Evaluating the role that Care Groups play in providing breastfeeding and infant feeding support at community level: a qualitative study in Dedza district in Malawi

Aims and objectives

Our research project, focusing on Malawi’s health and nutrition policy implementation regarding exclusive breastfeeding and infant feeding support at community level, was guided by the following aims and objectives:

Aim: Evaluating the role that Care Groups play within Malawi’s breastfeeding and infant feeding support provision at community level.

Study location

The Care Group interventions that were the focus of this study were implemented by an international NGO that had been actively implementing the SUN programme in Dedza District since 2012. Dedza District is located in the Central Region of Malawi. Poverty remains widespread in Malawi, where 61.7% of the population was reported to be multi-dimensionally poor, according to a 2021 research report (NSO et al., 2021). 20% of the country’s population live in extreme poverty, defined as an inability to satisfy basic food needs, while 70.3% live below the international poverty line of $1.90 a day (World Bank, 2020). Food insecurity is high, and a significant portion of Malawi’s population require food assistance annually, with malnutrition remaining a challenge nationally as a major contributor to preventable child deaths in Malawi (UNICEF, 2019). Dedza District has higher than the average mortality rates for the Central Region with a neo-natal mortality rate of 33 deaths per 1,000 live births and an infant mortality rate of 53 deaths per 1,000 live births, compared to national rates of 19 and 29. In Dedza, 18% of children are born with a low birth weight (below 2.5kg), compared with national average of 12.3% (NSO & ICF, 2017).

Ethical statement

Ethical approval for this research was obtained from Dublin City University Research Ethics Committee on the 11th January 2021 (approval reference: DCUREC/2020/268) and from the College of Medicine Research Ethics Committee (COMREC) on the 4th of February 2021 (approval reference: P.02/21/3266). During the application for ethical approval, the researchers were directed by COMREC to pay each interviewee the equivalent of US$10 in Malawi Kwacha in cash (Nyangulu et al., 2019), with which we complied. Written informed consent was obtained from all interviewees.

Study design

For the field research, we used a qualitative approach, to enable us to understand the meaning that our research participants attribute to their experiences and circumstances (Fossey et al., 2002; Hesse-Biber & Leavy, 2010). Using focus group discussions was ruled out to reduce the risk of COVID-19 and associated restrictions in place at the time of data collection. Therefore only one-to-one interviews were conducted. The research focused primarily on mothers with children under two, who were likely to have recently received breastfeeding and infant feeding support. A total of 36 mothers with children under two were interviewed. Among them were eight women who had a premature or low-birth-weight baby (weighing less than 2500 grams at birth), these women were assumed to have received extra attention after they brought their babies home.

To examine the role that healthcare providers, community leaders and district health officials’ play in supporting and integrating Care Groups into the communities, we interviewed village headmen (n=6), HSAs (n=5) and a number of district- level health officials (n=3), as well as an NGO representative. A total of nine Care Group leaders active in the community were also interviewed.

We made efforts to identify Care Group interventions that were established without the support of an international NGO or donor-funded intervention but were unable to find any that we could include in our research. A report commissioned by the Department of Nutrition, HIV and AIDS conducted at the time of our research, demonstrated that very few Care Groups have been started without external support in Malawi (GoM, DNHA, 2021), despite the national guidelines, which set out how this can be done.

Sampling and data collection

Standard operational procedures were developed for the researchers to guide convenience sampling. The research team were to arrive at a study site, find and interview the Village Headman, ask to be introduced to a HSA, interview the HSA, and then ask the HSA to bring them to houses of women who had a child under two years of age. The number of women who fitted the research participant criteria and were willing to be interviewed at each location, determined the total number of interviews conducted. The HSAs were also interviewed, as were any Care Group volunteer staff.

The interviewees at district-level were identified by the District Medical Officer, to whom the research team first reported to introduce themselves at the start of the data gathering visit in Dedza District.

Each of the women was interviewed using semi-structured interview guides, which were prepared in English and then translated into Chichewa by the researchers who conducted the interviews. The guides were developed from our aims and objectives and drew on a realist synthesis of Care Group literature (Pieterse et al., 2021)²⁷. The original interview guides were shortened, and some language was simplified after two members of the research team (MC and JM) used them to interview five women with children under two, in two villages close to Blantyre. The interview guides in English and Chichewa can be accessed via the open access data repository established for this research: https://osf.io/d4w2q/?view_only=6753e5c8bbdf4491b41031b4d345303b

All data were collected by three members of our research team (EC, MC and CM), who were joined by two additional research assistants (JM and JC). All five researchers were Malawian and used Chichewa to conduct the interviews, using the Chichewa version of the interview guides. Interviews were audio recorded and later transcribed and translated into English. The audio recordings were deleted after transcription. The translations were conducted by all Malawian research team members, who double checked each other’s translations against the Chichewa transcriptions. Table 1 shows how the research team endeavoured to preserve trustworthiness in qualitative data throughout the study.

