1. Academic Wits Research Publications (Faculties submissions)

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    Frontline health workers and exclusive breastfeeding guidelines in an HIV endemic South African community: a qualitative exploration of policy translation
    (BioMed Central, 2018-06) Nieuwoudt, Sara; Manderson, Lenore
    Background: Mothers rely heavily on health worker advice to make infant feeding decisions. Confusing or misleading advice can lead to suboptimal feeding practices. From 2001, HIV positive mothers in South Africa were counseled to choose either exclusive breastfeeding or exclusive formula feeding to minimize vertical HIV transmission. On the basis of revised World Health Organization guidelines, the government amended this policy in 2011, by promoting exclusive breastfeeding and discontinuing the provision of free formula. We explored how health workers experienced this new policy in an HIV endemic community in 2015–16, with attention to their knowledge of the policy, counselling practices, and observations of any changes. Methods: We interviewed eleven health workers, from four community health clinics, who had counseled mothers before and after the policy change. The transcribed interviews were analyzed thematically, using a hybrid coding approach. Results: The scientific rationale of the policy was not explained to most health workers, who mostly thought that the discontinuation of the formula program was cost-related. The content of their counseling reflected knowledge about promoting breastfeeding for all women, and accordingly they mentioned the nutritional and developmental benefits of breastfeeding. The importance of exclusive breastfeeding for all infants was not emphasized, instead counseling focused on HIV prevention, even for uninfected mothers. The health workers noted an increased incidence of breastfeeding, but some worried that to avoid HIV disclosure, HIV positive mothers were mixed feeding rather than exclusively breastfeeding. Conclusions: Causal links between the policy, counseling content and feeding practices were unclear. Some participants believed that breastfeeding practices were driven by finance or family pressures rather than the health information they provided. Health workers generally lacked training on the policy’s evidence base, particularly the health benefits of exclusive breastfeeding for non-exposed infants. They wanted clarity on their counseling role, based on individual risk or to promote exclusive breastfeeding as a single option. If the latter, they needed training on how to assist mothers with community-based barriers. Infant feeding messages from health workers are likely to remain confusing until their uncertainties are addressed. Their insights should inform future guideline development as key actors.
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    UNICEF’s contribution to the adoption and implementation of option B+ for preventing mother-to-child transmission of HIV: a policy analysis
    (BioMed Central, 2018-06) Chersich, M. F.; Newbatt, E.; Ng’oma, K.; de Zoysa, L.
    Background: Between 2011 and 2013, global and national guidelines for preventing mother-to-child transmission (PMTCT) of HIV shifted to recommend Option B+, the provision of lifelong antiretroviral treatment for all HIV-infected pregnant women. Methods: We aimed to analyse how Option B+ reached the policy agenda, and unpack the processes, actors and politics that explain its adoption, with a focus on examining UNICEF’s contribution to these events. Analysis drew on published articles and other documentation, 30 key informants interviews with staff at UNICEF, partner organisations and government officials, and country case studies. Cameroon, India, South Africa and Zimbabwe were each visited for 5–8 days. Interview transcripts were analysed using Dedoose software, reviewed several times and then coded thematically. Results: A national policy initiative in Malawi in 2011, in which the country adopted Option B+, rather than existing WHO recommended regimens, irrevocably placed the policy on the global agenda. UNICEF and other organisations recognised the policy’s potential impact and strategically crafted arguments to support it, framing these around operational considerations, cost-effectiveness and values. As ‘policy entrepreneurs’, these organisations vigorously promoted the policy through a variety of channels and means, overcoming concerted opposition. WHO, on the basis of scanty evidence, released a series of documents towards the policy’s endorsement, paving the way for its widespread adoption. National-level policy transformation was rapid and definitive, distinct from previous incremental policy processes. Many organisations, including UNICEF, facilitated these changes in country, acting individually, or in concert. Conclusions: The adoption of the Option B+ policy marked a departure from established processes for PMTCT policy formulation which had been led by WHO with the support of technical experts, and in which recommendations were developed following shifts in evidence. Rather, changes were spurred by a country-level initiative, and a set of strategically framed arguments that resonated with funders and country-level actors. This bottom-up approach, supported by normative agencies, was transformative. For UNICEF, alignment between the organisation’s country focus and the policy’s underpinning values, enabled it to work with partners and accelerate widespread policy change.