Infant feeding knowledge, perceptions and practices among women with and without HIV in Johannesburg, South Africa: A survey in healthcare facilities

International Breastfeeding Journal, Volume 12, No. 1, Year 2017

Interpretação

Background: South Africa has a history of low breastfeeding rates among women with and without Human Immunodeficiency Virus (HIV). In this study, we assessed infant feeding knowledge, perceptions and practices among pregnant and postpartum women with and without HIV, in the context of changes in infant feeding and Prevention of Mother-to-Child Transmission of HIV (PMTCT) guidelines. Methods: This was a cross-sectional survey conducted from April 2014 to March 2015 in 10 healthcare facilities in Johannesburg, South Africa. A total of 190 pregnant and 180 postpartum women (74 and 67, respectively, were HIV positive) were interviewed using a semi-structured questionnaire. Multiple regression analyses assessed factors associated with an intention to exclusively breastfeed, and exclusive breastfeeding of infants less than six months of age. Results: Women with HIV had better overall knowledge on safe infant feeding practices, both in general and in the context of HIV infection. There were however gaps in knowledge among women with and without HIV. Information from healthcare facilities was the main source of information for all groups of women in the study. A greater percentage of women without HIV 80.9% (93/115), reported an intention to exclusively breastfeed, compared to 64.9% (48/74) of women with HIV, p = 0.014. Not having HIV was positively associated with a reported intention to breastfeed, Adjusted Odds Ratio (AOR) 3.60, 95% CI 1.50, 8.62. Other factors associated with a reported intention to exclusively breastfeed were prior breastfeeding experience and higher knowledge scores on safe infant feeding practices in the context of HIV infection. Among postpartum women, higher scores on general knowledge of safe infant feeding practices were positively associated with reported exclusive breastfeeding, AOR 2.18, 95% CI 1.52, 3.12. Most women perceived that it was difficult to exclusively breastfeed and that cultural factors were a barrier to exclusive breastfeeding. Conclusions: While a greater proportion of women are electing to breastfeed, HIV infection and cultural factors remain an important influence on safe infant feeding practices. Healthcare workers are the main source of information, and highlight the need for accurate and consistent messaging for both women with and without HIV. A survey was undertaken from April 2014 to March 2015 in Soweto, Johannesburg. Ten medium and high volume public healthcare facilities, with 50–100 first antenatal care visit patients per month, and providing both antepartum and postpartum care, were selected for the study. Five facilities were selected from each of the two sub-districts in Soweto, a densely populated low and middle income area. At the time of study, the HIV prevalence among pregnant women attending antenatal clinics in Soweto was approximately 29% (unpublished programme data). All pregnant women receive group counselling on infant feeding, with individual counselling also provided for women with HIV. Group and individual counselling on safe infant feeding practices is provided by trained lay-counsellors and professional nurses, and at the time of the study reflected the 2013 and 2015 South African PMTCT guidelines, which are adapted from the WHO guidelines on infant feeding in the context of HIV infection [1, 5, 11]. In both the 2013 and 2015 South African guidelines, the recommendation is for women with HIV to exclusively breastfeed for six months, with introduction of complementary food from six months and continued breastfeeding for up to 12 months [5, 11]. In the 2013 guidelines, there was provision for either extended infant or maternal antiretroviral prophylaxis for the duration of breastfeeding in women who did not need lifelong ART for their own health [11]. The current recommendation, based on the 2015 guidelines, is for all pregnant and breastfeeding women with HIV to be initiated on lifelong ART, regardless of level of immune suppression [5]. Women without HIV are counselled to exclusively breastfeed for six months, with introduction of complementary food from six months and continued breastfeeding for up to two years or more [5]. A systematic sampling procedure was used to recruit women with and without HIV during pregnancy and up to 12 months postpartum. Every fifth pregnant or postpartum client to enter the facility was invited to participate in the study, and if she declined the next client was recruited. Pregnant women were recruited if they were attending a follow-up antenatal visit, and postpartum if they were attending a clinic visit beyond the sixweeks visit. The study was approved by the University of the Witwatersrand Human