Data analysis

Two researchers (PP and JM) coded all data using qualitative data analysis software Nvivo version 12 (https://lumivero.com/products/nvivo/) ensuring that 15% of the interviews were coded by a second person (any member of the research team) during the first round of inductive, open coding. A freely accessible software package, Taguette (https://www.taguette.org/), could also be used to run the same analysis.

We used Braun and Clarke’s (2006, 2021) approach to thematic analysis to guide our multiple rounds of coding: The manuscripts were read several times to familiarise ourselves with the content. The first round of coding was done inductively, where all interesting and relevant sections of text were coded openly, without any guidance, codebook or preconceived structure. The generated codes were then loosely grouped.

The second round of coding focused on the development of themes, based on the open codes generated in the first round of coding. Team discussions took place to agree on the formation of themes. Further coding took place to explore differences in the characteristics or themes across the different interventions or across variations in context (Bazeley, 2009). The codes were then agreed upon by the research team and named and ordered into several clusters of related findings.

The codebooks are available in the open access data repository established for this research. Table 2 shows the key themes identified using the described rounds of coding.

Sources of breastfeeding support

All 36 women who were interviewed reported delivering their baby at a health facility. On the question regarding where, or from whom, women received breastfeeding support (excluding support from family and friends), all women reported receiving some support at the facility where the baby was born. ‘Support’ was often no more than an instruction from somebody at the health facility that a mother should breastfeed her newborn infant; this was interpreted as support: “At that time, they the nurses said the baby was hungry and needed to feed; she also said that the baby was cold so I needed to warm her.” [04MCA].

Only eight out of 36 women with children under two, reported receiving breastfeeding support from Care Groups (CG). Those who received CG support reported anything from having been encouraged to breastfeed exclusively during a group meeting, to home visits whereby CG volunteers engaged with a mother and her newborn baby on a one-to-one basis “They [CG volunteers] had books; the books had pictures which they could show us and there were some explanations below to tell us what we can do with our babies when breastfeeding.” When asked how often they visited, the same interviewee responded: “Since my baby was born, they visited me twice. They first visited me when the baby had just born to advise me on how I can exclusively breastfeed my baby until she reached 6 months.” [03MCA].

Two-thirds of all women interviewed noted that they had been advised to exclusively breastfeed (EBF) their baby for the first six months during the health talks provided while they attended ante-natal care check-ups. One interviewee mentioned that frequent breastfeeding was advised: “[The health worker said] …that we should exclusively breastfeed; if the baby is sleeping, when she wakes up we should breastfeed her and after some time we should breastfeed the baby again so that the baby should grow healthy she should not become malnourished.” [35PLBWB].

Seven women mentioned receiving EBF support during the ‘under-five clinics’ (monthly baby check-ups usually conducted by a health facility out-patient team that provides vaccinations, growth monitoring, etc.) and six women reported receiving support from a HSA. From the responses it appears that the HSAs tended to be the individuals who conducted the under-five check-ups at the local clinics, so it is hard to know whether ‘receiving support from the HSA’ means during the under-five check up at the local clinic, or during a home visit. When an interviewee was asked about her interaction with the HSAs, she suggested that she and other women with babies and toddlers only saw HSAs and received BF advice when they brought their babies for vaccinations and check-ups [29PLBWA].

Care Group activities

The Care Groups in Dedza work with NGO-funded promoters, who train CG volunteers. CG volunteers pass on the promotors’ health and nutrition lessons on to so-called ‘cluster leaders’, who are tasked with home visits. Findings show that 18 interviewees mentioned interactions with Care Groups. Home visits were mentioned, as were group activities. The group activities, especially cooking demonstrations, appear to have been well received by the women who were interviewed. Several women credited Care Group cooking demonstrations for teaching them how to add nourishing ingredients to the porridge they feed their small children. Some linked this to their infants’ improved growth [18MCB] and mentioned learning “from the group”.

Group meetings that involved cooking and sharing food appeared to live up to some mothers’ expectations of what NGO-supported interventions do, while receiving breastfeeding counselling, or other advice and information, without any material benefits was not always appreciated in the same manner. A CG volunteer recounted being told by a family “we don’t see a reason why you come to visit us because there is nothing that you give us” [52CGVA], while several mothers explained during our interviews that they had received ‘no support’ from Care Groups, which later turned out to mean no material support, while the same women further expressed their satisfaction about the advice they have received from Care Group cluster leaders or volunteers [e.g. 02MCA].

