Infant Feeding Research Project (IFRP)

IFRP is fundamentally oriented around the use of research to explore and improve the relationship between a woman and a counsellor - an intensive form of one-on-one communication which can shape attitudes and behaviour with regard to both children's health and women's identities. A fundamental principle behind this process is that research participants are "the custodians of their own transformation while the researchers have the responsibility to guide the change processes implied in the research participants' desires for bettering their situations."

To begin, IFRP carried out an exploratory, ethnographic research phase which focused primarily on pregnant women and mothers with infants of up to one year old, in 11 sites: 8 in South Africa, 1 in Swaziland, and 2 in Namibia. The purpose was to explore infant feeding practices in communities most at risk through poverty and HIV in the context of customs, thoughts, tradition and the emotions they evoke, the circumstances that influence them, and the counselling strategies that might affect them. Overall, the study revealed that mothers' and counsellors' understandings of the encounter differed so greatly in terms of perceived purpose, benefits, risks, and nutritional logic that it caused a rift in the communication. Researchers found that, in order to achieve success - which, for the health service, is framed as persuading mothers to test for HIV, and to disclose the result - counsellors often felt compelled to be prescriptive and authoritative, reverting at times to confronting, judging, and shaming mothers. Many encounters were found to be confrontational, thereby de-motivating the mothers and frustrating the counsellors. (Click here for more information in the article "Demotivating infant feeding counselling encounters in southern Africa: Do counsellors need more or different training?" published in AIDS Care, Volume 20, Issue 3, March 2008, pps. 337-345.) Yet, researchers find, in order to adhere to their feeding choice consistently, mothers need to be motivated towards the significant behaviour change that disclosure implies: to change their traditional roles and identities, as women. (Click here for more information in the article "Infant feeding practices: Realities and mind sets of mothers in southern Africa," published in AIDS Care, Volume 19, Issue 9, October 2007, pps. 1101-1109.)

In response to these findings, from 2005-2006 IFRP conducted action research focused on training and supporting the counsellors in 4 sites in the same 3 countries. Phase 2 was designed to focus on the positive potential of the woman and counsellor relationship to motivate clients that need to make risky or difficult changes (transforming lifestyle, identity, or entrenched behaviours), while developing a model that was more coherent with women's need for professional guidance. This phase involved testing alternative methodologies and approaches, including:

• Brief Motivational Interviewing (BMI), a form of counselling developed to motivate clients to own and transform their own behaviour. Whereas typical counselling might leap straight to advice giving, exploring options, and problem-solving, BMI is more focused on facilitating change in a mother's own life through an attitude of compassionate detachment and respect for the client's choice, and a belief that the client has the capacity and motivation for change but may need guidance to reveal or manifest these. Training carried out as part of this approach involved helping counsellors foster a climate of collaboration, dialogue, and respect during the encounter, as well as to respect healthy and appropriate boundary management and maintain healthy levels of self-care. (That is, the goal is to ensure that counsellors do not define the value of their own efforts and thus their self-worth on the basis of the women's adherence to the prevention of MTCT (PMTCT) message - and they do not judge the woman's value on the same basis, either).
• Women-Centeredness (WC) is an approach of self-awareness, self-regard, and mutual respect designed to counter the internalised female sexism found amongst both mothers and counsellors in the first phase of this research. That is, interventions and research actions recognise women within their own context (a patriarchical one), and thus are designed to not contribute to the underlying problem of women not perceiving themselves as able to "save their babies". (Researchers claim that many traditional "gender-informed" or "gender-sensitive" interventions inadvertently cast women in a position of victim, which diminishes their self-efficacy). The idea is that internalised sexism within both mother and counsellor, and also within their relationship, can undermine the encounter at a subconscious level - IFRP recognises this dynamic and aims to shift it. IFRP also works to ensure that messages such as those ones pertaining to practical ways of exclusive breast feeding are both grounded in evidence and practically appropriate to the local conditions.
• Appreciative Inquiry (AI) is a form of action research that recognises that inquiry (research) and change (action) often happen in the same moment: the question is itself an intervention for change. Traditionally, the researchers explain, research questions are critical and analytical, focusing on the problems, gaps, and deficiencies in a situation. AI reframes the inquiry to focus on the successes, support, capacity, and potential to envision a new reality. Drawing on this model, after initial trainings researchers facilitated the counsellor's learning within AI groups at each site, while they themselves were learning to be trainers of counsellors in these approaches. The main purpose of this methodology is to understand the processes of (behaviour) change involved for mothers (and their families and communities), counsellors (and their colleagues and supervisors), and counsellor-trainers (the action researchers).
• Outcome Mapping (OM) focuses on how programmes facilitate change rather than how they control or cause change - This process involves other potential partner individuals and institutions as equals, and monitors change by "mapping" the mutual influence each partner has on the behaviour, relationships, activities, or actions of the "boundary" partners closest to it.

In Phase 3, IFRP plans to extend the research as well as deepen the understanding of the role female gender dynamics are playing in HIV/AIDS counselling.

HIV/AIDS, Children, Nutrition, Women, Gender.

The researchers explain that, in Southern Africa, HIV rates among mothers varies between 15% and 40%, and that gains in preventing MTCT before birth are commonly reversed by transmission after birth. While exclusive-feeding and anti-retroviral (ARV) treatment both hold great promise, findings from the first phase of the research indicated that mixed-feeding remains standard practice despite programmes to prevent MTCT. This practice of adding water, solids, formula, and/or herbal treatment to breastmilk carries the highest risk of HIV transmission in low-resource settings. The IFRP second phase piloted action research to reflect on counsellor-mother communication so as to better motivate clients towards exclusive rather than mixed infant feeding. (See the Related Summary, below.)