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Stansert Katzen L, le Roux KW, Almirol E, Hayati Rezvan P, le Roux IM, Mbewu N, Dippenaar E, Baker V, Tomlinson M, Rotheram-Borus MJ. Community health worker home visiting in deeply rural South Africa: 12-month outcomes. Glob Public Health 2021; 16:1757-1770. [PMID: 33091320 DOI: 10.1080/17441692.2020.1833960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
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).
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Affiliation(s)
- Linnea Stansert Katzen
- Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Zithulele Training and Research Centre, Zithulele Hospital, Eastern Cape, South Africa
| | - Karl W le Roux
- Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Zithulele Training and Research Centre, Zithulele Hospital, Eastern Cape, South Africa
- Department of Family Medicine, Walter Sisulu University, Mthatha, South Africa
- Primary Health Care Directorate, University of Cape Town, Cape Town, South Africa
| | - Ellen Almirol
- Department of Psychiatry & Biobehavioural Sciences, Semel Institute, University of California, Los Angeles, CA, USA
| | - Panteha Hayati Rezvan
- Department of Psychiatry & Biobehavioural Sciences, Semel Institute, University of California, Los Angeles, CA, USA
| | - Ingrid M le Roux
- Philani Maternal, Child Health and Nutrition Trust, Khayelitsha, Cape Town, South Africa
| | - Nokwanele Mbewu
- Philani Maternal, Child Health and Nutrition Trust, Khayelitsha, Cape Town, South Africa
| | - Elaine Dippenaar
- Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Zithulele Training and Research Centre, Zithulele Hospital, Eastern Cape, South Africa
| | - Venetia Baker
- Zithulele Training and Research Centre, Zithulele Hospital, Eastern Cape, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Nursing and Midwifery, Queens University, Belfast, UK
| | - Mary Jane Rotheram-Borus
- Department of Psychiatry & Biobehavioural Sciences, Semel Institute, University of California, Los Angeles, CA, USA
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le Roux KW, Almirol E, Rezvan PH, le Roux IM, Mbewu N, Dippenaar E, Stansert-Katzen L, Baker V, Tomlinson M, Rotheram-Borus MJ. Community health workers impact on maternal and child health outcomes in rural South Africa - a non-randomized two-group comparison study. BMC Public Health 2020; 20:1404. [PMID: 32943043 PMCID: PMC7496216 DOI: 10.1186/s12889-020-09468-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/28/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Karl W le Roux
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
- Zithulele Training and Research Centre, Zithulele Hospital, Ginyintsimbi Village, Eastern Cape, South Africa
- Family Medicine Department, Walter Sisulu University, Mthatha, South Africa
- Primary Healthcare Directorate, University of Cape Town, Cape Town, South Africa
| | - Ellen Almirol
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California, 10920 Wilshire Boulevard, Suite 350, Los Angeles, CA, 90024-6521, USA
| | - Panteha Hayati Rezvan
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California, 10920 Wilshire Boulevard, Suite 350, Los Angeles, CA, 90024-6521, USA
| | - Ingrid M le Roux
- Philani Maternal, Child Health and Nutrition Trust, Site C, Khayelitsha, Cape Town, South Africa
| | - Nokwanele Mbewu
- Philani Maternal, Child Health and Nutrition Trust, Site C, Khayelitsha, Cape Town, South Africa
| | - Elaine Dippenaar
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
| | - Linnea Stansert-Katzen
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
- Zithulele Training and Research Centre, Zithulele Hospital, Ginyintsimbi Village, Eastern Cape, South Africa
| | - Venetia Baker
- Zithulele Training and Research Centre, Zithulele Hospital, Ginyintsimbi Village, Eastern Cape, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Tygerberg, South Africa
- School of Nursing and Midwifery, Queens University, Belfast, UK
| | - M J Rotheram-Borus
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute, University of California, 10920 Wilshire Boulevard, Suite 350, Los Angeles, CA, 90024-6521, USA.
