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The Peer Counsellor Programme in South Africa

Loraine Hamm
Gauteng, South Africa
From: LEAVEN, Vol. 37 No. 3, June-July 2001, p. 66-68

South Africa is geographically divided into nine provinces and Peer Counsellor Programme training has been initiated in five of them. The programme began there in 1992 in Kwa-Zulu Natal. Jane Maasdorp, LLL Leaddr and present Area Coordinator of Leaders in South Africa, ran the first Peer Counsellor Programme (PCP) training course. The women who were trained were recommended for the course by The Valley Trust, a socio-medical project in the Valley of a Thousand Hills, a rural area on the urban periphery of the city. During the training, Jane realized that she had already met the women during previous trips and visits with the community nutritionist. Such community work by Jane and other LLL Leaders laid the foundation for the formal PCP training courses that would follow, just as it does in other areas.

The first course was presented to 21 active lay community health workers ("onompilo") who had already proved themselves to be highly motivated in helping others, had a good basic knowledge of nutrition, and understood the importance of breastfeeding within the context of the UNICEF/WHO Child Survival Strategy. They had each breastfed at least one child for at least six months, although most had nursed several children for periods of up to two years and more. The course was conducted over 13 weeks, one full morning per week, in a vibrant and successful mixture of English and Zulu.

In a report at the time, Jane wrote: "It soon became clear that, in spite of their previous training, the women had a lot to learn about breastfeeding, and this they did with great enthusiasm. There were many lively sessions; traditional beliefs were examined and debated; new ideas and facts were queried, puzzled over, discussed very seriously, and generally found to be good; and, most importantly, ways of communicating with and relating to people with whom they will share their knowledge were readily accepted." Jane perceived the teaching of communication skills during the course as "the most exciting aspect of the training." The women were all skilled at delivering messages about the health benefits of breastfeeding. They could sing songs, make up poems, and put on highly entertaining role-plays, and they acquired skills and information to give support to mothers.

On 12 July 1992, nineteen of these women became the first Peer Counsellors in South Africa to receive certificates from LLLI. Nan Jolly, LLL Leader, HRE Instructor, and now a member of the LLLI Board of Directors, also attended the moving graduation ceremony that took place soon after the 1992 LLL Conference in Kwa-Zulu Natal. "We were all in tears," she remembers.

Western Cape

The programme has taken root best in the Western Cape, with Cape Town as capital. With 13 experienced Leaders, some of whom had been involved in the Leader Accreditation Department in the area, the Western Cape has the womanpower to tackle the programme. The Leaders have all been networking in the area for several years, so the contacts they have developed are helpful. They have also put their hearts and souls into developing the programme. One of those Leaders, Elaine Dawson, was trained in the PC Programme at the LLLI Conference in Miami in 1991. When she returned home, her enthusiasm for and information about the programme helped encourage other Leaders to become involved.

The first course in the Western Cape was run at St. Monica's Hospital in 1993 by Elizabeth Robinson. St. Monica's later became the first hospital in the Western Cape to earn the Baby Friendly Hospital designation.

Rosemary Gauld, LLL Leader and retiring PCP coordinator, ran a course at Mitchells Plain, starting in March of 1994. Rosemary has an impressive record of running PCP courses in the Western Cape, at times even running two courses concurrently. After Mitchells Plain, 10 more courses followed at many different localities, yielding approximately 148 Peer Counsellors.

Elizabeth Robinson, who trained two groups at St. Monica's, comments that a tremendous demand for PC training has developed. Medical and nursing staff have seen the need for training and several professional people have completed the course. There has also been a demand from members of the community-people already involved in voluntary work through churches, and interested women identified by hospitals. There are now nearly 300 Peer Counsellors in the Cape Town area alone.

In Port Elizabeth, a nursing sister (nurse) in a maternity ward of a private hospital approached Marianne Brophy, LLL Leader, to get material for teaching her staff about breastfeeding. Marianne was asked to do PC training for the staff. The first Peer Counsellors graduated in 1994. The training in the hospital continued for a few years before the word spread beyond that hospital.

The PC Programmes in Gauteng and the Northern Provice are smaller in comparison to other provinces. The growing pains they have experienced make those of us, involved all the more aware of the tremendous effort that went into developing the programme to its present size in other provinces. Three LLL Leaders made a start in 1996 by running a course in Gauteng from which five Peer Counsellors graduated. In the Northern Province, which is a vast, mostly rural area, 27 health care workers attended a three-day course presented by two Gauteng LLL Leaders in 1999.

Funding

LLL South Africa received funding from Mobil's Energos Foundation that has kept the programme afloat for several years. The Leaders involved do not receive any fees; they may, however, be reimbursed for expenses. Some courses were funded by the Department of Health or by other institutions that requested training. The Provincial Administration of the Western Cape has provided funding for two PCP courses. Travel expenses and LLL membership for Peer Counsellors in training used up most of the funds, but Leaders are pleased to see that there is recognition of the impact of the programme and willingness to provide funding.

