Ms Philippa Barnard, a Nutritionist at Zoe-Life outlined the Tshwane Declaration of 2011, which advocated breastfeeding as the best infant feeding choice for all babies, regardless of HIV status. This great change in policy created massive potential for decreasing infant and child mortality. Ms Barnard also highlighted some of Zoe-Life's practical insights gained whilst training lay counsellors in infant and young child feeding.

1. Scaling-up in KZN:
Outcomes & Recommendations
Infant & Young Child Feeding

2. CONTEXT
• SA DoH revised PMTCT guidelines from 1st
April 2010
– All HIV exposed infants receive daily NVP from
birth – 6 weeks and continued daily for those who
are BF where mother is not taking lifelong ARVs
– Mothers not taking lifelong ARVs are encouraged
to BF for up to 12 months
• Integrating ARVs to BF is expected to reduce
HIV transmission rate to <2% (UNICEF, 2010)

3. CONTEXT
• KZN DoH (as of 1 January 2011) decided to cease
provision of free infant formula to HIV infected
mothers (except where clear medical indications)
• Mothers will choose desired feeding method but
will no longer be issued with free infant formula if
she chooses replacement feeding
• Extra support for BF is required to enable
mothers make informed decisions and sustain
exclusive BF

4. CONTEXT
Objectives of IYCF in the context of HIV training (as
per TOR):
1. To adapt or develop advocacy messages on the
new provincial guidelines on BF and infant
feeding to be shared with political leaders,
health practitioners, and communities
2. To develop training materials for health facility
based professional teams and lay counsellors on
IYCF in the context of HIV and conduct training
for these teams

5. CONTEXT
• Zoe-Life is a purpose-driven organisation based in
SA, working towards societal transformation
through direct service interventions, capacity-
building, technical support and skills training for
organisations and communities
• In 2010, Zoe-Life was commissioned by KZN DoH:
Nutrition Directorate and UNICEF to provide IYCF
training for District Trainers and 1850 Lay
Counsellors throughout KZN. The training was to
be rolled out between October 2010 and April
2011.

6. CONTEXT

7. CONTEXT

8. Tshwane Declaration (Aug 2011)
• SA to declare itself as a country that actively
promotes, protects and supports exclusive
breastfeeding, and takes actions to demonstrate this
commitment. This includes further mainstreaming of
breastfeeding in all relevant
policies, legislation, strategies and protocols;
• SA to adopt the 2010 WHO guidelines on HIV and Infant
feeding and to recommend that all HIV infected mothers
should breastfeed their infants and receive ARV drugs to
prevent HIV transmission. ARV drugs to prevent HIV
through breastfeeding and to improve the health and
survival of HIV infected mothers should be scaled up and

9. Tshwane Declaration (Aug 2011)
• Generally this was a welcomed decision:
– Unanimous decision from the top
– PMTCT experience revealed consistent practical,
implementation issues
• Overall reflections from the field = decision
positively welcomed

10. Tshwane Declaration (Aug 2011)
• Going forward:
– Not enough to simply welcome the declaration
– Need to act
• Discovered on the ground:
– Misconceptions from health workers and public
– Require uniform training with same messages
– Messages on IYCF have not saturated HCWs or
public
• Vital time has passed

11. STAKEHOLDERS
– KZN DOH Nutrition Directorate
– UNICEF
– Researchers – supporting policy change
– KZN Government – HOD
– Advocacy groups (TAC, Yezingane Network,
Children’s Rights Centre)
– 20 000+, UKZN (Quality Improvement)
– Zoe-Life (Resource Development, Training)
– MCDI (Community based response)

12. STRATEGY
Advocacy and
Preparation
Media and Political
support
Inter-programme
advocacy
Process
documentation and
lessons shared for
National response
Development of
Messaging,
Training and
Tools
Training of
Multidisciplinary
teams
Mentorship, QI, QA
Integration of
Implementation
Clinical, Psychosocial,
Community
Linkages, development
of tools to link C,P,C
QA/ QI at each level

13. AIMS OF THE TRAINING

14. DEVELOPMENT OF MESSAGES, TRAINING
AND TOOLS
• Unique opportunity to re-establish BRAND
IDENTITY of Exclusive Breastfeeding as a
public health intervention
• Other opportunities for key messaging
– Role of the male
– Attractiveness of breastfeeding as a choice for
families

15. BRAND IDENTITY as part of
COMMUNICATION STRATEGY
– Needed to speak to all target audiences
• Clinical HCWs
• Psychosocial and Community HCWs
• Patients in predominantly semi-urban culture groups
– Program branding
• Needed to establish some continuity with previous
PMTCT work done
• BUT needed to establish clear change.