Care Group interaction with HSAs and district officials

The second area of focus of the study was the examine how the Care Groups function and whether any of the relationships and interactions, as described by the policy document’s ‘Harmonised Care Group Model’ exist in practice.

The CG volunteers and promoters interviewed for this research did not make any references to HSAs. There was a strong sense that the entire Care Group structure was operated by the NGO, with little or no integration into the local healthcare structures. Even though Malawi’s integrated care group policy¹⁷ suggests that the volunteers should receive monthly behaviour change lessons from local frontline service providers, this was clearly not happening in Dedza. The NGO coordinator explained why:

“Because we [NGO staff] support the volunteers to work with the communities on the ground, with the Care Group structure, the HSAs are taking it as the NGO’s program and not their program. So that mind-set also affects the sustainability… What I mean is, for example, if there is no incentive for the HSAs like the ones that are available for the volunteers, they would not be willing to work. So there should always be something like a soft drink, then they will go to work with us. They should understand that it is their model and we, the NGO, are just supporting them.” [61DISTRICT].

At a higher level, it was clear that District Health Officials were aware that the Care Groups were supposed to be integrated in the district health and nutrition activities. Supervising the Care Group activities should be an integral, and motivational, part of the District Authorities’ responsibilities. However, the resources to support these activities are often lacking, which means that district officials have to rely on the NGOs to facilitate the monitoring of the NGO-supported Care Groups. When asked whether these monitoring visits happen, a district official admitted that “Since this is my 8^th month in this job and since I came here it has never happened”. One of the reasons appears to be that “at District Council level, nutrition is not funded.” [59DISTRICT].

The interview data contained just one reference from a mother that Care Groups worked with HSAs in her area [17MCB], which demonstrates that on an ad hoc basis, Care Group volunteers and HSAs do work together at community level. Most of the interviewees, however, did not indicate seeing HSAs and Care Group members together or appeared to associate HSAs and Care Groups.

Even among the women with preterm or low-birthweight babies, there was no evidence of a coordinated follow up by Care Groups, which could have been directed by a concerned HSA. Only two out of the nine women with preterm or low-birthweight babies had received EBF support from Care Groups, and in one case this was because the local Care Group volunteer was also an aunt of the new mother who was interviewed. None of the Care Group team (paid or unpaid staff) made any reference to coordination or collaboration with HSAs or other Ministry of Health staff at District level. One of the HSAs, who described himself as a HSA supervisor, gave an elaborate description of newborn mother support provided by a mixture of HSAs and Care Group members:

“When a pregnant woman delivers, we visit the woman to see if she had any complications… When she delivers we visit her to monitor the health of the baby… if the baby or the mother has a problem, we also refer them to the hospital. From there, we explain to her how she can exclusively breastfeed her baby. So if we leave the mother, we also refer her to Care Groups… So they go and find those people in their homes and teach them how they can take care of their babies.” [40HSAB].

Yet during the interviews with the mothers, none of them appear to have received the integrated care or the referrals from HSAs to the CGVs as is described by this HSA.

Our research showed that the HSAs were not always fully informed of what was happening in the community, especially if they do not live there, but in the nearest town. It is therefore not surprising, according to HSAs, that events such as twin or triplet births, or preterm babies brought home to a village after delivery, do not automatically come to a HSA’s attention:

“What happens at this facility is that mostly preterm babies are referred to X Hospital; that is where they are managed. And when they are being discharged they are told to pass through this health centre so that they can be linked up with a HSA from their community for follow up. So if they follow this process, they are followed up. However, there are others when they are told to pass through this health centre, they don’t, so it is difficult to follow them up.” [41HSAC].

From the perspective of the local hospitals where mothers deliver their babies and where vulnerable newborns such as premature babies or twins may spend several weeks before they are discharged, the referral system appears to be equally unclear, according to a District level interviewee: We have HSAs in the community who help us with that. We do refer the babies to the HSAs. If we have their numbers, we call them but if we don’t have their contact numbers, that is now where the challenge comes in, because we don’t know what they the mothers with premature babies are really doing at home, whether they are really breastfeeding the baby or not” [60DISTRICT].

Do Care Groups play a role in breastfeeding support?

