THEORETICAL BASIS FOR THE FEASIBILITY STUDY

In Malawi, stunting, wasting, and underweight are manifestations of a multi- sectoral problem developing from 3 different levels of causal factors: Immediate causes of malnutrition are inadequate dietary intake and infectious disease; Underlying causes include household food security, inadequate maternal and child care, early introduction of complementary foods, poor food preparation and hygiene, inadequate health services, inappropriate care of child illness, and a poor health environment; Basic causes include political, economic, cultural and social systems (ie. women’s status), and potential resources (Engle, 2000; Pollitt et al., 1993; Pollitt et al., 1995). The conceptual framework below, Fig 4.1, was adapted from the UNICEF 1990 model to explain the determinants of child nutritional status among our study population.

The social ecological framework is often used by public health researchers as a tool for understanding the determinants of health behaviors. This framework was

originally developed from Bronfenbrenner’s work on the ecology of human development proposing child development is guided and supported by the system of relationships (ie. layers of the environment) that provide constant interaction (Bronfenbrenner, 1977). The social ecological model recognizes human environments are multi-dimensional, resulting

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from the complex interplay between individual, interpersonal, institutional, community, and social policy factors.

While the UNICEF 1990 conceptual framework clearly illustrates the spectrum of problems contributing to malnutrition, it is our aim to investigate the immediate and underlying causal factors of undernutrition as they are perceived by caregivers. The ability and willingness of BAN Study mothers to comply with the HIV infant feeding guidelines is likely influenced by maternal attitudes and beliefs surrounding the guidelines; knowledge of infant feeding and care practices; interpersonal relationships and decision-making patterns; the attitudes and counseling messages of BAN health workers; infant feeding norms practiced in the community; HIV stigma in the community; and food security.

To investigate the determinants of infant feeding and care practices among BAN Study mothers we developed a conceptual model to illustrate the factors influencing a mother’s decision and ability to provide a replacement diet for their infant (Fig 4.2). The multiple levels of the socio-ecological framework are contextualized below to the

Malawian context.

Maternal knowledge, attitudes, beliefs, and intentions

Knowledge and understanding of MTCT is likely to influence maternal attitudes and motivation regarding the HIV and infant feeding guidelines. A small qualitative study conducted among low-income mothers in Lilongwe found mothers were willing to

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take the necessary steps to prevent their child from becoming infected (Piwoz et al., 2006). Attitudes and beliefs are therefore likely to influence initiation and adherence to the guidelines. In Zimbabwe, the ZVITAMBO intervention educated mothers infected with HIV (and those with unknown status) to practice exclusive breastfeeding with their infant. This knowledge and counseling effort alone increased the rate of EBF by 8.4 times (Piwoz et al., 2005). Equipped with knowledge, HIV-infected mothers are likely to adopt preventative behaviors unless it puts them at risk of domestic abuse, abandonment, or ridicule by their surrounding community.

Acceptance of LNS

Formative data found BAN Study mothers were highly accepting (88% of

mothers) of LNS; mothers requested additional LNS before the end of the month (Corneli et al., 2007). Non-formula weaning foods are uncommon in African settings and have never been used as a daily complementary food for infants 6-12 months. Among women who choose not to disclose their HIV status, LNS use within the home or marketplace may equate with disclosure. Ethnographic research conducted among BAN-exited mothers will retrospectively probe mothers for factors influencing their acceptance of LNS. Potential determinants of LNS use include infant care experience, maternal age, maternal education, food security, number of household members, HIV-status disclosure, and infant health. This study aims to understand the determinants and cultural

perceptions of LNS-use in order to successfully promote exclusive replacement diets in the future.

43 Fear and patterns of decision-making

Women’s willingness to follow the HIV and infant feeding guidelines is likely to be influenced by her disclosure status. Women fear HIV disclosure will result in

domestic violence and abandonment (Tembo, 2006). If atypical infant feeding patterns are indicative of HIV status, women will be reluctant to follow the guidelines. However, women in long term relationships (>2yrs) were more likely to disclose their HIV status to their partner than women in shorter term relationships (Medley et al., 2004). The quality of marital relations may influence the acceptance and ability of the mother to follow the WHO guidelines.