16. Continuity
• Used basic format from 2008 IYCF training:
– Participants manual
– Breastfeeding flipchart
– Pre- & post-course assessments
– Post-course evaluation
• For 2010 IYCF provincial scale-up:
– Facilitators’ manual
– Participant workbook
– Pocket tool
– IYCF flow path
– Project planning board
– CDs of training materials

17. Change
– Refreshed and modernised colours
– Added partner graphics
– Format of Breastfeeding flipchart
– Added tools – pocket tool, Flow path

18. Developing the IYCF Project
Training materials:
• For the 5 day TOT, participants
were given a facilitator’s manual,
participant’s manual, workbook,
flip chart and pocket tool.
• For the lay counsellor 3 day
training, participants were given a
manual, workbook and pocket
tool. One flip chart was given to
the participants per health facility
and mobile clinic.

19. MATERIAL CONTENT AND METHODOLOGY
• Used WHO 2010 guidelines as base,
• Added Values clarification
• Facilitators Manual:
• Facilitation skills
• How to use the tools
• QA QI principles
• Project planning
• Content and methodology workshoped with technical team and
facilitators

20. Developing the IYCF Project
Training Modules for the TOT programme
1. Reasons why children are dying
2. Knowledge, Attitudes & Practice
3. Importance of breastfeeding
4. How breastfeeding works
5. Assessing a breastfeed
6. Positioning a baby at the breast
7. Expressing and storing breast milk
8. Breastfeeding challenges (incl GMP)
9. Breast conditions
10. IYCF in the context of HIV
11. Breastfeeding & ARVs
12. Cost of formula (activity)
13. Counselling process
14. Preparation of formula
15. Heat treating EBM
16. Complementary feeding
17. Quality Assurance (QA) and Quality
Improvement (QI)
18. IYCF flow path
19. Project planning board (action plan)
20. Presentation of training tools
21. Discussion on facilitator’s manual
& its application

21. Developing the IYCF Project
Training Modules for the lay counsellor programme
1. Reasons why children are dying
2. Knowledge, Attitudes & Practice
3. Importance of breastfeeding
4. How breastfeeding works
5. Assessing a breastfeed
6. Positioning a baby at the breast
7. Expressing and storing breast milk
8. Breastfeeding challenges (incl GMP)
9. Breast conditions
10. IYCF in the context of HIV
11. Breastfeeding & ARVs
12. Cost of Formula (activity)
13. Counselling process
14. Preparation of formula
15. Heat treating EBM
16. Complementary feeding
17. IYCF flow path

22. FLOW PATH SIMPLIFIED
s
INFANT AND YOUNG CHILD FEEDING FLOW PATH
NOTE: These are the messages that should be communicated and practices that support
mothers in feeding their infants and young children.
Antenatal Clinic
Mothers who will be breastfeeding
• Definition of breastfeeding
• Benefits and risks of not breastfeeding
• Immature gut of the infant
Labour & Delivery
Breastfeeding Mothers
• Breastfeeding in the first hour
• Skin to skin contact
• ARVS for the baby (HIV positive
Post Delivery
Reinforce these messages
• Definition of breastfeeding
• Composition of breast milk
• Benefits and risks of not breastfeeding
• Immature gut of the infant
• Dangers of mixed feeding
• Good positioning and attachment
(demonstrate)
• Breastfeeding challenges
• Expressing and storing breast milk
• Breastfeeding in the first hour
• ARVs and breastfeeding (HIV positive
mothers only)
mother only)
Formula Feeding Mothers (HIV positive
mother):
• Skin to skin contact
• ARVS for the baby
• Dangers of mixed feeding
• Good positioning and attachment
(demonstrate)
• Breastfeeding challenges
• Expressing and storing breast milk
Breastfeeding Mothers
• ARVs for the baby
• Adherence to ARVs
• PCR testing for baby at 6 week
Mothers who choose to formula feed
(HIV positive mother)
• Dangers of mixed feeding
• Skin to skin contact
• Preparation of formula (demonstrate)
• Disclosure
• Feeding on demand
• Introducing complementary feeds at 6 months
• Vitamin A
• Stopping breastfeeding
Formula Feeding Mothers (HIV positive
mother):
• Exclusive formula feeding
• Demonstration of safe preparation of formula
• Introducing complementary feeds at 6 months
• Vitamin A
Designed and Produced by SMT Health Solutions cc T/A Zoë-Life 2010

