Exploring strategies for integrating breastfeeding peer supporters in public hospitals in Kenya

Acute malnutrition among infants aged under 6 months is a major public health problem. Recent reports indicate that globally, 8.5 million infants under 6 months suffer from moderate or severe acute malnutrition. Malnourished infants are significantly more likely to be hospitalized and die from treatable infectious diseases than non-malnourished infants. Studies have shown that the majority of these infants (up to 90%) are not exclusively breastfed, even though evidence suggests that exclusive breastfeeding is particularly important for recovery and survival among this group. To improve the nutritional status of hospitalized malnourished infants, the World Health Organization (WHO) recommends the re-establishment of exclusive breastfeeding. However, challenges such as shortages of appropriately trained health workers and lack of information on "how" exclusive breastfeeding can most effectively be re-established have hampered the effective implementation of these recommendations in many low-income settings, including Kenya. In Kenya, as elsewhere in sub-Saharan Africa, breastfeeding lay peer supporters (mothers from the local community trained in breastfeeding assistance) are used to promote and support exclusive breastfeeding among mothers of healthy infants in their communities. We are currently undertaking a study (IBAMI) in a hospital in Kenya investigating the maintenance of exclusive breastfeeding amongst infants recovering from acute malnutrition and infection after they have been discharged from hospital. We have introduced breastfeeding peer supporters in the hospital to help the health workers implement the WHO guidelines. With the support of study staff and funding, peer supporters have become a central part of the inpatient treatment management team undertaking tasks integral to the breastfeeding treatment plan. Our experiences from the IBAMI study suggest that breastfeeding lay peer supporters might be an effective strategy for enhancing the implementation of the WHO guidelines. However, the supportive financial and management conditions provided by the IBAMI study are unlikely to be repeated in resource constrained hospital settings in Kenya and routine implementation would involve introducing a new low skilled, as yet unrecognised cadre into complex, multi-professional hospital environments. To understand when, where and how breastfeeding peer supporters might be integrated into the routine treatment of inpatient malnourished infants, we propose to undertake a pilot study investigating the health system factors that are likely to enhance or constrain the use of breastfeeding peer supporters in the implementation the WHO guidelines for nutrition rehabilitation of inpatient infants under routine conditions in two public hospitals in Kenya.
To gauge policy level interest in the approach, we will identify and engage with key policy makers at national and county levels in Kenya; determine their views on employing lay peer supporters in a hospital setting and discuss potential barriers and facilitators to implementation. To assess the feasibility of using breastfeeding peer supporters, we will collaborate with the Kilifi County Ministry of Health (MoH), to identify two hospitals and in each we will work with the hospital management team, frontline health workers, UNICEF and National MoH to develop and agree on a strategy for the implementation of a breastfeeding peer supporters' intervention. During strategy implementation, quarterly meetings to review progress and identify factors enhancing or constraining the integration process will be held. After 12 months, we will estimate the costs of implementing the strategy and hold review meetings and interviews in each of the two hospital to assess perceptions of its feasibility, acceptability and sustainability. The findings from this study will generate new knowledge to improve the hospital management and treatment of malnourished infants under 6 months.

Globally, 8.5 million infants under 6 months suffer from moderate or severe acute malnutrition. The outcomes for malnourished infants admitted to hospital are particularly poor. WHO guidelines for the nutritional rehabilitation of such infants recommend the re-establishment of exclusive breastfeeding. However, in many low resource settings health system challenges, in particular deficits in human resources for health, impede their effective implementation. In Kenya, an ongoing pilot study exploring the role of relactation in the nutritional recovery of hospitalised malnourished sick infants (IBAMI study) (MRC grant no MR/N021940/1) is using lay peer supporters (PS) to facilitate the implementation of the WHO guidelines. Under the trial conditions (costs born by the study and supervision facilitated by the research team) the PS have been well received within the hospital and their activities are contributing to effective guideline implementation. However, such supportive conditions are unlikely to be repeated in routine settings and breastfeeding PS is not a recognised cadre within the Kenyan hospital system. This descriptive study is designed to explore the health system factors likely to enhance or constrain the use of PS as part of hospital nutrition rehabilitation teams in Kenyan hospitals. We will use stakeholder mapping and analysis to identify key stakeholders involved in infant care policies and practice at national and country levels, and engage them in PS strategy discussion and project planning. A participatory approach will be used to collect empirical data on the development, implementation and assessment of outcomes of a PS breastfeeding strategy in two hospitals in Kilifi, County Kenya. The results will be discussed and reviewed with county and national level stakeholders at an end of project workshop. The outcomes of these discussions will be used to inform potential strategies for integrating breastfeeding PS into inpatient infant care.

The process and outcomes of the proposed research have the potential to benefit several groups in a variety of ways.

International: WHO and Academics
The World Health Organization (WHO) has developed guidelines for the nutritional rehabilitation of hospitalized malnourished infants that focus on the re-establishment of exclusive breastfeeding. These guidelines are rarely fully implemented in low resource settings, often due to human resource (HR) constraints. In collaboration with researchers from the Kemri-Wellcome Trust Research Programme and UNICEF Kenya, hospitals in this study will develop and implement strategies to address HR constrains that incorporate lay breastfeeding peer supporters into hospital nutritional rehabilitation teams. The evidence generated will be shared with WHO to help inform potential strategies for more effective operationalization of the guidelines. The findings will also contribute new knowledge to international health policy and systems research debates on how, when and where lay peer supports might be incorporated into treatment management teams for inpatient infant care and for the management of other conditions.

National and county policy makers and stakeholders
The information generated through this project, on approaches for integrating lay peer supporters into treatment management teams in routine hospital settings, will provide county and national level policy makers in Kenya with evidence to inform discussions on the potential of task shifting in hospitals as a strategy for addressing human resource constraints. In particular, for nutritional rehabilitation management and other areas where the implementation of current treatment guidelines may benefit from formal task shifting such as the management of diabetes, high blood pressure, overweight and obesity, mental health and neurocognitive disorders.

Hospital management and practitioners
In the two hospitals in which the study will take place the hospital management team and health workers will benefits in several ways. Firstly, improved collection and management of records on inpatient infant nutritional rehabilitation will: i) provide evidence on the outcomes of current nutritional rehabilitation practices; and ii) demonstrate how routine data can be used to help identify and improve practice. Secondly, the process of intervention implementation will provide experience of support supervision practices that utilize routine data and involve monitoring and feedback that have the potential to be incorporated more broadly to improve hospital management practices. Thirdly, the study will assist the hospitals in implementing the WHO treatment guidelines for inpatient infant rehabilitation and will provide data on the potential costs. Finally, the experience of integrating lay breastfeeding supporters into hospital nutritional rehabilitation teams will provide the hospital management team with empirical evidence on when and how such a strategy might be employed for the management of other conditions.
Recipients: Infants living in Kenya and the region
During the project the malnourished infants in the study hospitals will benefit directly from the increased emphasis on their nutritional rehabilitation, particularly the re-establishment of breastfeeding. More broadly, the data from this project will be used to provide evidence of strategies to nutritional rehabilitation that will enhance the survival chances of infants admitted to hospital suffering from malnutrition in Kenya and potential more widely in the East Africa region.