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le Roux K, Christodoulou J, Stansert-Katzen L, Dippenaar E, Laurenzi C, le Roux IM, Tomlinson M, Rotheram-Borus MJ. A longitudinal cohort study of rural adolescent vs adult South African mothers and their children from birth to 24 months. BMC Pregnancy Childbirth 2019; 19:24. [PMID: 30634932 PMCID: PMC6330475 DOI: 10.1186/s12884-018-2164-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/26/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Adolescent motherhood has been repeatedly linked to poor child outcomes in high income countries and urban areas in low- and middle-income countries. We examine the structural, personal, and caretaking challenges of adolescent mothers and their children in rural South Africa compared to adult mothers over the first 24 months post-birth. METHODS A cohort of sequential births (n = 470/493) in the rural OR Tambo District was recruited and reassessed at 3, 6, 9, 12, and at 24 months post-birth, with a retention rate above 84% at all timepoints. Maternal and child outcomes were examined over time using multiple linear and logistic regressions. RESULTS Adolescent mothers reflect 17% of births (n = 76/458). Adolescent mothers were more likely to have water in their households, but less likely to live with a partner and to be seropositive for HIV than adult mothers. Risks posed by mental health symptoms, alcohol, and partner violence were similar. Adolescents exclusively breastfed for shorter time and it took longer for them to secure a child grant compared to adult mothers. Although obtaining immunizations was similar, growth was significantly slower for infants of adolescent mothers compared to adult mothers over time. CONCLUSIONS In rural South Africa, almost one in five pregnant women is an adolescent. Caretaking tasks influencing child growth, especially breastfeeding and securing the child grant appear as the greatest problems for adolescent compared to adult mothers.
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Affiliation(s)
- Karl le Roux
- Walter Sisulu University Family Medicine Department, Zithulele Hospital, Mqanduli District, 5080 South Africa
| | | | - Linnea Stansert-Katzen
- Walter Sisulu University Family Medicine Department, Zithulele Hospital, Mqanduli District, 5080 South Africa
| | - Elaine Dippenaar
- Walter Sisulu University Family Medicine Department, Zithulele Hospital, Mqanduli District, 5080 South Africa
| | - Christina Laurenzi
- Walter Sisulu University Family Medicine Department, Zithulele Hospital, Mqanduli District, 5080 South Africa
| | - Ingrid M. le Roux
- Walter Sisulu University Family Medicine Department, Zithulele Hospital, Mqanduli District, 5080 South Africa
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Private Bag X1, Matieland, 7602 South Africa
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Tomlinson M, Rotheram-Borus MJ, Harwood J, le Roux IM, O’Connor M, Worthman C. Community health workers can improve child growth of antenatally-depressed, South African mothers: a cluster randomized controlled trial. BMC Psychiatry 2015; 15:225. [PMID: 26400691 PMCID: PMC4581418 DOI: 10.1186/s12888-015-0606-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 09/10/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Maternal antenatal depression has long-term consequences for children's health. We examined if home visits by community health workers (CHW) can improve growth outcomes for children of mothers who are antenatally depressed. METHODS A cluster randomized controlled trial of all pregnant, neighbourhood women in Cape Town, South Africa. Almost all pregnant women (98 %, N = 1238) were recruited and assessed during pregnancy, two weeks post-birth (92 %) and 6 months post-birth (88 %). Pregnant women were randomized to either: 1) Standard Care (SC), which provided routine antenatal care; or 2) an intervention, The Philani Intervention Program (PIP), which included SC and home visits by CHW trained as generalists (M = 11 visits). Child standardized weight, length, and weight by length over 6 months based on maternal antenatal depression and intervention condition. RESULTS Depressed mood was similar across the PIP and SC conditions both antenatally (16.5 % rate) and at 6 months (16.7 %). The infants of depressed pregnant women in the PIP group were similar in height (height-for-age Z scores) to the children of non-depressed mothers in both the PIP and the SC conditions, but significantly taller at 6 months of age than the infants of pregnant depressed mothers in the SC condition. The intervention did not moderate children's growth. Depressed SC mothers tended to have infants less than two standard deviations in height on the World Health Organization's norms at two weeks post-birth compared to infants of depressed PIP mothers and non-depressed mothers in both conditions. CONCLUSIONS A generalist, CHW-delivered home visiting program improved infant growth, even when mothers' depression was not reduced. Focusing on maternal caretaking of infants, even when mothers are depressed, is critical in future interventions. TRIAL REGISTRATION ClinicalTrials.gov registration # NCT00996528 . October 15, 2009.
