Ethiopia Network for HIV/AIDS Treatment, Care & Support Program

Ethiopia Network for HIV/AIDSTreatment, Care and Support

(ENHAT–CS)

Mother Mentor/Mother Support Group Strategy for Expansion of

Peer Support forMothers Living with HIV

Ethiopia Network for HIV/AIDSTreatment, Care and Support

(ENHAT –CS)

Mother Mentor/Mother Support Group Strategy for Expansion of

Peer Support forMothers Living with HIV

MSG Strategy- List of Acronyms

AIDS AcquiredImmuneDeficiencySyndromeANC Antenatal CareANECCA AfricanNetworkfortheCareofChildrenAffectedbyHIV/ AIDSART Anti-RetroviralTreatmentC&S CareandSupportCBO CommunityBasedOrganizationEIFDDA EthiopiaInterfaithForumforDevelopmentDialogueand ActionENHAT-CS EthiopiaNetworkforHIV/AIDSTreatment,CareandSupportEPHA EthiopianPublicHealthAssociationEPI ExpandedProgramforImmunizationFP FamilyPlanningGBV GenderBasedViolenceGOE GovernmentofEthiopiaHC HealthCenterHCSP HIV/AIDSCareandSupportProgramHCT HIVCounselingandTestingHEI HIVExposedInfantHEW HealthExtensionWorkerHIV HumanImmune-deficiencyVirusIEC/BCC Information,EducationandCommunication/Behavior ChangeCommunicationIGA IncomeGenerationActivitiesIYCN InfantandYoungChildNutritionL&D LaborandDeliveryLTFU LostToFollowUpMNCH Maternal,NeonatalandChildHealthMSG MotherSupportGroupMSH ManagementSciencesforHealthNNPWE NationalNetworkofPositiveWomenEthiopiansNTDs NeglectedTropicalDiseasesOPD Out Patient DepartmentPCP PreventiveCarePackagePEPFAR President’sEmergencyPlanforAIDSReliefPHCU PrimaryHealthCareUnitPHDP PositiveHealth,DignityandPrevention

PITC ProviderInitiatedTestingandCounselingPLHIV PeopleLivingwithHIVPMTCT PreventionofMothertoChildTransmissionRHB RegionalHealthBureausSOC StandardsofCareSCI SavetheChildrenInternationalSTI SexuallyTransmittedInfectionTB TuberculosisU5 UnderFiveUSAID UnitedStatesAgencyforInternationalDevelopmentUSG UnitedSatesGovernmentWorHo WoredaHealthOffice

Since2005,theGovernmentofEthiopia(GOE)hasembarkedonanationalexpansionoffreeHIVandAIDSservices.WiththeassistanceoftheUnitedStatesGovernment(USG),GlobalFundandotherdonors,theGOErapidlyincreasedthenumberofhealthcenters(HCs)offeringcomprehensiveHIVandAIDSservices,fromnonein2005toover800by2013.

Today,theUSGiscontinuingtosupporttheGOEinitson-goingeffortstoprovidecomprehensiveHIV/AIDSservicesthroughanumberofmechanismsofwhichthePEPFARfundedUSAIDEthiopiaNetworkforHIV/AIDSTreatment,CareandSupport(ENHAT-CS)programisone.ENHAT-CSisimplementedbyaManagementSciencesforHealth(MSH)ledconsortiumofnationalandinternationalpartnersthatincludestheAfricanNetworkforCareofChildrenAffectedbyHIV/AIDS(ANECCA),DawnofHopeEthiopia(DHEA),theEthiopianInterfaithForumforDevelopmentDialogueandAction(EIFDDA),EthiopianPublicHealthAssociation(EPHA),HSTConsulting,AssociationforSocialServices&Development(IMPACT),InternationalTraining&EducationCenterforHealth(I-TECH),NationalNetworkofPositiveWomenEthiopians(NNPWE),andSavetheChildrenInternational(SCI).

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1. Background

2. MSG Program Overview

Ethiopia’sFederalMinistryofHealth(FMOH)beganintegratingmothermentorswithaMotherSupportGroup(MSG)intonationalHIVprogramingin2005toaddressthespecialneedsofHIV-positivepregnantandpostpartumwomenandtheirchildren.

TheENHAT-CSstrategyforsupportingmothermentorsbuildsonthemodeloftheEthiopiaMSGNationalCurriculum,whichitselfispartiallybasedonthemodeloftheSouthAfricamothers2mothers(m2m)program.