Institutional factors

Piwoz et al. (2006) explored health workers (N=19) attitudes toward WHO guidelines and found only 11 of 19 thought mothers could feasibly follow the

recommendations. The cultural norm of early complementary feeding (<4 months) was listed as a major barrier to adherence and most expressed concerns that early cessation would lead to malnutrition. The attitudes and counseling messages delivered by BAN health workers are likely to have influenced the infant feeding decisions of BAN participants (Piwoz et al., 2006).

HIV stigma and infant feeding norms

Strict adherence to the HIV and infant feeding guidelines over traditional practice, is likely to carry substantial stigma and identify mothers as infected to their community

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(Abiona et al., 2006). Women in Nigeria agreed the perceived stigma associated with not breastfeeding was a determining factor in feeding an exclusive replacement diet and that only certain foods were culturally acceptable (ie. infant formula, cow’s milk, soy milk) (Abiona et al., 2006). Previous support group meetings held with BAN participants identified fear of abandonment, spousal violence, stigma, and discrimination as

impediments to accessing HIV-care and status disclosure, potentially hindering adherence to non-normative feeding practices (Tembo, 2006).

Community factors

Malawian culture is largely rooted in Christian and Muslim values which promote purity and form the basis of societal intolerance towards sexually transmitted infections. Of all the sub-Saharan countries affected by the HIV/AIDS epidemic, Uganda was the first nation to successfully confront the epidemic and dramatically reduce their

prevalence from 15% in the early 1990’s to 6.5% by 2004 (www.usaid.gov). This nation used a successful combination of ABC strategies which rose above cultural religious values to educate the people and cultivate open discussions while promoting 1) Abstinence; 2) Being faithful (reducing number of partners); and 3) Correct and consistent condom use (www.usaid.gov) (Low-Beer D, 2003; Stoneburner R, 2004). Increasing the public’s knowledge of HIV helps to create a more accepting society in which people will be more likely to participate in PMTCT interventions (Eide et al., 2006). In recent years, the Malawian government declared 1 week in July as “National HIV Testing and Counseling Week” (Malawi National AIDS Commission, 2004). The

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number of people choosing to be tested has exponentially increased over the past 3 years indicating the nation is becoming more aware of the disease.

Environmental factors

In Malawi, maize accounts for 70-80% of daily energy intake but among non- farming urban families the cost of food can be prohibitive (www.projectpeanutbutter.org; Conroy et al., 2006). The rains primarily dictate national maize production, in turn affecting market prices and food accessibility. Maize prices are lowest following the harvest and rise as reserves are depleted, reaching their peak price in February ‘the hungriest month’ (Conroy et al., 2006; FEWSNET/WFP, 2005). Seasonality is a predictor of food availability and accessibility and therefore household food security (Quinn et al., 1990).

Feasibility factors

The practicality of replacement feeding among low-income populations in resource poor settings is reduced by barriers such as the high cost of feeds, the need for cooking fuel, unreliable power supply, and poor access to both clean water and adequate storage facilities (Abiona et al., 2006). The cost and complexity of preparation were listed as deterrents for using replacement foods in Tanzania (Burke, 2004). Recent ethnographic research in South Africa and Cote d’Ivoire identified 1) the social stigma of HIV, 2) maternal age and family influences, and 3) economic circumstances (ie. food security) as socio-cultural determinants of maternal compliance to the HIV and infant feeding guidelines (Becquet et al., 2005; Thairu et al., 2005). Mothers returning to the

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work force after delivery spend most of the day far from the child. Mothers working as domestic help or independently (ie. local market) may be more likely to practice EBF if they can keep the child with them. A small qualitative study conducted in Lilongwe, Malawi found mothers without work were more likely to practice EBF than working mothers (Piwoz et al., 2006). Most BAN Study mothers are unemployed making EBF to 6 months more feasible (Tembo, 2006).

Specific Research Aims

Aim 1: Conduct a quantitative dietary analysis of 400 non-breastfeeding infants,