Influences of HIV on exclusive breastfeeding: an exploration of community-based peer support in rural Malawi

Exclusive breastfeeding (EBF) for 6 months is recommended as the most cost-effective public health intervention to improve child survival particularly in Sub-Saharan Africa and is central to achieving Millennium Development Goal number 4 for child health. However, despite the benefits of EBF to infants and mothers, the rates continue to decrease as the age of the infant increases in an African cultural context including Malawi. There is increasing literature on the effectiveness of community-based peer counselling on EBF promotion in resource-poor settings but its effectiveness in the context of HIV and experiences of HIV positive women with the intervention remains a gap. The purpose of this thesis was to explore determinants of EBF using MaiMwana infant feeding peer-counselling intervention conducted in Mchinji, Malawi as a case study. Specifically, in this study I explored the effectiveness of the intervention to help HIV positive women to overcome the barriers and examine people’s experiences and perceptions towards the intervention with respect to HIV and poverty. I adopted qualitative in-depth interviews with 39 informants, including breastfeeding mothers, peer counsellors and key informants who were purposely selected. The data was analysed using a framework approach. I found that despite having good knowledge, women from rural communities face considerable challenges while practicing EBF. Cultural beliefs, economic constraints, lack of power and support, and fear of transmitting the virus to their infants were cited as major barriers that prevented them from practicing EBF. Overall, the findings from this study suggest that peer counsellors are well accepted by service-users and other community members as they positively viewed their frequent visits as providing additional support, reinforcing infant feeding messages and provide psychological support to women resulting in improved EBF rates. Furthermore, the presence of peer counsellors was viewed as “bringing services at their door step” which reduced time and cost to travel to the health facility. Nevertheless, the findings suggest that voluntary work in resource-poor settings presents considerable challenges such as: poor motivation due to lack of incentives, overworking, lack of knowledge and time to handle HIV positive cases and poor supervision. In order to effectively promote EBF in resource-poor settings, public health programme designers and implementers need to consider these barriers so as to design community-based interventions that suit the local context and create an enabling environment

Perceptions on acceptability of the 2016 WHO ANC model among the pregnant women in Phalombe District, Malawi – a qualitative study using Theoretical Framework of Acceptability

Abstract Background The World Health Organization introduced a new model of care, ‘The 2016 WHO ANC Model’ to overcome challenges encountered during the implementation of the Focused Antenatal Care Approach. For any new intervention to achieve its objective, it must be widely accepted by both the deliverers and recipients. Malawi rolled out the model in 2019 without carrying out acceptability studies. The objective of this study was to explore the perceptions of pregnant women and health care workers on the acceptability of 2016 WHO’s ANC model in Phalombe District, Malawi using the Theoretical Framework of Acceptability. Methodology We conducted a descriptive qualitative study between May and August 2021. The Theoretical Framework of Acceptability was used to guide the development of study objectives, data collection tools, and data analysis. We purposely conducted 21 in-depth interviews (IDIs) among pregnant women, postnatal mothers, a safe motherhood coordinator, and Antenatal care (ANC) clinic midwives, and two focus group discussions (FGDs) among Disease Control and Surveillance Assistants. All IDIs and FGDs were conducted in Chichewa, digitally recorded, and simultaneously transcribed and translated into English. Data was analysed manually using content analysis. Results The model is acceptable among most pregnant women and they reckoned that it would help reduce maternal and neonatal deaths. Support from a husband, peers, and health care workers facilitated acceptability of the model while the increased number of ANC contacts which resulted in fatigue and increased transportation cost incurred by the women was a deterrent. Conclusion This study has shown that most pregnant women have accepted the model despite facing numerous challenges. Therefore, there is a need to strengthen the enabling factors and address the bottlenecks in the implementation of the model. Furthermore, the model should be widely publicised so that both intervention deliverers and recipients of care implement the model as intended. This will in turn help to achieve the model’s aim of improving maternal and neonatal outcomes and creating a positive experience with health care among pregnant women and adolescent girls. </jats:sec

Management practices in facilities providing HIV services to key populations in Kenya and Malawi: A descriptive analysis of management in community-based organizations

HIV services for key populations (KP) at higher risk of HIV infection are often delivered by community-based organizations. To achieve HIV epidemic control, countries need to scale up HIV services for KP. Little is known about the management practices of community-based organizations delivering health services. We explored the management practices and facility characteristics of community-based health facilities providing HIV services to key populations as part of the LINKAGES program in Kenya and Malawi. We collected information on management practices from 45 facilities called drop-in centers (DICs) during US Government FY 2019, adapting the World Management Survey to the HIV community-based health service delivery context. We constructed management domain scores for each facility. We then analyzed the statistical correlations between management domains (performance monitoring, people management, financial management, and community engagement) and facility characteristics (e.g., number of staff, organization maturity, service scale) using ordinary least square models. The lowest mean management domain scores were found for people management in Kenya (38.3) and financial management in Malawi (25.7). The highest mean scores in both countries were for performance monitoring (80.9 in Kenya and 82.2 in Malawi). Within each management domain, there was significant variation across DICs, with the widest ranges in scores (0 to 100) observed for financial management and community involvement. The DIC characteristics we considered explained only a small proportion of the variation in management domain scores across DICs. Community-based health facilities providing HIV services to KP can achieve high levels of management in a context where they receive adequate levels of above-facility support and oversight—even if they deliver complex services, rely heavily on temporary workers and community volunteers, and face significant financial constraints. The variation in scores suggests that some facilities may require more above-facility support and oversight than others

Management practices in facilities providing HIV services to key populations in Kenya and Malawi:A descriptive analysis of management in community-based organizations

HIV services for key populations (KP) at higher risk of HIV infection are often delivered by community-based organizations. To achieve HIV epidemic control, countries need to scale up HIV services for KP. Little is known about the management practices of community-based organizations delivering health services. We explored the management practices and facility characteristics of community-based health facilities providing HIV services to key populations as part of the LINKAGES program in Kenya and Malawi. We collected information on management practices from 45 facilities called drop-in centers (DICs) during US Government FY 2019, adapting the World Management Survey to the HIV community-based health service delivery context. We constructed management domain scores for each facility. We then analyzed the statistical correlations between management domains (performance monitoring, people management, financial management, and community engagement) and facility characteristics (e.g., number of staff, organization maturity, service scale) using ordinary least square models. The lowest mean management domain scores were found for people management in Kenya (38.3) and financial management in Malawi (25.7). The highest mean scores in both countries were for performance monitoring (80.9 in Kenya and 82.2 in Malawi). Within each management domain, there was significant variation across DICs, with the widest ranges in scores (0 to 100) observed for financial management and community involvement. The DIC characteristics we considered explained only a small proportion of the variation in management domain scores across DICs. Community-based health facilities providing HIV services to KP can achieve high levels of management in a context where they receive adequate levels of above-facility support and oversight-even if they deliver complex services, rely heavily on temporary workers and community volunteers, and face significant financial constraints. The variation in scores suggests that some facilities may require more above-facility support and oversight than others