TheENHAT-CSprogramcurrentlysupportsmothermentorswithanMSGat85governmentHCsinAmharaandTigray.Overtime,themothermentorprogramintheseprogramsupportedsiteshasevolvedinresponsetoemergingissuesaroundPMTCT,ANC,MNCHandpediatricHIV.ThisdocumentdescribesthecurrentmodelbeingimplementedintheENHAT–CSsupportedsites.

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ENHAT-CS,startedinSeptember2011,operatesintheregionsofAmharaandTigray.Theprogramsupportstheregionalhealthbureaus(RHBs)oftheseregions,theirworedahealthofficesandHCstodeliverquality,comprehensiveHIVandAIDSservices(includingART)withinacontinuumofcarethatencompassesitsservedcommunitiesandwhichareintegratedwithandstrengthenotherprimaryhealthcareservices,including:antenatalcare(ANC),laboranddelivery(L&D)andotherkeyservicesformaternal,newborn,andchildhealth(MNCH);nutrition;familyplanning;tuberculosis(TB);malaria;sexuallytransmittedinfections(STIs);neglectedtropicaldiseases(NTDs);andmentalhealth.

TheENHAT-CSmothermentorprogramisHC-based,andlinkedtotheirANC/PMTCTandotherMNCHandHIVservices.ItisalsolinkedtoHCs’servedcommunitiesthroughtheworedaprimaryhealthnetwork(seefigure1).

Thereareanumberofadvantagestolocatingmothermentorledpeersupportinterventionswithinahealthfacility.Thisgreatlyenhancesmothermentors’capacitytodrawwomenintotheformalhealthcaresystemwhootherwisemightnotseekservices.IthasalsobeenobservedthatmostwomeninMSGstendtofeelsafewithandrespectedbytheirfellowHIV-positivepeers.Assuch,thepeermodelreducestheemotionaldistanceanddiscomfortthatwomencanfacewheninteractingwithhealthfacilityclinicians.Mothermentorsalsoalleviatesomeofthecounselingburdenexperiencedbytheclinicians,byallowingthemtoshiftbasiccounselingtasksfromprofessionalhealthcareproviderstopara-professionalslikethem.Thehealthfacilitybasedmothermentorsalsoplayakeyroleinfacilitatinglinkagesbetweenthefacilityandtheirservedcommunities,includingoverseeingcommunitytracingofHIV-positivemothersandtheirchildrenwhomissclinicappointmentsaswellashelpingthemaccesscommunitylevelcareandsupportservices.

2.1 Objectives

TheENHAT-CSmothermentorprogramhassevenbroadobjectivesthatareconsistentwithEthiopia’snationalPMTCTplanandmothermentor/MSGcurriculum:1.EnhanceaccesstoanduseofPMTCTservicesbybuildingstronglinkagesbetweenhealthcareprovidersandpeersupportnetworks2.Ensureadherencetoantiretroviraltherapyinpregnantandpostpartumwomen3.LessenHIV-relatedstigmaanddiscrimination4.IncreaseHIV-positivemothers’understandingofsaferinfantandyoungchildfeedingoptions5.ReducetheincidenceofSTIandHIVinfectionamongstgirlsandwomen6.Increaseacceptanceanduseoffamilyplanningamongpostpartumwomen7.Buildlinkageswithotherprogramsandservicesthatstrengthenwomen’shealthanddecision-makingroles(e.g.,nutritionalsupport,income-generatingactivitiesandskillstraining)

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*AlloftheabovearepartoftheEthiopianationalcurriculumexceptMothers-to-Fathers(#5),whichwasaddedtotheENHAT-CSstrategytoimprovePMTCT/MNCHoutcomesandaddress/reducegenderbasedviolence.

Component Who is Involved in addi-tion to mother mentors

Purpose

1.MotherstoMothers-to-be

√ Mothers-to-be(pregnantmothers)

√ Counseling, √ Peersupport

2.Motherstopostpartummothers

√ Postpartummothers(breastfeedingorwithchildrenupto5years)

√ Counseling, √ Peersupport

3.MotherstoCommunity

√ MSGgraduates √ Communitymembers

√ Education √ Referrals √ Tracing

4.Mothers’Creation(SavingsClubs)

√ Mothers-to-be √ Postpartummothers √ MSGgraduates

√ Economicempowerment √ Infantandyoungchildnutrition

5.Mothers-to-Fathers

√ HCsitecoordinatorsformothermentors/MSGprogram

√ Casemamgers √ MalepartnersofMSGmembers

√ PromotingmaleinvolvementinANC/PMTCTandMNCH

√ ReductionofGBV

Table 1: MSG intervention components-ENHAT-CS

2.3 Mother Mentor Program ElementsToachieveitsobjectives,theENHAT-CSmothermentorprogramfostersseveralmutuallyreinforcingstrategiesforpeer-to-peercontact,asshowninTable1.

