Focusing on Counsellor-to-Mother Communication in Order to Enhance Effectiveness and Quality of PMTCT Infant Feeding Counseling in Southern Africa

This 5-page paper - adapted from a poster presented at a conference in Rio de Janeiro, Brazil - provides an early overview of the rationale and methodologies of the Phase 2 pilot intervention of the Infant Feeding Research Project (IFRP), and explores how these emerged from the Phase 1 research findings. IFRP is a 3-phased research project/process designed to reduce the number of children dying through mother to child transmission (MTCT) of HIV by focusing on the positive potential of the woman and counsellor relationship to promote safe infant feeding practices. These phases include: an exploratory, ethnographic (research) first phase which focused primarily on mothers; an action research (pilot) second phase focusing primarily on the counsellors; and an implementation (proposed roll-out) phase focusing on training new partners.

Following a brief overview of the project, this paper details the methodology of Phase 1, which involved 16 researchers conducting ethnographic field research in indigenous language using a variety of qualitative techniques over a 7-month period (ending in November 2003). The 11 sites in Namibia, Swaziland, and South Africa were in low-resource urban, peri-urban, and rural settings. A total of 155 mothers and pregnant women, 31 relatives, 92 health workers, and 7 traditional healers were formally interviewed. Key research questions included: Who and what influences infant feeding decisions? How do perspectives and experiences of mothers and counsellors speak to the effectiveness of prevention of MTCT (PMTCT) infant feeding counselling?

Among the findings:

• Mixed feeding - including water, solids, and medicine - is the norm, but infant feeding counselling is not effective in preventing this type of feeding in resource-poor settings.
• Mothers tend to believe that breast milk is not a real food, or not food enough; they feel that the quantity, or the quality of their breast milk is not good enough. This correlates with low self-esteem: the belief that they too are "not good enough". In addressing these beliefs, health workers had to compete with other voices of "infant feeding counsel", such as a woman's relatives.
• Counsellors either "just" allowed mothers to make their choice without being actively assisted in making their decision, or - instead - they were simply told what to do. But neither approach, the non-directive or the instructive, was appropriate or able to manage differing agendas.
• In general, within the counselling encounter, "two very different agendas were at work, with both parties entertaining fixed expectations, talking past, at, and against each other. Professional and even personal boundaries are commonly crossed." Health workers were found to be suffering burn-out, depression, and even rage.

Based on these findings, IFRP researchers determined that - in Phase 2 of the project - they needed to explore an alternative counseling format that better acknowledges and manages the potentially conflicting agendas of the mother and the counselor. They traced some of the interpersonal problems hampering relationships between mothers and health workers to female gender dynamics within a patriarchal context, and also determined that over-identification might explain much of the lack of professional distance and health workers' emotional over-involvement and burnout. They acknowledged that an alternate approach, which focuses on guiding mothers instead of either directing them or leaving (allowing) them, "will require significant behaviour change of counselors, both to their counselling approach and to include deeper or psychological transformation."

This process of reflection led the researchers to develop a behaviour change strategy, which they stress needs to be consistent and coherent. Several charts within this report lay out the various components of this strategy - for mothers, counselors, and researchers. For instance, barriers to stimulating self-efficacy in mothers on the part of counselors can be traced to doubt in mothers' capacity for self-management, a need to control their behaviour, and a tendency to reinforce mothers' powerlessness by behaving as either "persecutors" or "rescuers". Several distinct strategies are outlined in bullet-point form to address these and other barriers to a successful infant feeding counseling encounter. These techniques include motivational interviewing and woman-centredness (within the mother/counselor dynamic), appreciative inquiry (within the counselor/researcher dynamic), and outcome mapping (within the researcher/health system dynamic).

Broadly, these approaches focus on such steps as empowering both mother and counselor by clarifying roles and boundaries (e.g., leaving responsibility for behaviour change clearly with the mother while stimulating her self-efficacy by listening, and by recognising and facilitating "change talk" from the mother). This involves stimulating motivational change through a participatory consultation process that is described as "more visionary and enabling than critical"; the focus is on assets and capacities (gleaned through "positive" questions) rather than needs, gaps, and problems. Participatory strategies come into play in the research strategy as well, in that the main "outcome challenge" - counsellors changing their own behaviour, rather than the compliance/behaviour of their clients - is tracked in an inclusive self-monitoring process that is supported by interaction with other stakeholders (boundary partners) such as the health service management.