Africa Regional BCC Advisor, LINKAGES Project (at the time of writing)

Presented at the Global Health Council's 33rd Annual International Conference on Global Health (May 30-June 2 2006, Washington, DC, United States), this 25-page evaluation report explores the experiences of The LINKAGES Project, a worldwide initiative dedicated to improving infant and early child feeding. Managed by the Academy for Educational Development (AED) and funded by the Bureau for Global Health of the United States Agency for International Development (USAID), LINKAGES was a 10-year project (1996-2006) that sought to: demonstrate that exclusive breastfeeding is an achievable goal, improve breastfeeding practices in a wide geographic area in several countries, and document what works at the community level.

This presentation examines LINKAGES' experience with counselling tools on HIV and infant feeding in four countries. The communication activities explored here - including training of health providers, community interventions, and the development of behaviour change communication (BCC) and counselling materials - were developed in response to the observation that infant feeding counselling is often the weakest component of prevention of mother-to-child transmission (PMTCT) programmes. (For example, there is a shortage of appropriate materials, and clients who do receive them do not read them and, thus, do not pass on messages to others or encourage action in the community). However, the conviction that HIV transmission can in fact be reduced through informed decision-making on optimal infant feeding led the LINKAGES Program to develop and disseminate HIV and infant feeding counselling materials for PMTCT programmes in Zambia, Ethiopia, and Haiti in an effort to improve the quality of the interactions. LINKAGES also collaborated with the University Research Co., LLC (URC) to disseminate URC's infant feeding counselling tools in Tanzania, where LINKAGES is testing an integrated PMTCT strategy.

As detailed here, the package of counselling tools varied by country.

1. In Zambia, LINKAGES created a maternal and child health (MCH) message booklet that contained messages on feeding options for HIV-positive women. This booklet was used by clinic health workers, community health workers, and mothers.
2. The Tanzania tools, developed originally by URC, consisted of a question-and-answer guide for health workers and brochures on different feeding options for HIV-positive mothers. The key strategy behind the Tanzania tools was to integrate and standardise messages across agencies and services in a user-friendly book that could serve as a long-term information resource in clinic, family, and community settings - hopefully thereby strengthening linkages between facility- and community-based services and ensuring message consistency.
   
   • These tools were adapted for use in Haiti by LINKAGES, which modified the content, created Haitian versions of the illustrations, and translated the text into Creole.
3. In Ethiopia, LINKAGES developed a flipchart for health workers, as well as clinic posters, to remind them of infant feeding counselling steps. All of the packages addressed critical needs for information about the risk of HIV transmission through breastfeeding and infant feeding options for HIV-positive mothers. The Ethiopia flipchart also contained a simple decision tree to help counsellors determine if replacement feeding was acceptable, feasible, affordable, sustainable, and safe for mothers who chose that option (The final choice is left to the mother).
• LINKAGES adapted it for use in the Haiti tools.

Following a detailing of the materials themselves, the presentation outlines how they have been used in the clinic setting. In brief, mothers who have received the booklet at antenatal care (ANC) and well child clinics are asked to bring the booklet back with them every time they return for a visit. Health workers/counsellors then select topics from the book and use it for teaching, using the relevant page(s) to educate and counsel mothers on the service(s) she and/or her baby are receiving or being asked to consider. The counsellor is also trained to point out other portions of the book, and to encourage the mother to use it to stimulate discussions at home and among friends. Ideas for using the BCC tools in homes and in the community are also presented here.

The authors explain here that LINKAGES gathered anecdotal evidence of lessons learned during the adaptation, development, and roll-out of the tools. For example, they learned that the adaptation of Tanzanian tools for Haiti was easily accomplished through minor changes to the content and the illustrations. Because the Zambia material contained broader MCH messages as well as HIV and infant feeding messages, more time was required to solicit input from various key players. This resulted in a longer development phase, but the booklet was advantageous in its applicability to a broad array of MCH interventions. LINKAGES has also learned that formal orientations for health workers on how to use tools are critical in order for them to be used well.


Here are a few specific lessons learned:

• Most clients tended to retain the booklet because it is "nicely packaged" and health workers ask to see it.
• Pictures and simple language have increased understanding of topics.
• The booklet has served as a reference resource and a reminder tool for clients (e.g., after reading, clients have come to the clinic to seek more information and/or to remind workers about the services they should be receiving).
• Health workers report that the booklet has made their work easier in many ways, such as by reminding them of what messages they should be communicating during counselling sessions.
• Adaptation of these materials from one country to another can be a long, involved process.
• There is a need for more systematic evaluation of the tools' impact on mother and provider behaviour.

In conclusion, based on LINKAGES experience, the authors assert that infant feeding counselling can be strengthened through different counselling tool packages, and that these tools can be successfully adapted either wholly or in part for use in other countries.

Please note: The LINKAGES Project ended December 2006. For information on AED's ongoing nutrition activities, click here or contact nutrition@aed.org