ThecoreoftheprogramisHCbasedmothermentorswhoprovideindividualsupportandleadapeerMSGforHIV-positivepregnantwomenandpostpartummothers.Withinpeergroupsettings,trainedmothermentorshelptheirHIV-positivepeersaddressunmetneedsforunderstandingHIV,psychosocialsupportandacceptance,self-care,infantcare,andoverthelongerterm,economicneeds.

MothermentorsareHIV-positivewomenwhohavegonethroughPMTCTandarewillingtoassistothermotherstodothesame.ThepackageofservicesthattheyprovideincludesbasicunderstandingofHIV,psycho-socialsupport,adherencecounseling,promotionoffacilitydelivery,encouragementofmaleinvolvementandfamilytesting,groupsupport,FPpromotionanddualprotection,andappropriateinfantfeedingoptions.TheprogramhasanenhancedfocusonpreventionofunintendedpregnanciesamongstHIV-positivewomenthroughimprovedprovisionofFPservices,aswellaspersonaltestimonials,toHIV-positivelactatingmothersonthebenefitsofFP.

MotherMentorsalsoplayakeyroleinstrengtheninglinkageswithintheprimaryhealthcareunit,whichinvolvesaHCanditsservedcommunities(kebeles),whicharecomprisedofhealthextensionworkers(HEWs)andtheircommunitysupportnetworkofwomenwithinthegovernmentmobilizedhealthdevelopmentarmy,aswellasreligiousleadersandmembersofcommunityorganizations,PLHIVassociationsandNGOs.

AkeycomponentismothermentorparticipationinamonthlyHCbasedHEWmeeting,whichbringstogetherHIVfocusedstafffromtheHCwiththeHEWsandothercommunitymembers.Theirparticipationstrengthenslinkagesandcoordinationwithcommunitylevelsupport,includingthetracingofmothersandchildrenwhohavemissedtheirclinicappointment,andlinkagesofMSGmemberstoaccesslocallyavailablecareandsupportservices.

2.4 ENHAT-CS MSG Strategic Model

AlthoughtheENHAT-CSstrategyhasretainedthekeyelementsofEthiopia’snationalmodel,somechangeshavebeenmadetoenhancedemandcreationanduseofANC/PMTCT/MNCHservicesaswellaspromotionofmaleinvolvementinMSGactivities.Themodel,reflectingthesechanges,ispresentedinFigure1below:

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Figure 1. ENHAT-CS Mother Mentor/MSG Strategic Model

HCServices•CounselingandTesting•ANC/PMTCT,L&D,FP•ART•EPI,Pediatrics&postpartum

Woreda Primary Health Network-Comprehensive HIV/AIDS Treatment, Care

and Support services•Communityvolunteers,religiousleadersandgovernmentmobilizedwomenmembersofthehealthdevelopmentarmy(counselingandreferralofpregnantwomen,HIV-positivemothersandtheirchildren).•Casemanagersandhealthextensionworkers(tracingoflostclients,linkagestomothermentors/MSGsandotherservices).•MonthlyattendanceatamonthlyHCbasedPHCUmeetingthatincludesHIVrelatedHCstaffandHEWs(linkagesandstrengtheningHC-communityreferralnetwork)•HCsitecoordinatorofthemothermentors/MSG(on-site,dailysupportandsupervisionofmothermentorsreportingandreferrals)•PLHIVassociations(referrals,peersupportandtracing)

HIV-Positive:• children• Pregnant and lactating mothers

MSG activities by mother mentors•Groupcounselingduringcoffeeceremoniesandindividualcounselingguidedbyajobaid•ParticipationinPLHIVassociationmeetingsforpromotingpositiveliving,providingcounseling,conductingtracing,andcarryingoutreferralsandoutreachactivities•ParticipationinamonthlyHCbasedPHCUmeetingattendedbyHIVrelatedHCstaffandHEWs•Overseetracingofpatientswhohavemissedtheirappointmentthroughhomevisits,linkageswithcasemanagers,HEWs,PLHIVassociationmembersetc.•Reportingtositecoordinator•PromotionofmaleinvolvementinANC/PMTCT/MNCH,includingMothers-to-FathersmeetingsatMSG•Promotionofsavingsandnutritionactivities