The PC Programme in South Africa has also generated funds from within. Lingoma Zokuncancisa-South African Peer Counsellor Songs--were recorded by the Cape provincial education department for use in training programs. The idea was sparked by a remark Marian Tompson, LLL co-Founder, made when she was in South Africa with a People-to-People Delegation in 1998. On the day of the recording each of the three PCP choirs, dressed in their traditional outfits, sang their own songs. A group presentation was also recorded. The audio and video recordings are selling extremely well. Many were sold at the LLLI Conference in 1999, and a part of the video recording was played during one of the LLLI Conference luncheons.

Curriculum and Culture

Jean Ridler, Leader from the Western Cape who is involved in PC training, led a session at the 1998 South Africa Area Conference about the Peer Counsellor Programme. She describes the development of the curriculum:

"We have had to learn about adult education, how to develop an appropriate cumculum, and how to work with different cultures. For some of us, it was really the first experience we had in dealing with truly diverse groups with different languages, educational backgrounds, and cultures."

"In the beginning, in Cape Town, we used the LLLI Peer Counsellor Curriculum with some changes to reflect local conditions and culture, with each Leader using different approaches with different groups. In 1996, we learned about the Training Curriculum for Community-Based Breastfeeding Support from Wellstart International. This curriculum and the teaching methods used seemed more suited to the training of Xhosa-speaking Community Health Workers (CHWS) with whom we were busy working at the time. The Wellstart Programme was adapted and found to work extremely well in practice. It is very interactive and draws strongly on the knowledge of the CHWs regarding child health problems experienced in their communities and links this to breastfeeding. This has now also been used successfully in different cultural groups. A curriculum is not a static concept. Rather it is a growing, dynamic creation that will need constant modification in the light of evaluation and new ideas and is thus never finished."

Discussing culture, Jean remarked: "It is within the cultural context that solutions to underlying infant feeding problems must ultimately emerge. Changes, if they are to last, need to originate from within a culture, not be imposed from without."

Different Groups, Different Challenges!

In planning the training, the PC Administrator needs lots of flexibility to adjust the curriculum to the needs of the group. The chversity of groups comes across in the experience of these Leaders.

Jane Maasdorp writes of her with two groups of trainees in Kwa-Zulu Natal: "Regarding cultural beliefs about breastfeeding, in both the above groups I have found no uniformity about some of the practices sometimes assumed to be pervasive in Kwa-Zulu Natal. For example, some mothers may discard their colostrum but many do not; a few believe that nursing the baby beyond the age of two will make him 'stupid,' but many do not; some people believe that a woman should not make love while breastfeeding, but many do not. The belief that plenty of helpings of a thin porridge will enhance the milk supply is found farther south, but some migrants have introduced the practice here, too. And whilst it may be believed that Zulu-speaking women are uninhibited about displaying their breasts in public, a young mother was not supposed to allow her breasts to be seen by her father-in-law (it would have been disrespectful), and this is still true now for many."

One Leader shared her frustration about the authoritarian attitudes of some of the people being trained, which persisted even after repeated efforts at teaching empathetic communication skills: offering suggestions, specific praise, and many, many practice role-plays. Another Leader says, "I guess I had the easiest bunch, with the Peer Counsellors communicating so well with the mothers. Very little time was formally spent on 'counselling skills' as these were demonstrated so well in the role-plays that they enjoyed so much."

Materials

Handouts are kept to minimum because of costs, language, and literacy concerns. All participants receive a copy of Felicity Savage King's Helping Mothers to Breastfeed. Trainers refer to this often to help the participants become familiar with it and to suggest ways of using the diagrams when talking to mothers. Presentations are as visual as possible, using various models, many slides, and videos.

A Day in the Life of a Peer Counsellor

A Peer Counsellor may use her skills in several ways. Some may be more active than others, depending on personal circumstances. Even if she decides to limit her help to her own family and friends, she is still a valuable asset for her community.

Shaheeda Abrahams, from Port Elizabeth, is passionate about her work as a PC. She took the initiative to approach the staff of a large acadenuc hospital in the city. Shaheeda arranged regular visits to the hospital during which she gives talks to women at their initial antenatal clinic visit. During her ten-minute talk she covers the most important advantages of breastfeedmg and the most common problenls. After her talks, she visits the postnatal wards and admires babies and gives tips to new mothers. Shaheeda was one of the copresenters of a special session for PCs at the LLL Conference in Port Elizabeth.

Peer Counsellors are not always women. Patrick Jelele is a PC from Philippi in the Western Cape. Patrick is very happy to make a contribution in his community by helping mothers to breastfeed. He attended the LLL Conference in Gauteng in 1998 and poured out his enthusiasm for breastfeeding in a poem he especially wrote for the occasion.

Ongoing Support and Education

Training does not end at graduation! Communicating regularly with the Peer Counsellors is very important, but can also be very challenging as many people do not have access to a phone. We cannot schedule frequent meetings as time, distance, and cost do not allow them. In 1997, a system of links was established. Those in each geographical area identified "link persons" -someone to form a link in the communication chain. Bimonthly meetings are held with people who act as links where we can address many issues.

