Abstract
BackgroundConcurrent epidemics of HIV, depression, alcohol abuse, and partner violence threaten maternal and child health (MCH) in South Africa. Although home visiting has been repeatedly demonstrated efficacious in research evaluations, efficacy disappears when programs are scaled broadly. In this cluster randomized controlled trial (RCT), we examine whether the benefits of ongoing accountability and supervision within an existing government funded and implemented community health workers (CHW) home visiting program ensure the effectiveness of home visiting.Methods/DesignIn the deeply rural, Eastern Cape of South Africa, CHW will be hired by the government and will be initially trained by the Philani Programme to conduct home visits with all pregnant mothers and their children until the children are 2 years old. Eight clinics will be randomized to receive either (1) the Accountable Care Condition in which additional monitoring and accountability systems that Philani routinely uses are implemented (4 clinics, 16 CHW, 450 households); or (2) a Standard Care Condition of initial Philani training, but with supervision and monitoring being delivered by local government structures and systems (4 clinics, 21 CHW, 450 households). In the Accountable Care Condition areas, the CHW’s mobile phone reports, which are time-location stamped, will be monitored and data-informed supervision will be provided, as well as monitoring growth, medical adherence, mental health, and alcohol use outcomes. Interviewers will independently assess outcomes at pregnancy at 3, 6, 15, and 24 months post-birth. The primary outcome will be a composite score of documenting maternal HIV/TB testing, linkage to care, treatment adherence and retention, as well as child physical growth, cognitive functioning, and child behavior and developmental milestones.DiscussionThe proposed cluster RCT will evaluate whether routinely implementing supervision and accountability procedures and monitoring CHWs’ over time will improve MCH outcomes over the first 2 years of life.Trial RegistrationClinicalTrials.gov registration #NCT02957799, registered on October 26, 2016.
Highlights
Concurrent epidemics of HIV, depression, alcohol abuse, and partner violence threaten maternal and child health (MCH) in South Africa
The proposed cluster randomized controlled trial (RCT) will evaluate whether routinely implementing supervision and accountability procedures and monitoring community health workers (CHW)’ over time will improve MCH outcomes over the first 2 years of life
The proposed RCT will evaluate whether routinely implementing training as well as accountability structures to monitor CHW behavior and MCH outcomes with mobile phones and providing data-informed supervision will result in government services becoming efficacious
Summary
The proposed RCT will evaluate whether routinely implementing training as well as accountability structures to monitor CHW behavior and MCH outcomes with mobile phones and providing data-informed supervision will result in government services becoming efficacious. South Africa did not meet the MCH Millennium Development Goals 4 (child health), 5 (maternal health), or 6 (infectious diseases) [51, 52] This project will be a strong test to assess if the government-employed CHWs can create efficacious outcomes, within a challenging work culture that currently does not have the resources to provide ongoing in-service training nor vigorous structures to maintain what is delivered during home visits. By establishing training, monitoring, and supervision structures of the government’s CHWs, significantly improved MCH outcomes over 5 years are predicted The results of this RCT will be applicable to the existing 1.2 million CHWs globally, to the 50% of Africa that is deeply rural.
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