Research Ethics Committee (No. M130801), and access to the facilities was granted by the Johannesburg District Health Department. Women who agreed to be part of the study, and were 18 years and older, were interviewed using a semi-structured questionnaire. All study participants provided written informed consent. Approximately 20 antepartum and 20 postpartum women were interviewed in each facility. The questionnaire was in English and the interviews were conducted by lay-educators who had a good understanding of the infant feeding guidelines as they provided PMTCT education sessions at the sites. The interviewers completed the questionnaire and were trained on how to explain the technical terms, and where necessary, translated from the English interview into the two predominant vernacular languages in Soweto, Sesotho and Zulu. A field manager and the study investigators provided supervision throughout the study period. The questionnaire had subsections in the following order: demographics, self-reported HIV status and ART use if HIV-infected, infant feeding intentions among pregnant women and practices among postpartum women, and factors influencing the intentions and practices, sources of infant feeding information, general knowledge on infant feeding, perceptions on exclusive breastfeeding, knowledge of infant feeding in the context of HIV infection, and factors supportive of exclusive breastfeeding. The questions in the questionnaire were a mixture of open-ended and closed questions. The closed questions had predefined options of Yes/No, True/False, and multiple response items. The Food and Agriculture Organization of the United Nations (FAO) guidelines for assessing nutrition-related knowledge, attitudes and practices manual lists open-ended and closed questions as types of questions that can be used in infant feeding surveys [12]. In formulating the knowledge questions, we identified key items that are integral to core knowledge on safe infant feeding practices in general and in the context of HIV infection. The questions were based on the WHO definitions and guidelines on infant feeding, South African PMTCT guidelines and published literature [1, 5, 11, 13, 14]. Several studies on infant feeding, conducted in sub-Saharan Africa, have used questions based on WHO definitions and guidelines on infant feeding to assess knowledge in pregnant and postpartum women with and without HIV [7, 15–19]. In our survey, a total of 16 key-knowledge questions were selected for both pregnant and postpartum women (Table 1). Questions on general knowledge of safe infant feeding practices were asked first, followed by questions on infant feeding in the context of HIV infection, and the questions were ordered such that earlier questions in the questionnaire did not influence responses to later questions. Each question was assigned a score of 1 for a correct answer, and 0 for an incorrect answer, with a maximum score of 16. To assess perceptions on exclusive breastfeeding, we formulated four statements with response options of True, False and Don’t know. The four statements were on perceived ease of exclusive breastfeeding and factors that impact on this practice. Our statements to assess perceptions on exclusive breastfeeding are similar to those used by Kafulafula et al. and Mogre et al. in assessing attitudes towards exclusive breastfeeding [19, 20]. Questions on safe infant feeding practices Study data were collected and managed using REDCap electronic data capture tools hosted at the University of the Witwatersrand, and analysed using Dell Statistica (data analysis software system), version 12, software.dell.com, Dell Inc. (2015) [21]. Means, with standard deviations (SD), and medians with interquartile ranges (IQR) were calculated for continuous data, and frequencies were determined for categorical data. Student’s t-tests and Mann-Whitney tests were used for comparison of means and medians, respectively. Chi-squared and Fisher’s exact tests were used for categorical data and statistical significance was accepted as the two-tailed p < 0.05. Multiple logistic regression analyses were done to determine associations between independent variables and the binary outcome of intention to exclusively breastfeed among pregnant women and exclusive breastfeeding among postpartum women with infants less than six months of age. Variables that had an association with the binary outcomes with a p - value of 0.20 or less in the bivariate analyses were included in the final multivariate model. Variables of particular interest in this study, such as HIV status and feeding knowledge scores, were also included in the final models, irrespective of their significance in the bivariate analyses. The Wald test statistic was used to assess the significance of association between the independent variables, and the intention and practice of exclusive breastfeeding.

