Sunday, December 10, 2006

Communication and Consideration of Cultural Values: Benefits for a Prevention of Mother-To-Child Transmission (PMTCT) Program - Jean Gregory Jerome

In a rural setting in Haiti where about 50,000 people are facing extreme poverty and disruption of family structure, and where the prevalence of HIV/AIDS is more than 5%, a NGO with dedicated members commit their knowledge and resources to help this population. One of their top priorities is to endeavor to do whatever it takes to reduce the rate of mother- to-child transmission of HIV. However, in spite of their motivation and their commitment on this matter, the NGO’s intervention in the first year is considered to be a failure because it didn’t take into account some particular social and cultural aspects distinctive to this population. During the first year of this program 31 children born from HIV positive women were followed on a monthly regular basis, and formula milk and accessories to prepare the milk were given for free to the mothers, along with an individual education session covering the basic rules of hygiene and the importance of replacing breastfeeding with formula to reduce the risk of transmission of the virus to their beloved children. A monthly fee for transportation was also provided to the mothers when they came to the clinic for a physical exam and for supplies. Within one year of this program’s initiation, four children among the 31 died of diarrhea resulting from an incorrect application of the providers’ recommendations for formula use. At this point the providers needed to evaluate their program and to consider the internal and external factors that could explain such a terrible failure despite the availability of the necessary financial resources to support the program.

Based on Maslow’s hierarchy of needs (1) we can say that it was a good approach to provide to those poor mothers who couldn’t afford the price of the formula milk not only this milk but also the accessories to boil and prepare the milk in good hygienic conditions. In this way their basic needs to feed their children were met. However, the consideration of this same pyramid would help to understand that when dealing with people in order to intervene effectively one has to take into account the other dimension of needs that people have besides those basic ones which consist in food, water, etc… At a certain point of their intervention the providers needed to understand that those people, even if they are poor, also need to feel that they can have confidence in their helpers, that they can really trust them. Maslow describes this level of need as the need of esteem. More emphasis on regular meetings with the patients would not only be an opportunity to further educate the mothers on how to avoid contaminating the milk they have to prepare for their children, but would also help provide mothers with the feeling of social belonging. They would feel that they were part of a group of mothers who were facing the same danger for their babies’ life, that they were accepted themselves as well as their children. Those meetings would give to the mothers an opportunity to share their own feelings and their concerns regarding the program, and at the same time would help the providers to strengthen their relationship with their clients, and to learn from them how to adapt certain aspects of their program to each individual according to their specific needs and social context.

After the four deaths from diarrhea, the providers were alerted and began to focus on some social aspects of their intervention like regular meetings and workshops in which they emphasized the importance of preparing the milk in hygienic conditions, and demonstrated these methods. In this community the lack of clean water has made the project particularly challenging. In order to find water some mothers have to walk for a long time before reaching the source, and often this water is contaminated by the animals that drink at the same source. Sometimes also they have to use water from the river, or even stagnant water remaining after the rain. Not only is the water they could get unclean, but also the containers they used to transport the water are often very dirty, and the way they store this water is unsafe particularly for their babies’ health. To provide clean water to the mothers, the providers started some satellite projects, such as spring caps, in collaboration with the men living in this community, as well as the use of water filters made by craftsmen that had also been tested to safely provide clean water.

Despites those considerable new measures in terms of material resources, and a low transmission rate of HIV (2%), during the second year of the program three children died of diarrhea of out the total of 56 children followed. The providers had to challenge some cultural beliefs specific to this community which constituted further obstacles to the effectiveness of their intervention. One of those cultural beliefs is related to a negative view of milk formula. In this community, breastfeeding is highly valued as it is a symbol of femininity and fertility. Women are very proud when they can show off this practice in their community. This cultural value made it difficult for a woman to choose the formula milk as an option to feed her baby. As the formula milk was given for free, they did accept it from the providers, along with instructions and recommendations. However, in order to avoid being stigmatized in their neighborhood, or having to explain why they don’t breastfeed like other mothers, some HIV positive mothers did breastfeed their children from time to time. This has led to the practice of mixed feeding, which is twice as risky for their babies because of the potential for HIV infection, and also at risk of diarrhea from improper formula preparation. This is another level of Maslow’s pyramid that the providers needed to consider in planning this challenging program. This theory would help them to understand that those mothers being part of a community would always behave in a way to protect their image in this community because they had another need which is described by Maslow as the need of esteem. In this community HIV is viewed as an evidence of infidelity and immorality; therefore, these mothers would even put their children at risk of HIV infection and diarrhea so that they can avoid any suspicion from their neighbors who would automatically stigmatize them. If a woman is infected, it is interpreted as a sign that she had sex with other men besides her husband, and she is someone who should be despised in the community. If she has a business they would not buy anything from her, they would avoid eating with her. That means she would be excluded from the social life of this community. Considering this socio-cultural context, the application of the Social Expectations Theory during education sessions would probably help the providers to better address the problem of stigmatization attached with the milk formula option. This theory presents an individual as part of the “webs of complex social interaction.”(3) The mothers being part of this community, their behavior and their decision regarding the option of breastfeeding was dictated by the unformal social norms of the community.

It is necessary to mention that the providers had to face also another major problem related to the level of education of those mothers. About 90 percent of them were illiterate which explains why it was hard for them to understand what it means to be HIV positive. Since most of them were asymptomatic, they tended to not take seriously their diagnosis and the risk this represented for their children. Therefore, at home some of them would even use this milk formula to feed other children or themselves, and would continue to breastfeed the baby for whom the milk was provided. Based on the Health Belief Model which points out how it is important for the beneficiaries of such program to perceive the severity of their condition before they can be motivated to change their behavior (3), the providers should have put more emphasis on education. In addition to the other measures already applied, some other activities addressing this other aspect of the program would better armed the providers to tackle the transmission of HIV from the mothers to the children. For example, they could arrange to have a PMTCT mothers club where they could meet those mothers on a regular periodic basis to further educate them about basic knowledge on HIV, the severity of the consequences of having this disease for their babies. After being convinced about the importance of safe feeding practices, the mothers would probably become more cooperative. In other words, trough those education sessions adapted to their level of education, their understanding of the potential danger that the practice of breastfeeding represents for their baby’s health would probably motivate them to adopt formula feeding as a safer option.

In conclusion, the failure of this program during the two first years of implementation can at least in part be explained by the lack of consideration of social and behavioral sciences principles. Even though the providers had the appropriate financial resources and the commitment of a well-trained team to help the mothers, they needed to take into account some basic principles of social sciences in order to be effective. Because the public health problems relate directly to the social and cultural values that individuals of a given community share and cherish, it is not unexpected that a program which fails to address them effectively will consequently fail, and, in fact, can even worsen the underlying problems that prompted the intervention in the first instance by adding its side effects.


1- Maslow, A. H. (1943). A Theory of Human Motivation. Psychological Review, 50, 370-396.
2- DeFleur, Melvin L (1923). Theories of Mass Communication
3-The Communication Intiative. Change Theories.


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