Category: Resourceful Young Children | Test population-based models of provision | 26 August, 2012 - 13:24← BACK
South Africa is far from reaching the Millenium Development Goals 4 and 5 despite the country’s commitment to make every effort to decrease maternal and child morbidity and mortality. Philani has developed a home based maternal, child health and nutrition model in an effort to work with the South African government in reaching these goals. The model has been shown to be effective in an urban setting (ref 1,2,3,4) and the Philani Mentor Mother (MM) programme in the Eastern Cape has been initiated to test its effectiveness in isolated rural areas.
Philani’s target groups are pregnant women and children 0-6 years old and their families. The programme aims to identify every malnourished child and pregnant women in the target community and it moves health, nutrition, protection and care beyond clinics and institutions into the community, making it home based. The philosophy behind this programme is one of finding and building on knowledge and experience present in the community, recognising and developing women’s resources and facilitating women’s support of each other to protect their own health and the healthy mental and physical development of their children.
The Mentor Mother programme is based on two international child health models: the “Positive Deviant Model” implemented in Vietnam by J. Sternin and the “Nurse Home Visiting Programme” in the US extensively documented and evaluated by David Olds. “Positive Deviant” mothers who themselves have raised healthy children, despite their own limited circumstances are trained to be Mentor Mothers in the Philani programme and fulfil the same role as the nurse home visitors in David Olds’ model, which has had a remarkably positive effect on maternal and child health in poor communities in the US as well as on child health policy in that country.
In the context of four critical factors in the implementation of the Philani Mentor Mother programme, namely community, recruitment, training, and supervision, this learning brief explores issues that have helped and hindered the rural outreach, notes some differences between our urban and rural experience and comments on lessons learned.
Eastern Cape: Zithulele and Coffee Bay
Zithulele is the site of a former mission hospital, some 350 km from East London, in the remote Mqanduli sub district of the O R Tambo district, acknowledged to be one of the poorest areas of South Africa. This is the site of the first Philani Mentor Mother programme, initiated in 2010 and now working with 22 Mentor Mothers implementing the programme in as many communities in the district. Although homesteads often provide better housing than township shacks, and some subsistence farming is possible, there are significant challenges - water must be carried from nearby rivers and dams, electricity is mostly not available, roads are poor, distances great and transport to hospital, clinics and other basic services unaffordable for many.
Social problems are rife - a high portion of the male population in rural Transkei goes to work in the mines to bring in more money for their families. This along with the impact of HIV has decreased the number of family members able to do any manual work in the homesteads. It is not uncommon to find young children heading households, not attending school and looking after younger siblings.
In late 2011 20 women were recruited from remote communities around Coffee Bay for an expansion of the Philani Mentor Mother programme to these areas.The training of the recruited women by a Cape Town team started in middle February and a project manager, a coordinator and two assistant coordinators have been employed to run this extension.
The introduction of the Mentor Mother programme to the Zithulele and Coffee Bay communities was done through consultation with the headmen and local community structures. Staff had initial meetings with the various headmen explaining who they were and what they would like to do. They had community meetings and information leaflets were given out about the Mentor Mother positions with guidelines of the criteria for selection. The headmen then sent the staff a list of women to interview.The careful consultation process has been essential to the successful implementation of the Mentor Mother programme in Zithulele.
This experience proved to be less political in the rural areas compared to the urban setting. The programme has been enthusiastically received and the Mentor Mothers are accepted and respected by their communities. Another essential ingredient to working successfully in the Zithulele community has been the support of the programme by the hospital and surrounding clinics. The acceptance that Philani Mentor Mothers have received from the hospital has been inclusive and natural, compared with urban health facilities where liaison is sometimes hard-won.
Where Philani has been less successful despite many attempts is in liason and communication with the Provincial Department of Health to establish a memorandum of understanding.
Insofar as geographic location is a community factor, it has proved to be an issue that cannot be under-estimated. The distances between towns, villages and homesteads, coupled with bad roads are daily challenges. Simple tasks such as drawing petty cash for transport and driving 75km just to fill the car up with pertrol takes half a day. Everything takes twice as long and demands much patience. Service in these areas is poor and trying to refer patients to other departments such as social workers is time consuming and often with no beneficial outcome.It takes time to travel to distant clients - an assistant sometimes have to wait 30min-1hr for transport to or back home after a day with a Mentor Mother. The bad roads have played havoc with vehicles, changed estimates of the number of home visits that can be done in a day , of transport budgets , of training schedules and uniform provision and also impacts significantly on building construction too.
In Zithulele and Coffee Bay, the Mentor Mother candidates were proposed by the headman during the consultation process, according to various criteria of postive deviant, maturity, respectability, commitment to the community and basic literacy.
After being interviewed by a senior staff member, the candidates go through initial training and are only finally accepted onto the staff after completing the training and passing a competency test. The trainers have had a chance to observe the candidates, and assess their level of commitment.
The training and final recruitment are undertaken by experienced field and supervisory staff seconded from Cape Town. The latter provide mother-tongue instruction, based on years of experience, and they can accurately convey the vision of the intervention, the values of the project, its working routines and core activities.
The success of the programme is dependent on the commitment and knowledge of the Mentor Mothers. They must be equipped with up to date knowledge especially in the rapidly changing areas of HIV and TB treatment.
The core training blocks include:
Training is classroom based, with presentations and role plays over a three week period, done by a professional Xhosa speaking nurse and a programme coordinator from the Cape Town programme. A more ideal way to train would be to have one week of classroom training followed by one week of field exposure, better integrating the theory and practice as done in Cape Town. This would however require Cape Town based staff to be away from home for lengthy periods.
The initial training of three weeks is followed up throughout the year with additional input from the project manager and coordinator on topics such as new protocols for breastfeeding, HIV, PMTCT etc.
The importance of a respectful attitude and willingness to listen to mothers/caretakers is stressed in the training, creating good relationships where a positive change of behaviour is possible. The importance of not attempting to solve the family’s many social problems but supporting them in finding their own solution is continuously stressed.
In both the rural and urban context the availability of supervision and support is a key ingredient to quality intervention, essential to maintain motivation and commitment.
The current staff ratio in the programme is 10-12 Mentor Mothers to 1 assistant co-ordinator, who is usually a more experienced Mentor Mother who has come through the ranks, and shown leadership. The support received from the assistants is essential; the Mentor Mothers are often faced with traumatic cases, and situations of poverty or abuse that are not readily resolved. Their emotional burden is better managed when shared in a supportive context.
With the Mentor Mothers as role models it is hoped that this programme will empower the rural women in their quest for better services, and for improved access to facilities such as Home Affairs Department and welfare offices.
1.Ingrid le Roux et al, Home visits by neighbourhood Mentor Mothers provide timely recovery from childhood malnutrition in South Africa: results from a randomised controlled trial. Nutrition Journal 2010. 9:562.
2. Ingrid le Roux et al, A randomized controlled trial of home visits by neighbourhood mentor mothers to improve children’s nutrition in South Africa. Vulnerable Children and Youth Studies 2011. 6:2, 91 - 102
3. Mary Jane Rotheram-Borus & Ingrid M. le Roux et al, Philani Plus (+): A Mentor Mother Community Health Worker Home Visiting Program to Improve Maternal and Infants’ Outcomes. Prev Sci (2011) 12:372–388 DOI 10.1007/s11121-011-0238-1
4. Ingrid le Roux et al, Professional Home Visiting to Improve Pregnant Mother and Infant Outcomes in South Africa.2012. Out on review for publication
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