23. Training
• Zoë-Life Facilitators
– Selected because of previous health and
nutrition-related training experience
– 4 teams: 1 clinical and 1 psychosocial
• Pre-testing of training materials and
methodology
– 23 Community Caregivers (Masisizane)
– KZN DOH and UNICEF
DEVELOPMENT OF TRAINERS

24. Training
• Trainer of Trainers
– 2 from each District – District Trainer (Clinical)
with Mentor coordinator (Psychosocial)
– Aim: Provide ongoing training and support of both
clinical and psychosocial staff.
• Lay Counsellor and nurse training
– Recognizing role of LC as first point of contact and
follow up support
TRAINING COURSES

25. TARGETS & DEMOGRAPHIC ANALYSIS
34 TOTs representing all
Districts
District Scale Up for LCs:
• Target 1850
• Attended 1706
• LCs trained 1496

26. TRAINING EVALUATION
• Numbers attended all sessions
• Discipline type
• Facility/ District/ Demographics
• Years of experience
• Pre and Post course questionnaires
• Values clarification
• Qualitative data- FAQs, comments, concerns,
beliefs of participants

30. PRE- AND POST COURSE QUESTIONNAIRE

31. PRE- AND POST COURSE QUESTIONNAIRE

32. TRAINING EXPERIENCE
• 43% of participants indicated that they had
previous IYCF training
• Previous training did not translate to
competence on IYCF principles and on self-
reported quality of IYCF counselling

33. VALUES CLARIFICATIONS

38. Whilst feedback has been both negative and positive, it must be clearly
stated that the overwhelming response was positive and the districts
are supportive of the new guidelines.
Communications and logistics challenges, whilst dominating much of
the feedback, are expected in a project of this size.
Improvements will reduce frustrations and cost. However, participants
and trainers should be commended for rising above the challenges.
Knowledge transference was successful and participants are eager to
implement the new guidelines.

39. Brand identity and user acceptability of tools
• Pocket tool most used
• Flip chart second
• Used by nurses and lay counsellors, with
recommendations for use in community
• Communication strengthens with standardization
of messages – both words and graphics
LESSONS LEARNED

40. • Efficient and rapid scale up of Back to back
training requires logisitics and communication
SOP
– Detail the specific roles and responsibilities of
stakeholders
– Detail a communication flow
• This will minimise disruptions and improve
cost efficiencies
LESSONS LEARNED

41. • Facility management reluctance to release staff
for training: Formulate a strategy for
uninterrupted services during rapid scale up
– LCs offered more than one opportunity to attend
training
• Combine training for Nurses and LCs
LESSONS LEARNED

42. LESSONS LEARNED
• IYCF training standardised and provided to all
HCWs regularly with onsite focussed follow up
• Counsellors may need more training time to build
foundational sciences knowledge
• More time allocated to unpack values on IYCF in
the context of HIV
• IMCI training needed for LCs

43. • AFASS poorly understood –may need to
rethink tools and terminologies
• Multidisciplinary team dynamics and
advantages
• Call for professionalisation of counsellors
• Training props are essential for effective group
health education
• Strong call for rapid community training to
ensure standardisation of messaging
LESSONS LEARNED

44. • Follow up support:
– To reinforce the PMTCT and IYCF policies (ART
during BF)
– To ensure all misinformation is corrected
– Use pre and post questionnaire results to direct
support
– Mentorship and QA tools with clear guidance
LESSONS LEARNED

45. • Cross border alignment of policy
• Labour law regulations to support
breastfeeding mothers
• Integration of training into Education Life
orientation, Department of Social
Development
• Code of Marketting violations – mechanisms
for reporting
• Professionalisation of LCs
ADVOCACY ISSUES ARISING

46. • This is a great opportunity to come alongside
government
• It is one of the most impressive policy changes with the
potential to impact on child mortality
• Ask ourselves:
– How best can we come alongside government?
– How does the Tshwane Declaration fit in with maternity
leave?
– What can our organisations do to maintain the positive
momentum?
– Vital time has passed
– Advocate for well constructed, strong, mass-media
movement
– Bridge the public-private divide
Tshwane Declaration

47. Thank you !Demonstrating the
lying down position
Group work
Practice positioning a baby
at the breast