The effect of supervision on community health workers' effectiveness with households in rural South Africa: A cluster randomized controlled trial.

BACKGROUND: Community health workers (CHWs) can supplement professional medical providers, especially in rural settings where resources are particularly scarce. Yet, outcomes of studies evaluating CHWs effectiveness have been highly variable and lack impact when scaled nationally. This study examines if child and maternal outcomes are better when existing government CHWs, who are perinatal home visitors, receive ongoing enhanced supervision and monitoring, compared to standard care. METHODS AND FINDINGS: A cluster randomized controlled effectiveness trial was conducted comparing outcomes over 2 years when different supervision and support are provided. Primary health clinics were randomized by clinic to receive monitoring and supervision from either (1) existing supervisors (Standard Care (SC); n = 4 clinics, 23 CHWs, 392 mothers); or (2) supervisors from a nongovernmental organization that provided enhanced monitoring and supervision (Accountable Care [AC]; n = 4 clinic areas, 20 CHWs, 423 mothers). Assessments were conducted during pregnancy and at 3, 6, 15, and 24 months post-birth with high retention rates (76% to 86%). The primary outcome was the number of statistically significant intervention effects among 13 outcomes of interest; this approach allowed us to evaluate the intervention holistically while accounting for correlation among the 13 outcomes and considering multiple comparisons. The observed benefits were not statistically significant and did not show the AC's efficacy over the SC. Only the antiretroviral (ARV) adherence effect met the significance threshold established a priori (SC mean 2.3, AC mean 2.9, p < 0.025; 95% CI = [0.157, 1.576]). However, for 11 of the 13 outcomes, we observed an improvement in the AC compared to the SC. While the observed outcomes were not statistically significant, benefits were observed for 4 outcomes: increasing breastfeeding for 6 months, reducing malnutrition, increasing ARV adherence, and improving developmental milestones. The major study limitation was utilizing existing CHWs and being limited to a sample of 8 clinics. There were no major study-related adverse events. CONCLUSIONS: Supervision and monitoring were insufficient to improve CHWs' impact on maternal and child outcomes. Alternative strategies for staff recruitment and narrowing the intervention outcomes to the specific local community problems are needed for consistently high impact. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02957799.

Community health worker home visiting in deeply rural South Africa: 12-month outcomes.

Home visiting by community health workers (CHW) improves child outcomes in efficacy trials, there is however limited evidence of impact evaluating CHW programmes when operating outside of a research project. A CHW programme, previously demonstrated efficacious in a peri-urban township, was evaluated in a deeply rural context in a non-randomised comparative cohort study. Two non-contiguous, rural areas in the Eastern Cape of South Africa of about equal size and density were identified and 1469 mother-infant pairs were recruited over 33 months. In one area, CHWs conducted perinatal home visits (intervention group). Mothers in the comparison group received standard clinic care. Maternal and child outcomes were compared between the groups at one year. Mothers in the intervention group had significantly fewer depressive symptoms than mothers in the comparison group. Children of intervention mothers attained a higher proportion of their developmental milestones, compared to children in the comparison group. There were no other significant differences between mothers and children in the two groups. It is important to establish key parameters for implementing efficacious CHW programmes, especially as the numbers of CHWs are rapidly increased and are becoming critical components of task-shifting strategies of health departments in low and middle income countries (LMIC).

Community health workers impact on maternal and child health outcomes in rural South Africa - a non-randomized two-group comparison study.

