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

6个月以下婴儿的急性营养不良是一个主要的公共卫生问题。最近的报告显示，全球有850万6个月以下的婴儿患有中度或重度急性营养不良。营养不良的婴儿比非营养不良的婴儿更容易住院和死于可治疗的传染病。研究表明，这些婴儿中的大多数（高达90%）没有得到纯母乳喂养，尽管有证据表明，纯母乳喂养对这一群体的恢复和生存特别重要。为了改善住院的营养不良婴儿的营养状况，世界卫生组织（世卫组织）建议重新建立纯母乳喂养。然而，缺乏受过适当训练的卫生工作者和缺乏关于“如何”最有效地重新建立纯母乳喂养的信息等挑战阻碍了在包括肯尼亚在内的许多低收入环境中有效执行这些建议。在肯尼亚，与撒哈拉以南非洲其他地方一样，利用母乳喂养的非专业同伴支持者（接受过母乳喂养援助培训的当地社区母亲）来促进和支持其社区中健康婴儿母亲的纯母乳喂养。我们目前正在肯尼亚的一家医院进行一项研究（IBAMI），调查在急性营养不良和感染出院后康复的婴儿中维持纯母乳喂养的情况。我们在医院引入了母乳喂养同伴支持者，以帮助卫生工作者执行世卫组织的指导方针。在研究人员和资金的支持下，同伴支持者已经成为住院治疗管理团队的核心部分，承担着母乳喂养治疗计划不可或缺的任务。IBAMI研究的经验表明，母乳喂养的外行同伴支持者可能是加强实施世卫组织指南的有效策略。然而，IBAMI研究提供的支持性财务和管理条件不太可能在肯尼亚资源有限的医院环境中重复，而且常规实施将涉及在复杂的多专业医院环境中引入新的低技能、尚未得到认可的骨干。为了了解何时、何地以及如何将母乳喂养同伴支持者纳入营养不良住院婴儿的常规治疗，我们建议开展一项试点研究，调查在肯尼亚两家公立医院实施世卫组织常规条件下住院婴儿营养康复指南时，可能加强或限制母乳喂养同伴支持者使用的卫生系统因素。为了衡量政策层面对该方法的兴趣，我们将确定肯尼亚国家和县一级的主要决策者并与他们接触；确定他们对在医院环境中雇用外行同伴支持者的看法，并讨论实施的潜在障碍和促进因素。为了评估使用母乳喂养同伴支持者的可行性，我们将与基利菲县卫生部合作，确定两家医院，在每家医院，我们将与医院管理团队、一线卫生工作者、儿童基金会和国家卫生部合作，制定并商定一项战略，以实施母乳喂养同伴支持者的干预措施。在战略执行期间，将举行季度会议，审查进展情况并查明促进或限制一体化进程的因素。12个月后，我们将估算实施该战略的成本，并在两家医院分别举行审查会议和访谈，以评估其可行性、可接受性和可持续性。这项研究的结果将为改善6个月以下营养不良婴儿的医院管理和治疗提供新的知识。

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.