Strategic focus•ConductrapidassessmentsandstandardsofcareassessmenttoinformprogramMSGstrategy•ConductsupportivesupervisionandmentorshipvisitstoimproveMSGservices•IncorporateMSGactivitiesintoamonthlyPHCUmeeting•MainstreamgenderintoMSGactivities•Linkmothermentorswithcasemanagers•LinkandcoordinateMSGactivitieswithhealthcareprovidersandtheirotherservicesandsupport

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AtENHATCSinception,theprogramcarriedoutarapidassessmentofmothermentor/MSGsitestobesupportedandusedthefindingsasabasisforrevisingitsstrategy.Keychangesincluded:•Extendedmothermentors’reachandMSGentrypointsforincreasingdemandforMSGservicesbeyondANCandL&D,toadditionalHCclinicssuchasVCT,EPI,U5,ARTandFPclinicsetc.•LinkedmothermentorsandtheirMSGmothermemberswithcommunitylevelsupport,suchasPLHIVassociations,religiousleaders,HEWs,andothercommunitystructures•Establishedon-siteprogramsupport,includingmonthlymentorshipbyaclinicalmentorandquarterlysupportivesupervisionbyaprogramMSGcapacitybuildingofficer•Developedastandardsofcareassessmenttoprovidedetailedunderstandingoftheirservicedeliveryandkeyareasthatneedimprovement•Integratedmothermentoractivitieswithcasemanagementforpromotionofmaleinvolvement,reductionoflost-to-follow-upratesandimproveddocumentationandreporting•Promotedhealthsystemownershipofmothermentor/MSGactivitiesthroughfacilitationofmothermentors’participationinamonthlyHCbasedPHCUmeetingwithHCHIVcareprovidersandcommunityHEWs•EmphasizeduseofpersonalizedcareplansforeachMSGmothermemberthatinvolvesPLHIVassociations,religiousleadersandcommunityvolunteersthatincludedanemphasisonfollow-upandcareofHIVExposedInfants(HEI),andaddressinggenderrelatedbarriersandviolence•Developedastrategicfocusonmaleinvolvement,seeingthisasintegraltoMSGactivitiesandoverallANC/PMTCT/MNCHoutcomes•Introducedthemesrelatedtogenderdynamicstoimprovethesupportiveenvironmentforwomen•DevelopedastrategicfocusonexpandingpeersupporttoincludesavingsinitiativesincollaborationwithSavetheChildrenandNNPWE•Reinforcedhealthymaternalnutrition,infantandyoungchildnutrition(IYCN)•MainstreamedGenderintoMSGservices•Strengtheneddocumentationofgoodpractices,recordkeeping,andreportingthroughuseofstandardizedrecordkeepingandreportingformats•ExpandedscopeofMSGsessionstoincludeothertopicslikegenderbasedviolence(GBV),TB/HIV,Malaria,WASH,useoftheUSAIDpreventivecarepackage(PCP)andpositivehealth,dignityandprevention(PHDP)practices•TrainedmothermentorsonactivecounselingonIYCN,includingoptimuminfantfeedingoptions,andnutritionforpregnantandlactatingmothers

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2.4.1 Mothers-to-Fathers component

InthefirstyearoftheENHAT-CSprogram,afewmenwerefoundattendingMSGsessionswithpartnerswhohaddisclosedtheirHIVstatustothem.Theirpresencedemonstratedtheimportanceandviabilityofpartnersupportformothers’adoptionofsuchkeypracticessuchassafeinfantfeedingoptions,FPandinstitutionaldelivery.

ENHAT-CSsubsequentlybeganpilotingmaleforums(mothers-to-fathers)atselectedHCs,complementedbytargetedcommunitydialoguesandoutreachactivitiesbyprogramtrainedreligiousleaders.

TheprogramcreatedMSGmaleforumswithmenwhohadalreadyexpressedawillingnesstoparticipateinMSGsessionswiththeirpartner.Thisnewstrategydidrecognizethegenderdynamicsofconductingmixedgroupsession,includingthelikelihoodofmaledominance,andthatMSGsisawomencenteredspaceforpeersupport.TheMothers-to-Fathers’maleforumsinitiallymetonceaquarter,includingguidanceandtargetedmessagingforthemothermentors,supportedbyajobaid.

AtHClevel,theMothers-to-FatherscomponentiscomplementedbyeffortsatPICT/VCTandARTservicedeliverypointspromotecouplecounselingandtestingandreferringallHIV-positivepregnantwomenandtheirpartnerstothemothermentors.AttheMSGroom,couplesarecounseledandbriefedbythemothermentorsontheimportanceofMSGswithemphasisontheimportanceofmaleinvolvementinthesuccessofANC/PMTCT/MNCHoutcomes.

