest income compared to those with the highest income (p = 0.027). Women who received financial support from the baby's father were less likely to be food insecure (p = 0.03). Using EPDS scores, 22/265 (8.3%) women were designated as being at risk of depression. This was similar among postnatal women and women with older children. Household food insecurity was significantly associated with depression risk (p < 0.001). CONCLUSIONS: Informal women workers were shown to be vulnerable with low incomes and high rates of food insecurity, thus increasing the risk for poor maternal health. However, levels of depression risk were low compared to previous estimates in South Africa, suggesting that informal workers may have high levels of resilience. Interventions to improve social protection, access to health services, and support for safe childcare in the workplace could improve the health and wellbeing of these mothers and support them to care for their children.

'I decided to go back to work so I can afford to buy her formula': a longitudinal mixed-methods study to explore how women in informal work balance the competing demands of infant feeding and working to provide for their family.

BACKGROUND: In South Africa almost 2 million women work informally. Informal work is characterised by poor job security, low earnings, and unsafe working conditions, with high rates of poverty and food insecurity. The peripartum period is a vulnerable time for many working women. This study explored how mothers navigate the tension between the need to work and the need to take care of a newborn baby, and how this affects their feeding plans and practices. METHODS: A mixed methods longitudinal cohort method was employed. Informal workers were recruited in the last trimester of pregnancy during an antenatal visit at two clinics in Durban, South Africa. Data were collected using in-depth interviews and quantitative questionnaires at three time points: pre-delivery, post-delivery and after returning to work. Framework analysis was used to analyse qualitative data in NVIVO v12.4. Quantitative analysis used SPSSv26. RESULTS: Twenty-four participants were enrolled and followed-up for a period of up to 1 year. Informal occupations included domestic work, home-based work, informal trading, and hairdressing, and most women earned

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.

OBJECTIVES: We report the effectiveness of a mentoring approach to improve health workers' (HWs') knowledge, attitudes and confidence with counselling on HIV and infant feeding. DESIGN: Quasi-experimental controlled before-after study. SETTING: Randomly selected primary healthcare clinics (n=24 intervention, n=12 comparison); two districts, South Africa. PARTICIPANTS: All HWs providing infant feeding counselling in selected facilities were invited. INTERVENTIONS: Three 1-2 hours, on-site workshops over 3-6 weeks. PRIMARY OUTCOME MEASURES: Knowledge (22 binary questions), attitude (21 questions-5-point Likert Scale) and confidence (19 questions-3-point Likert Scale). Individual item responses were added within each of the attitude and confidence domains. The respective sums were taken to be the domain composite index and used as a dependent variable to evaluate intervention effect. Linear regression models were used to estimate the mean score difference between intervention and comparison groups postintervention, adjusting for the mean score difference between them at baseline. Analyses were adjusted for participant baseline characteristics and clustering at health facility level. RESULTS: In intervention and comparison sites, respectively: 289 and 131 baseline and 253 and 114 follow-up interviews were conducted (August-December 2017). At baseline there was no difference in mean number of correctly answered knowledge questions; this differed significantly at follow-up (15.2 in comparison; 17.2 in intervention sites (p<0.001)). At follow-up, the mean attitude and confidence scores towards breast feeding were better in intervention versus comparison sites (p<0.001 and p=0.05, respectively). Controlling for confounders, interactions between time and intervention group and preintervention values, the attitude score was 5.1 points significantly higher in intervention versus comparison groups. CONCLUSION: A participatory, low-intensity on-site mentoring approach to disseminating updated infant feeding guidelines improved HWs' knowledge, attitudes and confidence more than standard dissemination via a circular. Further research is required to evaluate the effectiveness, feasibility and sustainability of this approach at scale.

Evaluation of the effectiveness of a quality improvement intervention to support integration of maternal, child and HIV care in primary health care facilities in South Africa.