BACKGROUND: Home visits by paraprofessional community health workers (CHWs) has been shown to improve maternal and child health outcomes in research studies in many countries. Yet, when these are scaled or replicated, efficacy disappears. An effective CHW home visiting program in peri-urban Cape Town found maternal and child health benefits over the 5 years point but this study examines if these benefits occur in deeply rural communities. METHODS: A non-randomized, two-group comparison study evaluated the impact of CHW in the rural Eastern Cape from August 2014 to May 2017, with 1310 mother-infant pairs recruited in pregnancy and 89% were reassessed at 6 months post-birth. RESULTS: Home visiting had limited, but important effects on child health, maternal wellbeing and health behaviors. Mothers reported fewer depressive symptoms, attended more antenatal visits and had better baby-feeding practices. Intervention mothers were significantly more likely to exclusively breastfeed for 6 months (OR: 1.8; 95% CI: 1.1, 2.9), had lower odds of mixing formula with baby porridge (regarded as detrimental) (OR: 0.4; 95% CI: 0.2, 0.8) and were less likely to consult traditional healers. Mothers living with HIV were more adherent with co-trimoxazole prophylaxis (p < 0.01). Intervention-group children were significantly less likely to be wasted (OR: 0.5; 95% CI 0.3-0.9) and had significantly fewer symptoms of common childhood illnesses in the preceding two weeks (OR: 0.8; 95% CI: 0.7,0.9). CONCLUSION: The impact of CHWs in a rural area was less pronounced than in peri-urban areas. CHWs are likely to need enhanced support and supervision in the challenging rural context.

Home visits by community health workers in rural South Africa have a limited, but important impact on maternal and child health in the first two years of life.

BACKGROUND: More than 50% of Africa's population lives in rural areas, which have few professional health workers. South Africa has adopted task shifting health care to Community Health Workers (CHWs) to achieve the Sustainable Development Goals, but little is known about CHWs' efficacy in rural areas. METHODS: In this longitudinal prospective cohort study, almost all mothers giving birth (N = 470) in the Zithulele Hospital catchment area of the OR Tambo District were recruited and repeatedly assessed for 2 years after birth with 84.7-96% follow-up rates. During the cohort assessment we found that some mothers had received standard antenatal and HIV care (SC) (n = 313 mothers), while others had received SC, supplemented with home-visiting by CHWs before and after birth (HV) (n = 157 mothers, 37 CHWs). These visits were unrelated to the cohort study. Multiple linear and logistic regressions evaluated maternal comorbidities, maternal caretaking, and child development outcomes over time. RESULTS: Compared to mothers receiving SC, mothers who also received home visits by CHWs were more likely to attend the recommended four antenatal care visits, to exclusively breastfeed at 3 months, and were less likely to consult traditional healers at 3 months. Mothers in both groups were equally likely to secure the child grant, and infant growth and achievement of developmental milestones were similar over the first 2 years of life. CONCLUSION: CHW home visits resulted in better maternal caretaking, but did not have direct benefits for infants in the domains assessed. The South African Government is planning broad implementation of CHW programmes, and this study examines a comprehensive, home-visiting model in a rural region.

Maternal and child health outcomes in rural South African mothers living with and without HIV.

In the era of widespread antiretroviral therapy (ART), consequences of being HIV-exposed is unclear for children, especially in rural communities. A population sample of consecutive births (470/493) in the Eastern Cape of South Africa (SA) were recruited and reassessed at five points over the first 24 months. Maternal and child outcomes between mothers living with and without HIV were assessed using multiple linear and logistic regressions. At birth, 28% of the sample was mothers living with HIV and five additional mothers seroconverted. All mothers living with HIV reported taking ART. The rate of depressed mood and IPV was similar across serostatus. However, mothers living with HIV significantly decreased their alcohol use after learning about their pregnancy and were more likely to exclusively breastfeed when compared to mothers without HIV. Despite maternal HIV status, children had similar growth across the first 24 months of life. Future work is needed to assess if these developmental trajectories will persist.

Mentor Mothers Zithulele: exploring the role of a peer mentorship programme in rural PMTCT care in Zithulele, Eastern Cape, South Africa.