Our research focused on whether or not women had received breastfeeding support from members of the Care Groups working in their community, given that the Care Group members were mandated to engage with all pregnant women and women with children under two, and focus on spreading key nutrition messages, including the promotion of exclusive breastfeeding. Finding that only eight out of 36 of the women participants had received EBF support from Care Group members meant that their performance was well below expectations. Care Group interventions have often been successful in bringing women together and promoting important behaviour change messages such as those regarding breastfeeding and handwashing, which are no- or low-cost interventions that can be adopted by the large majority of women who live within the reach of Care Group activities (Davis et al., 2013; George et al., 2015). The same level of success does not seem to have been achieved and sustained by the interventions focused on during this research.

Where Dedza’s Care Groups were active, they were reported to have reinforced all-important EBF messages, but overall, it appears that breastfeeding support was not a priority for the Care Group interventions we studied. 18 out of the 36 women in areas with Care Groups reported receiving support of some kind (other than EBF) from Care Group members. In most cases this related to cooking demonstrations. Such cooking demonstrations were done in groups, as opposed to ‘passing on/receiving Care Group messages’, which the Care Group volunteers were expected to deliver by going house-to-house. This is a huge workload for volunteers, much greater than it would have been in the ‘normal Care Group model’. Several references to what the community’s expectations Care Group support entails, might explain why some volunteers were reluctant to engage in visiting households empty-handed with ‘just advice’.

While volunteer attrition is an issue that is highlighted by most researchers and practitioners of Care Groups, it was noted that the NGO that implemented the Dedza-based interventions reported high numbers of drop-out rates, in the earlier (pre-2019) phases of the Care Group interventions we studied; between 32% and 16% of the trained CGVs and/or cluster leaders reportedly becoming inactive before the end of the programme (United Purpose, 2022). Given that this reported high attrition rate predated the COVID-19 pandemic (during which a lot of Care Group activities, including motivational visits and training sessions, had to be cancelled), we suspect that the lack of integration into the community-based HSA system may have undermined the Care Groups’ perceived legitimacy and standing within the community, thereby demotivating the volunteers.

A lack of budget for supportive supervision by the district health authorities also deprived Care Group volunteers of the validation such exposure to higher level officials would bring. Research into HSA motivation shows that attrition is also a challenge among HSAs. Finding high drop-out rates is therefore not surprising (Guenther et al., 2019), yet, the budget shortage at district level that leads to a lack of opportunity to supervise and motivate both cadres is regrettable, as HSAs could potentially delegate the important role of visiting newborns and supporting EBF to Care Group volunteers, potentially saving lives.

A lack of collaboration between HSAs and Care Groups

Overall, the level of support for EBF provided by any member of a professional or volunteer health workers cadre, was found to be limited, especially considering that a one in four of our interviewees were mothers of vulnerable babies, who included those in need of support with expressing breastmilk and managing this hygienically, whilst their babies needed the protection and nourishment from EBF all the more.

Summary numerical responses were included in the findings to illustrate patterns and variations related to where (exclusive) breastfeeding support was obtained, and the role of HSAs in the support for mothers with newborn babies, including in terms of HSA interaction with Care Group structures. In addition, the analysis of the data gave an impression of how Care Group interventions ‘sit’ within the wider system of local-level healthcare support structures in Dedza District. It demonstrated that, despite a Harmonised Care Group Design being put in place by Malawi’s Department of Nutrition, HIV, and AIDS in 2012 (which should allow for an integration of the NGO-supported Care Groups into the community-level government health system), such integration does not seem to be realised.

The evident absence of communication and collaboration between HSAs and Care Group members can only be perceived as a missed opportunity. Given that one HSA explained in detail how a system of integrated and delegated care for women with newborn babies should have worked, there appears to be an intention on part of the HSA structures to collaborate more closely with Care Groups, but that these plans were simply not followed through on. The NGO’s programme documents also suggest that greater engagement with government structures was wished for, at District level specifically, but that government officials’ heavy workloads made scheduling meetings with the relevant individuals challenging. Similar challenges have been noted in other Care Group interventions in Malawi (World Relief, 2004). It appears to be difficult to receive district-level buy-in for a well-integrated Care Group intervention, which translates into a lack of higher-level facilitation of the HSA-Care Group relationship that could have created the types of linkages that Malawi’s national Care Group strategy called for.

