Evaluating Nurses' Implementation of an Infant-Feeding Counseling Protocol for HIV-Infected Mothers: The Ban Study in Lilongwe, Malawi

Up to 42% of all HIV infected children less than two years of age contract the virus during the breastfeeding period (Breastfeeing and HIV Transmission Study Group, 2004). Among sub-Saharan Africa communities, the infant feeding information and advice nurses communicate influence mothers’ infant feeding practices (Seidel, Sewpaul, & Dano, 2000; Semega-Janneh, Bohler, Holm, Matheson, & Holmboe-Ottesen, 2001; Piwoz, Iliff, et al., 2005). International guidelines recommend that HIV-infected mothers exclusively breastfeed during an infant’s first 6 months of life and stop breastfeeding once replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS) (World Health Organization [WHO], 2001, 2006). When replacement feeding is AFASS, avoidance of all breastfeeding by HIV-infected mothers is recommended (WHO, 2001, 2006). Furthermore, guidelines recommend that mothers receive counseling about the risks and benefits of their infant-feeding options, as well as guidance and support in their infant feeding decisions (WHO, 2001, 2006). In accordance with the WHO (2001) guidance on infant feeding and formative research results focusing on infant feeding knowledge, attitudes, and behaviors in Malawi (Bentley et al., 2005; Corneli et al., 2007; Piwoz & Bentley, 2005), we developed an infant-feeding counseling protocol for nurses to implement as part of the Breastfeeding, Antiretroviral and Nutrition (BAN) Study. The BAN Study is an open-label clinical trial evaluating the safety and efficacy of antiretroviral and nutrition interventions to reduce maternal morbidity and MTCT among breastfeeding mothers in Lilongwe, Malawi (Galliard et al., 2004; van der Horst et al., 2009). The three main objectives of the BAN Study are to evaluate: (a) the benefit of nutritional supplementation given to women during breastfeeding; (b) the benefit and safety of antiretroviral medications given either to infants or to their mothers to prevent HIV transmission during breastfeeding; and (c) the feasibility of mothers exclusively breastfeeding their infant for 6 months, followed by early, rapid breastfeeding cessation (Bentley et al., 2005; Corneli et al., 2007). Although infant feeding cultural norms in Malawi include prolonged breastfeeding up to 2 years and a median duration of exclusive breastfeeding of 2 months (National Statistical Office [Malawi] & ORC Macro, 2005), our formative research results suggested that HIV-infected mothers would adhere to the BAN Study infant-feeding recommendations if nurses explained why and how these practices would decrease the risk of mortality and HIV transmission to their infant (Piwoz et al., 2006). Evidence from a Zambian study, concluding that infant-feeding counseling by trained nurses was associated with mothers exclusively breastfeeding for more than 2 months, support our formative findings (Piwoz et al., 2005). In the context of prevention of mother-to-child transmission (PMTCT) clinical trials, with a nurse-delivered behavioral intervention component, nurses’ implementation of the intervention is often not evaluated. Researchers agree that evaluating the process by which an intervention is implemented helps to inform study impact and outcome results (Corbett, Thompson, White, & Taylor, 1991; Dehar, Casswell, & Duignan, 1993; Israel et al., 1995; Linnan & Steckler, 2002; McGraw et al., 1994) and avoid intervention implementation failure (Basch, Sliepcevich, Gold, Duncan, & Kolbe, 1985). Knowing the content of infant-feeding information and quality of infant-feeding counseling nurses communicate to HIV-infected mothers is important in PMTCT of HIV during the postnatal period. We conducted a study to assess trained nurses’ implementation adherence to an infant-feeding counseling protocol within the context of a PMTCT clinical trial in Lilongwe, Malawi.