AI Digest

Study Justification:

This study aimed to assess the knowledge, perceptions, and practices of infant feeding among pregnant and postpartum women with and without HIV in Johannesburg, South Africa. The justification for this study is based on the history of low breastfeeding rates in South Africa, particularly among women with HIV. The study aimed to identify gaps in knowledge and understand the factors influencing infant feeding practices in order to inform interventions and improve breastfeeding rates.

Highlights:

1. Women with HIV had better overall knowledge on safe infant feeding practices, both in general and in the context of HIV infection.
2. There were gaps in knowledge among women with and without HIV, indicating the need for accurate and consistent messaging.
3. Information from healthcare facilities was the main source of information for all groups of women in the study.
4. A greater percentage of women without HIV reported an intention to exclusively breastfeed compared to women with HIV.
5. Factors associated with a reported intention to exclusively breastfeed included prior breastfeeding experience and higher knowledge scores on safe infant feeding practices in the context of HIV infection.
6. Cultural factors were perceived as a barrier to exclusive breastfeeding.

Recommendations:

1. Improve knowledge and awareness of safe infant feeding practices among women with and without HIV.
2. Provide accurate and consistent messaging on infant feeding practices, particularly in the context of HIV infection.
3. Strengthen support and counseling services for pregnant and postpartum women, addressing cultural barriers to exclusive breastfeeding.
4. Enhance training and education for healthcare workers to ensure they can provide accurate and up-to-date information on infant feeding.

Key Role Players:

1. Healthcare workers: They play a crucial role in providing information and counseling to pregnant and postpartum women.
2. Lay-counselors: They provide support and counseling services to women, particularly those with HIV.
3. Professional nurses: They are involved in providing group and individual counseling on safe infant feeding practices.
4. Researchers: They conduct studies and provide evidence-based recommendations to inform interventions and policies.

Cost Items for Planning Recommendations:

1. Training and education programs for healthcare workers and lay-counselors.
2. Development and dissemination of educational materials on safe infant feeding practices.
3. Support and counseling services for pregnant and postpartum women.
4. Research and data collection to monitor and evaluate the effectiveness of interventions.
5. Collaboration and coordination efforts among healthcare facilities and stakeholders.
Please note that the cost items provided are general suggestions and may vary based on the specific context and resources available.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is cross-sectional, which limits the ability to establish causality. Additionally, the sample size is relatively small, with 190 pregnant and 180 postpartum women interviewed. To improve the strength of the evidence, future studies could consider using a longitudinal design to better assess changes over time and include a larger sample size to increase generalizability. Furthermore, the abstract does not provide information on the representativeness of the healthcare facilities selected or the demographic characteristics of the participants, which could impact the generalizability of the findings. Including this information would enhance the transparency and applicability of the study. Overall, the evidence is informative but could benefit from methodological enhancements.