2.5 MSG program structure2.5.1 HC site selection

CriteriaforselectionofahealthcenterasanMSGsiteincludesthefollowing:•ANC/PMTCTpatientload,HIVprevalenceatHC,andavailabilityofcomprehensiveHIVandAIDSserviceatthefacility.•AvailabilityofspaceformothermentorservicesandanMSG•WillingnessofHCtosupportmothermentor/MSGactivities,includingassigninganANC/PMTCT/MNCHhealthcareprovidertobetrainedtooverseetheprogram

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•AbilitytorunMSGactivitieswithminimalsupport,asENHAT-CSonlyprovidesmodestmaterialassistancetotheHCs.ThisincludestrainingofHCstafftooverseethemothermentor/MSGactivities,whichincludesoverseeingprogramprovidedstipendforcoffeeceremony/meetingsupplies,andsupporting/participatinginongoingprogramprovidedtechnicalassistanceandmentorship.

2.5.2. Mother mentors selection criteria and duties

FourmothermentorsareassignedperMSGsite,withtwoeachworkingtwodailyshiftsduringtheweek.Inafewcases,somemothermentorsworkonweekendstocaterforthosemotherswhocanonlyattendsessionsatweekends.MothermentorsareselectedbyHCandworedahealthofficestaffinconsultationwithprogramstaff.Theymustbewillingtospendatleast3fulldaysperweeksupportingHIV-positivemothersattheHC.

The selected mother mentors need to meet the following conditions

•HIV-positivewomenwhohavepersonallygonethroughPMTCTservicesandwhoknowtheentiretreatmentandfollow-upprocess•WillingtoservefellowHIV-positivewomenthroughpersonaltestimoniestopromotepositiveliving•Abletosecuresupportfromtheirfamiliestoparticipateorareabletomakepersonaldecisionsontheirowntobecomeamothermentor•LivewithinareasonabledistancetotheHCwitheasyaccesstolocaltransportation•WillingtoopenlydisclosetheirHIVstatus•Abletoreadandwrite.Althoughdesired,thisisnotanabsoluterequirementasnon-literatemothershaveproventobeeffectiveprovidersofpeersupportandsharingofpersonalexperiences•AbletokeepinformationonMSGmothermembersconfidential•WillingandreadytoworkincollaborationwithPLHIVassociations,religiousleadersandothercommunitystructures•Effectiveverbalcommunicationskills•ReadytocarryoutactivitiesthatmakestheMSGprogrameffective,suchashomevisitsandleadingthetracingoflostclients

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Major roles of mother mentors

•WorkcloselywithHCclinicsthatprovidehealthservicestowomenandchildrene.g.ANC/PMTCT/L&D,PNC/FP/EPI/U5,wheretheyidentify,counselandreferHIV-positivewomentomothermentor/MSGservices•IdentifypregnantwomennottestedforHIVandprovidepersonaltestimoniestoencouragethemtoaccepttesting•SupportMSGmothermembersandtheirchildrentoaccessneededhealthcareservices•IdentifywomenwhocometoANCwhoalreadyknowtheirHIV-positivestatusandencouragethemtojointheirMSG•IdentifythedailyMSGparticipantsandprepareforandleadthedailysessions,includingpreparationofcoffeeandteaandsnacksforparticipants•ProvidereliableinformationtoHIV-positivemothersthatencouragesthemtogivebirthatahealthfacility•CounselmothersonIYCN,guidedbyajobaid•EnsureallchildrenofMSGmothermembersarevaccinatedaccordingtoschedule•FacilitatepeersupportbetweenMSGmothersmembersthatincludessharingofcopingstrategies,promotionofpositiveliving,advantagesofdisclosureandpositivehealth,dignityandpreventionpractices

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•EnsureMSGactivitiesarewelldocumented,includingthedailyMSGactivities,intheappropriateformats/registerswithmemberfilesproperlystored•Providemonthlyactivityreporttomothermentor/MSGsitecoordinatorandcasemanager•OnemothermentorattendsamonthlyHCbasedPHCUmeetingalongwithHCHIVstaffandHEW

2.5.3 Site coordinators selection criteria and performance guidance

EachHCsupportingaMSGprogramshouldhaveonetotwositecoordinators,usuallyanANC/PMTCThealthcareprovider,whosupervisesthemothermentors;identifiesandrecruitspregnantandlactatingmotherstoparticipateintheMSGprogram;andensuresthatactivitiesaretakingplacesmoothly.