BACKGROUND: Despite policies and guidelines recommending integration of health services in South Africa, provision of maternal and child health services remains fragmented. This study evaluated a rapid, scaleable, quality improvement (QI) intervention to improve integration of maternal and child health and HIV services at a primary health level, in KwaZulu-Natal, South Africa. METHODS: A three-month intervention comprised of six QI mentoring visits, learning sessions with clinic staff to share learnings, and a self-administered checklist aimed to assist health workers monitor and implement an integrated package of health services for mothers and children. The study evaluated 27 clinics in four sub-districts using a stepped-wedge design. Each sub-district received the intervention sequentially in a randomly selected order. Five waves of data collection were conducted in all participating clinics between December 2016-February 2017. A multi-level, mixed effects logistic regression was used to account for random cluster fixed time and group effects using Stata V13.1. RESULTS: Improvements in some growth monitoring indicators were achieved in intervention clinics compared to control clinics, including measuring the length of the baby (77% vs 63%; p = 0.001) and health workers asking mothers about the child's feeding (74% vs 67%; p = 0.003), but the proportion of mothers who received feeding advice remained unchanged (38% vs 35%; p = 0.48). Significantly more mothers in the intervention group were asked about their baby's health (44% vs 36%; p = 0.001), and completeness of record keeping improved (40% vs 26%; I = < 0.0001). Discussions with the mother about some maternal health services improved: significantly more mothers in the intervention group were asked about HIV (26.5% vs 19.5%; p = 0.009) and family planning (33.5% vs 19.5%; p <  0.001), but this did not result in additional services being provided to mothers at the clinic visit. CONCLUSION: This robust evaluation shows significant improvements in coverage of some services, but the QI intervention was unable to achieve the substantial changes required to provide a comprehensive package of services to all mothers and children. We suggest the QI process be adapted to complex under-resourced health systems, building on the strengths of this approach, to provide workable health systems strengthening solutions for scalable implementation. TRIAL REGISTRATION: ClinicalTrials.gov NCT04278612. Date of Registration: February 19, 2020. Retrospectively registered.

An educational intervention to update health workers about HIV and infant feeding.

Clinical guidelines are used to translate research findings into evidence-based clinical practice but are frequently not comprehensively adopted by health workers (HWs). HIV and infant feeding guidelines were revised by the World Health Organization to align feeding advice for HIV-exposed and unexposed infants, and these were adopted in South Africa in 2017. We describe an innovative, team-based, mentoring programme developed to update HWs on these guidelines. The intervention was underpinned by strong theoretical frameworks and aimed to improve HWs' attitudes, knowledge, confidence, and skills about breastfeeding in the context of HIV. On-site workshops and clinical mentoring used interactive participatory methods and a simple low-tech approach, guided by participants' self-reported knowledge gaps. Workshops were conducted at 24 participating clinics over three sessions, each lasting 1-2 hr. Evaluation data were collected using a self-administered questionnaire. Of 303 participating HWs, 249/303 (82.2%) attended all workshops. Achieving high workshop attendance was challenging and "catch-up" sessions were required to achieve good coverage. Common knowledge gaps identified included antiretroviral therapy adherence monitoring during breastfeeding and management of viral load results (173 participants), management of breast conditions (79), and advice about expressing and storing breastmilk (64). Most participants reported all their knowledge gaps were addressed and anticipated that their practice would change. We describe a feasible, sustainable approach to updating HWs on HIV and infant feeding guidelines and improving skills in breastfeeding counselling in resource-constrained settings. This approach could be adapted to other topics and, with further evaluation, implemented at scale using existing resources.

Breastfeeding advice for reality: Women's perspectives on primary care support in South Africa.

Breastfeeding education and support are critical health worker skills. Confusion surrounding infant feeding advice linked to the HIV epidemic has reduced the confidence of health workers to support breastfeeding. High antiretroviral therapy coverage of breastfeeding women living with HIV, and an Infant Feeding policy supportive of breastfeeding, now provides an opportunity to improve breastfeeding practices. Challenges remain in restoring health worker confidence to support breastfeeding. This qualitative study presents findings from focus group discussions with mothers of young infants, exploring their experiences of health worker breastfeeding counselling and support. Analysis followed the thematic framework approach. Six researchers reviewed the transcripts, coded them independently, then jointly reviewed the codes, and agreed on a working analytical framework. Although mothers received antenatal breastfeeding messages, these appeared to focus rigidly on the importance of exclusivity. Mothers described receiving some practical support with initiation of breastfeeding after delivery, but support and advice for post-natal breastfeeding challenges were often incorrect or absent. The support also ignored the context in which women make infant feeding decisions, including returning to work and pressures from family members. Despite improved breastfeeding policies, restoring confidence in health workers to support breastfeeding remains a challenge. The post-natal period, when mothers experience breastfeeding difficulties, is particularly critical, and our findings reinforce the importance of continuity of care between communities and health facilities. This research has implications for how health workers are trained to support breastfeeding. Greater attention is needed on developing skills and confidence in identifying, assessing, and supporting women experiencing breastfeeding challenges.