Background: The majority of global HIV infections in children under 10 years of age occur during pregnancy, delivery or breastfeeding, despite improved coverage of 'prevention of mother-to-child transmission' (PMTCT) guidelines to reduce vertical transmission. This article looks closer at one community-based peer mentorship programme [Mentor Mothers Zithulele (MMZ)] in the Eastern Cape, South Africa which aims to supplement the existing heavily burdened antenatal programmes and improve PMTCT care.Methods: Semi-structured interviews were undertaken with HIV-positive women participating in MMZ and women receiving standard PMTCT care without any intervention. A focus group discussion (FGD) was conducted with women working as Mentor mothers (MMs) for MMZ to explore their experience of the impact of peer mentoring on the rural communities they serve.Results: Six main themes were identified in the interviews with antenatal patients: (i) MMs were a key educational resource, (ii) MMs were important in promoting exclusive breastfeeding, (iii) encouraging early HIV testing during pregnancy and (iv) providing psychosocial support to patients in their homes, thereby reducing stigma and sense of alienation. Respondents requested (v) additional focus on HIV education. MMs can (vi) function as a link between patients and health-care providers, improving treatment adherence. During the FGD two themes emerged; MMs fill the gap between patients and health services, and MMZ should focus on HIV awareness and stigma reduction.Conclusion: Peer mentoring programmes can play an important role in reducing vertical HIV transmission in resource-limited, rural settings by providing participants with education, psychosocial support, and a continuum of care.

A Case Study of an Effective and Sustainable Antiretroviral Therapy Program in Rural South Africa.

The delivery of high-quality HIV care in rural settings is a global challenge. Despite the successful expansion of antiretroviral therapy (ART) in Africa, viral load (VL) monitoring and ART adherence are poor, especially in rural communities. This article describes a case study of an ART program in the deeply rural Eastern Cape of South Africa. The Zithulele ART Program initiated five innovations over time: (1) establishing district hospital as the logistical hub for all ART care in a rural district, (2) primary care clinic delivery of prepackaged ART and chronic medications for people living with HIV (PLH), (3) establishing central record keeping, (4) incentivizing VL monitoring, and (5) providing hospital-based outpatient care for complex cases. Using a pharmacy database, on-time VL monitoring and viral suppression were evaluated for 882 PLH initiating ART in the Zithulele catchment area in 2013. Among PLH initiating ART, 12.5% (n = 110) were lost to follow-up, 7.7% (n = 68) transferred out of the region, 10.2% (n = 90) left the program and came back at a later date, and 4.0% (n = 35) died. Of the on-treatment population, 82.9% (n = 480/579) had VL testing within 7 months and 92.6% (n = 536/579) by 1 year. Viral suppression was achieved in 85.2% of those tested (n = 457/536), or 78.9% (n = 457/579) overall. The program's VL testing and suppression rates appear about twice as high as national data and data from other rural centers in South Africa, despite fewer resources than other programs. Simple system innovations can ensure high rates of VL testing and suppression, even in rural health facilities.

"What is killing me most": chronic pain and the need for palliative care in the Eastern Cape, South Africa.

Palliative care and the provision of pain relief medicine are essential components of health care, yet little research has been conducted on access to pain medicine in rural areas of sub-Saharan Africa. The objective of this study was to examine patient experiences and health care provider attitudes towards chronic pain and palliative care in Eastern Cape Province, South Africa. The study used a mixed-methods approach to evaluate experience of chronic pain in a district hospital and associated clinics. Questionnaires and in-depth interviews were conducted with 45 current and former patients receiving care and 26 health care providers. Forty-six percent (n = 19) of patients rated their pain in the last month as severe. Thirty-nine percent (n = 17) of individuals stated that they had never been provided with an explanation for the cause of their pain. Multiple regression analysis found that being female, not having received a social welfare grant, and not having received an explanation for the cause of pain were associated with higher ratings of pain (P < .10 for each variable). Factors inhibiting the provision of palliative care included insufficient access and availability of pain medication and providers' association of palliative care with end-of-life care. Adequate pain relief is often deprioritized in a busy health care setting. Ensuring patients receive sufficient relief for their pain requires interventions at clinical and policy levels, including the provision of needed pain medication and training in palliative care for all providers.