TheENHAT-CSmodelfollowstheselectioncriteriaforsitecoordinatorsinthenationalcurriculum.However,sincethePMTCTnurse(s)areautomaticallyassignedassitecoordinators,thefollowingprovidesguidanceoneffectivecoordination:

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•SkilledandpreferablyfemalePMTCTprovidere.g.nurse,midwife,healthofficer•GoodlisteningskillsandwillingnesstoworkcloselywithmothermentorsandMSGmothermembers•WillingtoserveandempathizewithHIV-positivemothers•Goodunderstandingofthelocalculturalcontext•Capacitytofullyunderstandthemothermentortrainingmanualandwillingnesstoparticipateintheirtraining•Willingnesstoworkcloselywithotherhealthcareworkers•RespectfortheMSGmembers’needforprivacyandconfidentiality•Willingnesstoworkwithcommunityresources/organizationsthatprovideHIVcareandsupport

Role of site coordinators under ENHAT-CS

•WorkcloselywithHCclinicsthatprovidehealthservicestowomenandchildrene.g.ANC/PMTCT/L&D,PNC/FP/EPI/U5andencouragethemtoidentify,counselandreferHIV-positivewomentomothermentor/MSGservices•DiscussthebenefitsofMSGmembershipwithHIV-positivemothers,usingcaringcommunicationskills,andinvitethemtojointheMSGincollaborationwiththeANC/PMTCThealthcareprovider(s)andotherconcernedhealthworkers•PrepareapersonalfileforeachHIV-positivemotherregisteringtotheMSG•Introducethemothertothemothermentor(s)•Participateinmothermentorbasictrainings•Superviseandsupportthedailyactivitiesofthemothermentors•EnsuretheMSGroom(s)provideprivatespaceandanon-disruptiveenvironment•EncouragemotherstocontinuetheirfollowupattheHCafterdeliveryandensurethatmothersaredoingso•Provideon-the-jobsupportandmentoringtomothermentorstoindependentlycarryouttheirresponsibilities•ProvideamonthlyreporttotheHCthroughthesitecoordinatoronMSGactivitiesusingtheappropriatereportingformat•AttendamonthlyHCbasedPHCUmeetingwithHIVrelatedhealthcareprovidersattending,includingthecasemanagerandamothermentorrepresentative,aswellascommunitybasedHEWsandideallyothercommunityrepresentative

ThecurriculumusedtotrainmothermentorswasoriginallydevelopedbytheSouthAfricam2mproject,whichwasthenadaptedtotheEthiopiancontext.UnderENHATCS,themothermentorsaretrainedfor5days,withthesitecoordinatorsjoiningthemforthelasttwodaystoenhancetheirsenseofinvolvement,whileallowingthemtosharewiththetraineestheirexperiences,challenges,andlessonslearned,includingissuesrelatedtorecordkeepingandreporting.

Thefive-daytrainingcoverssuchkeytopicsasHIVtransmissionandinfection,HIVandpregnancy,psychosocialissues,self-care,antiretroviraltherapy,antenatalcare,laboranddelivery,infantcareandhomebasedcare.

ThetopicscoveredinthecurriculumareshowninthebelowFigure2,withtopics1-12fromtheEthiopiannationalMSGcurriculumTopic13wasaddedtopresentthesavingsclubcurriculum(developedincollaborationwiththeSCIimplementedUSAIDTransACTIONproject.Topic14wasaddedtoaddresstheprogram’sstrategicfocusoninvolvingmalepartnersinMSGactivities.Additionally,TB/HIV,Malaria,WASH,theUSAIDpreventivecarepackage(PCP)andPHDPhavebeenintegratedintothevarioustopicswhenappropriate.

2.6. Training of mother mentors and site coordinators

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1)Mothermentor/MSGprogramgoalandobjectives• BenefitsofMSGprogramforHIV-positivemothers• HCclinicswhereMSGrelatedservicesareprovidede.g.ANC,VCT,FP,PNC,EPI,U5etc.