In Cape Town, follow-up meetings are organized two or three times a year. Up to 60 counsellors may attend. They have an opportunity to ask questions, raise problems, and enjoy group activities. One get-together was spent making posters with messages relevant to breastfeeding problems experienced in each community. Another focused on the theme and ideas for World Breastfeeding Week. Leaders' feelings about the follow-up meetings range from "These are proving to be a real headache ... just too few of us with too much to do!" to "Follow-up sessions are inspiring - we hear about such wonderful work and good outcomes." All agree that these sessions are essential to find out what is going on and keep knowledge and skills on track.

Keeping in Touch

Elizabeth Robinson edits "Peer-to-Peer," a twice-yearly one-page newsletter which is published in English. It is sent it to all Leaders involved in training and they copy and distribute it in their areas. In the Cape Town area, 150 copies are distributed at workshops and by link people.

"Peer to Peer" provides another avenue for ongoing support and education. For example, not all Peer Counsellors were reporting on a regular basis so an article appeared in the newsletter that encouraged reporting of activities. The feedback from these reports can be a valuable source of information. Elizabeth writes: "We picked up from these forms that counsellors often recommend Vaseline for sore nipples and were able to put an article in "Peer to Peer" explaining why Vaseline is not such a good idea."

Success stories from the reports also make inspiring reading matter for "Peer to Peer." The editor often feels discouraged by lack of contributions from Peer Counsellors, but the Leaders find it valuable.

A Leader comments: "The women I work with love 'Peer to Peer.' We make a point of reading it together in the group and translating it. They really do identify with the local content. Even back issues are popular reading matter."

PCP Training on Board the SS Anastasis

The SS Anastasis is a mercy ship that goes from port to port. The crew of the SS Anastasis are volunteers who pay or are sponsored to take part in the voyage. Volunteers give medical treatment to people who live in countries where services are poor or nonexistent, including surgical operations and quite sophisticated treatment. Those who participate come from USA, England, Switzerland, Australia, Holland, Gemiany, and South Africa. Since they were to call at ports along the African coastline during this voyage, Leaders adapted the PC training for the countries they would visit. When the steamship docked in Cape Town harbor around the millennium celebrations, Rosemary Gauld and Jean Ridler trained 19 of the ship's medical staff to become Peer Counsellors. They used LLLI books, along with videos, tapes, and slides. They based their presentation on the Breastfeeding Five Prime Messages taken from [i]Facts for Life[/i] (UNICEF, WHO, UNESCO). Participants who completed the course became members of LLLI. This project was sponsored with funds donated to LLLI by Medela, Inc.

From Peer Counsellor to Leader

We have been fortunate to see two LLL Leaders coming from among the Peer Counsellors. Dilshaad Sungay attended a PCP course at Grootte Schuur hospital soon after the birth of her second child in 1996. Dilshaad says that doing the course changed her whole life and she started looking at breastfeeding and mothering in a completely different way. She began attending LLL Series Meetings after becoming a Peer Counsellor and read many books from the Group's Library. It helped her as a mother and she enjoyed the fact that her children were always welcome at the meetings. Ditshaad's passion for breastfeeding culminated in her becoming a La Leche League Leader. She is co-Leading an LLL Group and is very proud of the steady growth this Group has experienced.

Sophia Blows was recruited from a community support group and after completion of the training course, she became interested and involved in other LLL activities. Sophia is also involved in the Breastfeeding Liaison Group and Baby-Friendly Hospital Initiative in her area.

As LLL and the Peer Counsellor Programme grows in South Africa, Leaders and Peer Counsellors alike will continue to expand the community of breastfeeding support for all mothers who are interested in the art of breastfeeding.

Breastfeeding Week in Port Elizabeth

  • Dora helped the mother of a two-month-old underweight baby to relactate.
  • Sylvia held fruitful discussions with mothers.
  • Suraya organized practical demonstrations where mothers at the clinic showed mothers how to breastfeed. They concentrated on latching the baby on correctly. The working mothers were met by giving information on cup feeding and storing milk.
  • Stalls (booths or tables) were set up at Hypervalue Stores enabling mothers to come and talk about breastfeeding.
  • An engorgement problem was sorted out by using ice-cups, warm compresses, breast massage, and follow-up help and encouragement. The mother concerned was grateful to the clinic staff for their support and interest. Her mother-in-law and husband were also encouraged to give her support.

Reprinted from "Peer to Peer" No 2, Nov CE97

Breastfeeding Song

by Thandie Manona of Guguletu

Botile sukl endleleni Awuboni
siyancancisa Siza kulithengelwa
ngubani na.
(Bottle stand out of the way; Can't you see that we are breastfeeding? If not, who is going to buy milk for us?)
Reprinted from "Peer to Peer" No 2, Nov CE97

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