Resumo

A survey was undertaken from April 2014 to March 2015 in Soweto, Johannesburg. Ten medium and high volume public healthcare facilities, with 50–100 first antenatal care visit patients per month, and providing both antepartum and postpartum care, were selected for the study. Five facilities were selected from each of the two sub-districts in Soweto, a densely populated low and middle income area. At the time of study, the HIV prevalence among pregnant women attending antenatal clinics in Soweto was approximately 29% (unpublished programme data). All pregnant women receive group counselling on infant feeding, with individual counselling also provided for women with HIV. Group and individual counselling on safe infant feeding practices is provided by trained lay-counsellors and professional nurses, and at the time of the study reflected the 2013 and 2015 South African PMTCT guidelines, which are adapted from the WHO guidelines on infant feeding in the context of HIV infection [1, 5, 11]. In both the 2013 and 2015 South African guidelines, the recommendation is for women with HIV to exclusively breastfeed for six months, with introduction of complementary food from six months and continued breastfeeding for up to 12 months [5, 11]. In the 2013 guidelines, there was provision for either extended infant or maternal antiretroviral prophylaxis for the duration of breastfeeding in women who did not need lifelong ART for their own health [11]. The current recommendation, based on the 2015 guidelines, is for all pregnant and breastfeeding women with HIV to be initiated on lifelong ART, regardless of level of immune suppression [5]. Women without HIV are counselled to exclusively breastfeed for six months, with introduction of complementary food from six months and continued breastfeeding for up to two years or more [5]. A systematic sampling procedure was used to recruit women with and without HIV during pregnancy and up to 12 months postpartum. Every fifth pregnant or postpartum client to enter the facility was invited to participate in the study, and if she declined the next client was recruited. Pregnant women were recruited if they were attending a follow-up antenatal visit, and postpartum if they were attending a clinic visit beyond the sixweeks visit. The study was approved by the University of the Witwatersrand Human Research Ethics Committee (No. M130801), and access to the facilities was granted by the Johannesburg District Health Department. Women who agreed to be part of the study, and were 18 years and older, were interviewed using a semi-structured questionnaire. All study participants provided written informed consent. Approximately 20 antepartum and 20 postpartum women were interviewed in each facility. The questionnaire was in English and the interviews were conducted by lay-educators who had a good understanding of the infant feeding guidelines as they provided PMTCT education sessions at the sites. The interviewers completed the questionnaire and were trained on how to explain the technical terms, and where necessary, translated from the English interview into the two predominant vernacular languages in Soweto, Sesotho and Zulu. A field manager and the study investigators provided supervision throughout the study period. The questionnaire had subsections in the following order: demographics, self-reported HIV status and ART use if HIV-infected, infant feeding intentions among pregnant women and practices among postpartum women, and factors influencing the intentions and practices, sources of infant feeding information, general knowledge on infant feeding, perceptions on exclusive breastfeeding, knowledge of infant feeding in the context of HIV infection, and factors supportive of exclusive breastfeeding. The questions in the questionnaire were a mixture of open-ended and closed questions. The closed questions had predefined options of Yes/No, True/False, and multiple response items. The Food and Agriculture Organization of the United Nations (FAO) guidelines for assessing nutrition-related knowledge, attitudes and practices manual lists open-ended and closed questions as types of questions that can be used in infant feeding surveys [12]. In formulating the knowledge questions, we identified key items that are integral to core knowledge on safe infant feeding practices in general and in the context of HIV infection. The questions were based on the WHO definitions and guidelines on infant feeding, South African PMTCT guidelines and published literature [1, 5, 11, 13, 14]. Several studies on infant feeding, conducted in sub-Saharan Africa, have used questions based on WHO definitions and guidelines on infant feeding to assess knowledge in pregnant and postpartum women with and without HIV [7, 15–19]. In our survey, a total of 16 key-knowledge questions were selected for both pregnant and postpartum women (Table 1). Questions on general knowledge of safe infant feeding practices were asked first, followed by questions on infant feeding in the context of HIV infection, and the questions were ordered such that earlier questions in the questionnaire did not influence responses to later questions. Each question was assigned a score of 1 for a correct answer, and 0 for an incorrect answer, with a maximum score of 16. To assess perceptions on exclusive breastfeeding, we formulated four statements with response options of True, False and Don’t know. The four statements were on perceived ease of exclusive breastfeeding and factors that impact on this practice. Our statements to assess perceptions on exclusive breastfeeding are similar to those used by Kafulafula et al. and Mogre et al. in assessing attitudes towards exclusive breastfeeding [19, 20]. Questions on safe infant feeding practices Study data were collected and managed using REDCap electronic data capture tools hosted at the University of the Witwatersrand, and analysed using Dell Statistica (data analysis software system), version 12, software.dell.com, Dell Inc. (2015) [21]. Means, with standard deviations (SD), and medians with interquartile ranges (IQR) were calculated for continuous data, and frequencies were determined for categorical data. Student’s t-tests and Mann-Whitney tests were used for comparison of means and medians, respectively. Chi-squared and Fisher’s exact tests were used for categorical data and statistical significance was accepted as the two-tailed p < 0.05. Multiple logistic regression analyses were done to determine associations between independent variables and the binary outcome of intention to exclusively breastfeed among pregnant women and exclusive breastfeeding among postpartum women with infants less than six months of age. Variables that had an association with the binary outcomes with a p – value of 0.20 or less in the bivariate analyses were included in the final multivariate model. Variables of particular interest in this study, such as HIV status and feeding knowledge scores, were also included in the final models, irrespective of their significance in the bivariate analyses. The Wald test statistic was used to assess the significance of association between the independent variables, and the intention and practice of exclusive breastfeeding.

Materiais

N/A

Inovações

Based on the information provided, here are some potential innovations that could be used to improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide accurate and up-to-date information on safe infant feeding practices, including guidelines for women with and without HIV. These apps can be easily accessible on smartphones and can provide personalized information and reminders to pregnant and postpartum women.

2. Telemedicine: Establish telemedicine services that allow pregnant and postpartum women to consult with healthcare professionals remotely. This can help overcome barriers to accessing healthcare facilities, particularly for women in remote or underserved areas. Telemedicine consultations can provide guidance on infant feeding practices and address any concerns or questions women may have.

3. Community Health Workers: Train and deploy community health workers who can provide education and support to pregnant and postpartum women in their communities. These workers can conduct home visits, organize support groups, and provide accurate information on safe infant feeding practices. They can also serve as a link between women and healthcare facilities, ensuring that women receive the necessary care and support.

4. Peer Support Programs: Establish peer support programs where women who have successfully practiced safe infant feeding, including exclusive breastfeeding, can provide guidance and support to other women. Peer support can help address cultural barriers and provide practical advice based on personal experiences.

5. Health Education Campaigns: Conduct targeted health education campaigns to raise awareness about safe infant feeding practices, particularly among women with HIV. These campaigns can utilize various media channels, such as radio, television, and social media, to reach a wide audience and provide accurate information.

6. Integration of Services: Ensure that maternal health services, including antenatal care, postpartum care, and HIV care, are integrated to provide comprehensive and coordinated care. This can help ensure that women receive consistent and accurate information on safe infant feeding practices throughout their pregnancy and postpartum period.