• ComponentsoftheMSGprogram o MotherstoMothers-to-be o Mothers-to-Mothers o Mother’sCreation(SavingsClubs) o Mothers-to-community

2)Module1:HIV/AIDSbasicfacts3)Module2:PMTCT4)Module3Disclosure5)Module4:CounselingtoreduceMTCT,includinginfantfeedingoptions6)Module5:Familyplanning7)Module6:Positiveliving8)Module7:ART(generalawareness)9)Module8:Childcareandimmunization10)Module9:Sexuallytransmitteddiseases11)Module10:Preventingopportunisticinfections12)Module11:Homebasedcare13)Module12:Conceptofself-helpgroup14)Module13:MaleinvolvementinANC/PMTCT/MNCHandreductionofgenderbasedviolence

Figure 2: Mother mentor training curriculum

2.7. Cohort-based MSG sessions

Theprogramencompasses52individualsessions,guidedbyaprogramdevelopedjobaid.DuringtheMSGsessions,theMSGmothermembersareseparatedintotwomajorgroups;pregnantwomenandpostpartummothers.Thesetwocategoriesarethendividedintosub-groups/cohortsaccordingtoamother’sjoiningdateandbasedonneede.g.thosewhojoinedtheMSGatthesametimeandarebreastfeedingaregroupedtogether.Inaddition,mothersareencouragedtojointheMSG’ssavingsgroup.

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ENHAT–CSrecognizesthechallengesofattendingall52sessions.MSGmembersattendaccordingtotheirindividualavailability,somemaycompletethe52sessionsinsixtosevenmonths(2sessionsaweek),whileothersmayremainintheprogramforuptoayear.

Althoughthereisnocleardescriptionof‘graduating’MSGmothermembersinthenationalcurriculum,itisimpliedthatmotherswhocompletetheirANCfollow-upattheHCwillbeprovidedwithhomebasedcaretrainingandgraduated,withthesemothersthenengagingwiththeircommunityforpromotingANC/PMTCTandpositiveliving.TheyarealsoexpectedtoprovidehomebasedcareservicesfortheirfellowPLHIV.

TheENHAT-CSprogramdoesnotincludeastructuredgraduationandsubsequentcommunityaspect.TheprogramcontinuouslypromotesMSGmothermemberlinkageswithcommunitycareandsupport,includingjoiningtheircommunityPLHIVassociationsandaccessingavailableservices,

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2.8 Graduating from MSG activities

includinganyincomegeneratingopportunities.MSGmothermembershavealreadybeenenrolledbymothermentorstoassisttheircommunitytracingofmothersandchildrenwhohavemissedtheirHCappointments.However,theprogramdoesprovidethemwiththeknowledge,alongwithteachingaidsforcounselingandeducatingothermothers,ifwilling,intheircommunitye.g.membersofcommunityPLHIVassociations,andhavebeenenabledtoprovidecommunitytestimonialsonpositivelivingand/orserveasvolunteers.

TheprogramsupportsthewishesofthoseMSGmothermemberswhoprefertocontinueattendingtheirHCMSGsessionstocontinueaccessingpeersupport.ContinuedattendancealsofosterscontinuedaccesstootherHCservices,includingART,andallowslongerfollow-upofHEIupto18months.These‘veteran’MSGmothermembersalsocansharetheirlivedexperiencesandtestimonialstothenewmothers/pregnantwomen.

TheMSGmothermentorscanalsocontinuetobemembersoftheMSGsavingsgroup,orformnewones.DiscussionswithMSGmothermembersofthesesavinggroupsindicatethatthey:

• Providelifeskillsandfinancialliteracynecessaryforstrengtheningone’seconomicsituation• Providesocialcapitalintheformofapeernetwork• Provideastructuredmeansofengagingwithinawomen’sgroup•OffersustainablesupportbeyondthataHCcantypicallyprovide

2.9 Challenges and proposed solutions based on lessons

Implementingamothermentor/MSGprogramisnotwithoutchallenges.Someareinherentintheoriginalmodel,whichtheprogramhasidentifiedandaddressed.Thefollowingtableshowschallengesthattheprogramhasfacedandhowtheyhavebeendealtwith.

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Challenge Mitigation InterventionLackofownershipofthemothermentor/MSGprogrambyHCsandworedahealthoffices

InclusionofmothermentorrepresentativesinamonthlyHCbasedPHCUmeetingtoincreasetheirvisibility,recognitionandprovidethemwithaforumtodiscusstheirchallengesandsuccesses

ShortageofconvenientmeetingspaceatHCs

NegotiatedwithworedahealthofficesandHCheadsforallocationofadequatespace

Poormotivationandhighturnoveroftrainedmothermentor/MSGsitecoordinators

ENHAT-CSdoesnotpayastipendtoHCsitecoordinators,butseekstomotivatethemthroughinclusionintrainings/refreshertrainingsofmothermentors,aswellasinclusioninamonthlyPHCUmeetingtoenhancetheirvisibility