HSAs have been lauded with significantly expanding Malawi’s vaccine coverage, women’s access to antenatal and post-natal care and growth monitoring (Kok & Muula, 2013; Mziray et al., 2017). However, the expanding list of demands placed on HSAs have exacerbated the pressure on their time, which appears to have increased the risk of HSAs not being able to carry out all the tasks that are expected of them (Guenther et al., 2019; Kok & Muula, 2013; Ngwira et al., 2021). This context, whereby HSAs are overburdened and a substantial volunteer cadre (which the Care Group volunteers effectively are) has been in place since 2012, could have lent itself to task sharing and, for example, the delegation of ‘mother and newborn baby home visits’ to Care Group volunteers in Malawi. There has been no evidence of this in the literature to date. Instead, the NGO staff implementing the Care Group intervention clearly struggled to convince HSAs (and those in charge of managing the HSA programme) that proper integration of the CGVs would be to the benefit of the HSAs, in terms of workload reduction, and to the benefit of women and their infants, who do currently not receive sufficient EBF and infant feeding support.

The lack of integration of the Care Group members into the community-based healthcare system in Malawi means that overburdened HSAs have not been given the opportunity to systematically delegate some of their home visiting responsibilities to the Care Groups, which results in a continued lack of check-ups and support for newborn babies and their mothers at community-level. In Burundi, where a randomised-controlled trial showed that Care Group-inspired interventions can be successfully adapted to be managed by Ministry of Health staff, the key to its success appears to have been the active involvement of the HSAs (or their equivalents) at community-level from the outset. This allowed the HSAs to clearly see that there were potential advantages for them, in terms of being able to delegate certain time-consuming responsibilities (Weiss et al., 2015).

Our targeted search for, and reading of, all of the Government of Malawi’s health and nutrition-focused policy and strategy documents and key aid donor reports, led us to the identification of just three documents that reference Malawi’s national Care Group strategy (GoM, DNHA, 2012; GoM, DNHA, 2017; World Bank, 2019). These include the strategy document that first included the Care Group approach, the national guidelines (in English and Chichewa, counted as one document) and a World Bank report. More than ten years after its adoption into Malawi’s national policy, it is timely to reflect on this nutrition policy component and suggest ways that can improve the efficacy of Malawi’s adapted Care Group approach. Updating and improving Malawi’s national Care Group strategy and guidance could increase the chance of community-level integration that could see Care Group members develop into a more established volunteer cadre, similar to Community Health Workers (CHWs) in many other LMICs. According to the World Health Organisation, worldwide health workforce shortages are leading many low-income countries to consider ways in which CHWs can be adopted into national human resources for health strategies, inspired by examples from countries where this has been successful, for example the two-tier CHW model from Ethiopia (Rieger et al., 2019; WHO, 2020).

Recommendations for further research

Despite the need for greater access to basic primary care being felt in many LMICs, community-level healthcare provision remains a challenge.

Whist there is a wide range of literature on CHW programmes, many of those are based on pilot projects, short-term projects or interventions that are donor-driven and have not been tested in terms of long-term sustainability. The Malawi government’s efforts to integrate the Care Group approach into national policy is one of the few examples where a clear intention exists to integrate lay or volunteer health worker systems into the existing community-level healthcare structures, yet until now, this approach had not been evaluated and written up in detail. More research is needed into ways in which national-level or sub-national level efforts are made to integrate volunteer, lay and ‘stipended’ community-level healthcare providers in LMICs (such as Zulu et al., 2015), as are more explorations of what shape such integrations could take in future (such as Naimoli et al., 2015; Schneider & Lehmann, 2016).

Limitations

Our study of two Care Group interventions was focused on one district in Malawi only and was based on one implementing NGO. While this limits transferability to other Care Group interventions in Malawi, the authors of this study did further consider at least five published programme reviews and two peer reviewed articles on Care Groups in Malawi programme reviews (Best et al., 2017; Crespo et al., 2009; Robins & Best, 2009; van Haeften et al., 2013; World Relief, 2004), plus peer reviewed sources (George et al., 2015; Wilner et al., 2017) and the findings from our realist synthesis of Care Group literature that encompasses 42 texts from a range of LMICs (Pieterse et al., 2021) in our interpretation of these findings. The focus of our study was breastfeeding, which meant that we examined the efficacy of the interventions through that specific lens, although we did consider all other mentions of our interviewees’ interactions with Care Groups. Finally, we acknowledge that we have examined interventions that are based on group interactions and people learning from face-to-face meetings to pass on behaviour change messages, in the middle of a pandemic that necessitated the cancellation of many Care Group activities. It can therefore be assumed that overall efficacy of the examined interventions would have been better than what we recorded, had this not been the case. However, we managed to draw most of our conclusions from a mix of field research, as well as existing programme design, policy guidelines, and pre-COVID-19 Malawi-focused research reports, on which the pandemic had no bearing.