An Evaluation of PMTCT and Infant Feeding Training in Seven Provinces of South Africa

This report presents the results of this evaluation of the PMTCT and Infant Feeding Training. The evaluation was carried out in seven provinces, namely Gauteng, Free State, Mpumalanga, North West, Limpopo, Eastern Cape and Northern Cape between July and September 2003.

The evaluation reviewed the training model of the National Department of Health to determine its appropriateness for addressing the provincial training needs in the context of the necessary rapid scaling up of PMTCT services. It also explored the training strategy used in the provinces with regard to aspects of sustainability for future capacity development. The short term impact of the training was assessed to determine whether it responded to the new demands of the PMTCT programme in terms of knowledge, confidence in counselling skills and providing PMTCT care and infant feeding options to pregnant women.

The evaluation methods consisted of structured interviews and self administered questionnaires which were used to collect data from 147 respondents, including Provincial Managers of HIV/AIDS Units or MCWH Units, Provincial PMTCT Coordinators, Course Directors, Trainers and Trained Counsellors (participants).

As of September 2003, there were 50 Course Directors, 109 Trainers and 2 736 Health care providers trained in seven provinces. This is an indication of the dedicated training efforts that have been under way in the provinces. This is a remarkable achievement considering the constraining circumstances under which many Managers and Trainers have had to function. In most provinces, Course Directors have succeeded in continuing training efforts in their provinces under difficult circumstances and often with inadequate logistical and administrative support. These training efforts have resulted in the development of a Core Group of skilled Course Directors and Trainers in each of the seven provinces. The Core Group has been accredited by the National DOH.

The core team of Trainers and Course directors has had a crucial role to play in sustaining the PMTCT and Infant Feeding Training. Results of the evaluation highlight that Trainers need ongoing support from the National DOH in terms of updated information on PMTCT and IF, finalising the training manual and monitoring the quality of training. The knowledge assessment conducted as part of the evaluation showed that, following completion of the five day training course, there was a general improvement in knowledge, confidence in counselling pregnant women, and positive attitudes towards HIV positive pregnant women.

The evaluation questionnaires consisted of 12 knowledge questions. Results of the evaluation showed that the level of knowledge is not adequate for both Counsellors and Trainers. The means and ranges of scores on correct answers varied between provinces from 5 to 10 (out of 12). The mean across all seven provinces is 5.6 (out of 12) for participants and 7.6 for Trainers. Knowledge of the risks associated with different feeding options was also assessed, and the question was poorly answered. Most health care providers overestimated the risk of HIV transmission through breastfeeding and were unaware of the health risks associated with formula feeding. Correct knowledge of the risks of MTCT at different time points (during pregnancy, delivery and breastfeeding) and the risks of different options of infant feeding, is vital to ensuring that accurate information is given to mothers for safe and appropriate infant feeding choices.

The evaluation also showed that the five day PMTCT and Infant Feeding Training Course is adequate to address the core competencies of providers working in maternal and child health services. There is, however, room to improve the quality of the training. The manual needs to be more user friendly with a system for providing on-going updated information and relevant audio-visual aids for clinical cases, such as a video on exclusive breast feeding and common breast conditions. In addition, the topic of safe requirements for formula feeding/cup feeding, could be added to improve the effectiveness of the training. The assessment of the training model is based on the researchers observations of the five day training in different provinces and interviews with Provincial Managers, PMTCT Coordinators, Course Directors and Trainers. Our recommendations are that this model needs to be strengthened in order to enable rapid training of health care providers to accommodate the scaling up of the PMTCT programme. Furthermore, targets should be set for training initiatives, based on provincial needs. There is also a need for greater administrative support to improve the communication and effectiveness of training. Due to the significant problems which Trainers experience in being released from their clinical duties to facilitate training courses, we would strongly recommend that provinces make provision for a Core Team of dedicated Trainers to ensure the sustainability of these efforts. Ongoing evaluation of this initiative is needed for planning and quality assurance purposes.