Limited IGAopportunitiesforMSGmothermembers

√ Havetrainedandmentoredmothermentorsonrunningaself-savingsclub,incollaborationwiththeUSAIDTransACTIONproject √ LinkedMSGmothermemberswithcommunitylevelPLHIVassociationsandWorHOstolinkmotherswithcommunitylevelIGAsandmicrofinanceinstitutions

Lackofstandardizedrecordingandreportingformatsandlowliteracyofmothermentors

√ Developedandprovidedmothermentorswithrecordingandreportingformatsandboxfilesfororganizingtheirdocumentation √ Retrainedmothermentorsonproperuseofrecordingandreportingformats √ Providedongoingonsitesupportonrecordingandreportingduringmentorshipandsupportivesupervision

Table 2. Challenges and Interventions

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DelaysinfollowupofMSGmothermemberswhomissappointments

√ Retrainedmothermentoronproperrecordkeepingandmaintainingup-to-dateregistersallowingforearlydetectionofmissedappointmentsandinitiatingfollow-up √ Formalizedmothermentors’workingrelationshipwiththeirHCcasemanager,communityvolunteeroutreachworkersandPLHIVassociationsfortracinglostclients √ Promotedmaleinvolvement

Lowliteracyamongmothermentors

√ Ongoingonsitesupportbysitecoordinatorsandprogramstaff

WeakservicedeliverybyMSGs

√ Rapidassessmentcarriedouttoidentifycriticalgapandtrainingneeds √ ProvidedongoingmentorshipandsupportivesupervisionbyENHAT-CSmentorsandMSGcapacitybuildingofficers,guidedbyaprogramdevelopedmentorshipchecklist √ Developedastandardsofcaresurveyformattoprovidedetailedassessmentofperformance √ Formalizedmothermentors’workingrelationshipwiththeirHCsitecoordinatorsandcasemanagersforadditionalsupportandfollow up √ IntegratedMSGactivitiesintoamonthlyHCbasedPHCUmeetingthatincludestheHIVrelatedhealthcareprovidersandcommunityHEWs

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Inconsistentmessagesespeciallyoninfantfeeding,postnatalPMTCT,newPMTCTregimen

√ Ongoingonsitementorshipandtrainingofmothermentors √ UseofIYCNguideonnutrition √ Provisionofrefreshertrainingtomothermentorsonkeymessages,includinginfantfeeding,postnatalprevention,newPMTCTregimensetc.

UnclearapproachtograduationofMSGmothermembers

√ PromotinglinkageswithcommunitythroughoutMSGparticipation √ Allowingmemberstoindividuallydecideifandwhentheywishtostoptheirparticipation,recognizingthatthemothermentorsandtheirMSGprovidesasafespacewithpeer

Lackofmaleinvolve-mentinANC/PMTCT/MNCHactivities

√ PromotingmaleinvolvementbyintroducingmaleMSGforums,underamothers-to-fatherscomponentatselectedHCs √ DevelopedtargetedmessagesthatpromotemeninvolvementinANC/PMTCT/MNCHandgeneralchildcare,supportedatcommunitylevelbyENHAT-CStrainedreligiousleaders √ IncludedpromotionofcouplecounselingandtestingatANC/PMTCT

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LimitednumberofmothersjoiningMSGs

√ Involvedcasemanagersandotherhealthcareproviderse.g.FP,OPD,aswellasANCsitecoordinatorstodirectlyreferHIVpositivepostpartummothersandpregnantwomentomothermentors/MSG √ ExpandedcommunitydemandcreationthroughpartnershipswithPLHIVassociations,religiousleadersandoutreachvolunteerworkers √ DevelopedwaystomakeMSGmembershipmoreappealing,includingmorecomfortablemeetingspaces,improvingtheknowledgeofmothermentors(refreshertraining),availingIEC/BCCmaterials,promotingmaleinvolvement,addingsavingsclubstotheMSG,andpromoting IGA

Supporting documents

1. MSGjobaidforusebymothermentors2. MSGrapidassessmenttool3. MSGregisterbook4. MSGpersonaldatasheetfornewmembers5. MSGreportingformats a.MSGdailyactivityregister b.MSGmonthlyreportingformat6. MSGquarterlymentorshipchecklist7. MSGgendermainstreamingassessmenttool8. MSGgendermainstreamingfocusgroupdiscussiontool9. MSGstandardsofcare(SOC)assessmenttool

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IMPACT NNPWEANECCA DHEA EIFDDA EPHA