7. Training and Capacity Building: Provide training and capacity building programs for healthcare workers to improve their knowledge and skills in providing accurate and consistent messaging on safe infant feeding practices. This can help ensure that healthcare workers are equipped to address the specific needs and concerns of women with and without HIV.

It is important to note that these recommendations are based on the information provided and may need to be adapted to the specific context and resources available in Johannesburg, South Africa.

AI Innovations Description

Based on the description provided, the recommendation to improve access to maternal health and address the gaps in knowledge and practices related to infant feeding among women with and without HIV in Johannesburg, South Africa is as follows:

1. Strengthen healthcare facility-based education and counseling: Healthcare facilities should prioritize providing accurate and consistent messaging on safe infant feeding practices to both women with and without HIV. This can be achieved through comprehensive training programs for healthcare workers, including lay-counselors and professional nurses, who interact with pregnant and postpartum women. The training should cover the latest guidelines on infant feeding in the context of HIV infection, as well as general knowledge on safe infant feeding practices.

2. Enhance community-based support: In addition to healthcare facility-based education, community-based support systems should be established to reinforce the importance of exclusive breastfeeding and address cultural barriers. Community health workers and peer support groups can play a crucial role in providing ongoing guidance and encouragement to women, especially those living with HIV, to promote exclusive breastfeeding.

3. Improve access to accurate information: Efforts should be made to ensure that women have access to reliable sources of information on infant feeding. This can be achieved through the development and dissemination of culturally appropriate educational materials, such as brochures and posters, that are easily accessible in healthcare facilities and community settings. Additionally, digital platforms, such as mobile applications and websites, can be utilized to provide up-to-date information and support to women.

4. Conduct targeted interventions: Tailored interventions should be designed to address the specific needs and challenges faced by women living with HIV. These interventions can include additional counseling sessions, peer support groups specifically for women with HIV, and strategies to address stigma and discrimination related to HIV and infant feeding.

5. Collaborate with stakeholders: Collaboration between healthcare facilities, community organizations, and relevant stakeholders, such as government agencies and non-governmental organizations, is essential to ensure a coordinated and comprehensive approach to improving access to maternal health. This collaboration can help leverage resources, share best practices, and advocate for policy changes that support safe infant feeding practices.

By implementing these recommendations, it is expected that access to maternal health will be improved, leading to increased knowledge, improved practices, and better health outcomes for both mothers and infants in Johannesburg, South Africa.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening healthcare worker training: Provide comprehensive training to healthcare workers on safe infant feeding practices, including the latest guidelines for women with and without HIV. This will ensure that healthcare workers have accurate and up-to-date knowledge to effectively counsel pregnant and postpartum women.

2. Enhancing community education and awareness: Develop community-based programs to raise awareness about the importance of exclusive breastfeeding and dispel myths and misconceptions surrounding it. This can be done through community health workers, support groups, and educational campaigns targeting both women with and without HIV.

3. Improving access to antenatal and postnatal care: Ensure that pregnant and postpartum women have easy access to healthcare facilities that provide antenatal and postnatal care services. This includes increasing the number of healthcare facilities in low-income areas and improving transportation options for women to reach these facilities.

4. Strengthening support systems: Establish support systems for women, such as breastfeeding support groups and peer counseling programs. These support systems can provide emotional support, practical advice, and guidance to women during their breastfeeding journey.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as the percentage of women receiving antenatal and postnatal care, the percentage of women exclusively breastfeeding, and the percentage of women with adequate knowledge on safe infant feeding practices.

2. Collect baseline data: Gather data on the current status of these indicators in the target population. This can be done through surveys, interviews, and data from healthcare facilities.

3. Implement the recommendations: Roll out the recommended interventions, such as healthcare worker training, community education programs, and improved access to care. Ensure that these interventions are implemented consistently and monitored closely.

4. Collect post-intervention data: After a certain period of time, collect data on the indicators again to assess the impact of the interventions. This can be done through follow-up surveys, interviews, and data from healthcare facilities.

5. Analyze the data: Compare the baseline data with the post-intervention data to determine the changes in the indicators. Use statistical analysis techniques to assess the significance of these changes and identify any patterns or trends.

6. Evaluate the impact: Assess the impact of the recommendations on improving access to maternal health based on the changes observed in the indicators. This evaluation can help identify the effectiveness of the interventions and inform future decision-making.

By following this methodology, it is possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for further improvements.

Autor

Dima Health

Statistics:

Citations: 22

Identifiers:

DOI: 10.1186/s13006-017-0109-x

Research Areas:

Community Interventions, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

South Africa

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female

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