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Affiliation(s)
- Mark Tomlinson
- Department of Psychology, Stellenbosch University, Private Bag X1, Matieland, South Africa.
| | - Mary Jane Rotheram-Borus
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA.
| | - Jessica Harwood
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA.
| | - Ingrid M. le Roux
- Philani Maternal, Child Health, and Nutrition Project, Cape Town, South Africa
| | - Mary O’Connor
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA
| | - Carol Worthman
- Department of Anthropology, Emory University, Atlanta, USA.
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Tomlinson M, O'Connor MJ, le Roux IM, Stewart J, Mbewu N, Harwood J, Rotheram-Borus MJ. Multiple risk factors during pregnancy in South Africa: the need for a horizontal approach to perinatal care. Prev Sci 2015; 15:277-82. [PMID: 23475562 DOI: 10.1007/s11121-013-0376-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
South African children's long-term health and well-being is jeopardized during their mothers' pregnancies by the intersecting epidemics of HIV, alcohol use, low birth weight (LBW; <2,500 g) related to poor nutrition, and depressed mood. This research examines these overlapping risk factors among 1,145 pregnant Xhosa women living in 24 township neighborhoods in Cape Town, South Africa. Results revealed that 66 % of pregnant women experienced at least one risk factor. In descending order of prevalence, 37 % reported depressed mood, 29 % were HIV+, 25 % used alcohol prior to knowing that they were pregnant, and 15 % had a previous childbirth with a LBW infant. Approximately 27 % of women had more than one risk factor: depressed mood was significantly associated with alcohol use and LBW, with a trend to significance with HIV+. In addition, alcohol use was significantly related to HIV+. These results suggest the importance of intervening across multiple risks to maternal and child health, and particularly with depression and alcohol use, to positively impact multiple maternal and infant outcomes.
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Affiliation(s)
- Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa,
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Rotheram-Borus MJ, Tomlinson M, le Roux IM, Harwood JM, Comulada S, O'Connor MJ, Weiss RE, Worthman CM. A cluster randomised controlled effectiveness trial evaluating perinatal home visiting among South African mothers/infants. PLoS One 2014; 9:e105934. [PMID: 25340337 PMCID: PMC4207699 DOI: 10.1371/journal.pone.0105934] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/27/2014] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Interventions are needed to reduce poor perinatal health. We trained community health workers (CHWs) as home visitors to address maternal/infant risks. METHODS In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to 1) the control, healthcare at clinics (n = 12 neighbourhoods; n = 594 women), or 2) a home visiting intervention by CBW trained in cognitive-behavioural strategies to address health risks (by the Philani Maternal, Child Health and Nutrition Programme), in addition to clinic care (n = 12 neighbourhoods; n = 644 women). Participants were assessed during pregnancy (2% refusal) and 92% were reassessed at two weeks post-birth, 88% at six months and 84% at 18 months later. We analysed 32 measures of maternal/infant well-being over the 18 month follow-up period using longitudinal random effects regressions. A binomial test for correlated outcomes evaluated overall effectiveness over time. The 18 month post-birth assessment outcomes also were examined alone and as a function of the number of home visits received. RESULTS Benefits were found on 7 of 32 measures of outcomes, resulting in significant overall benefits for the intervention compared to the control when using the binomial test (p = 0.008); nevertheless, no effects were observed when only the 18 month outcomes were analyzed. Benefits on individual outcomes were related to the number of home visits received. Among women living with HIV, intervention mothers were more likely to implement the PMTCT regimens, use condoms during all sexual episodes (OR = 1.25; p = 0.014), have infants with healthy weight-for-age measurements (OR = 1.42; p = 0.045), height-for-age measurements (OR = 1.13, p<0.001), breastfeed exclusively for six months (OR = 3.59; p<0.001), and breastfeed longer (OR = 3.08; p<0.001). Number of visits was positively associated with infant birth weight ≥2500 grams (OR = 1.07; p = 0.012), healthy head-circumference-for-age measurements at 6 months (OR = 1.09, p = 0.017), and improved cognitive development at 18 months (OR = 1.02, p = 0.048). CONCLUSIONS Home visits to neighbourhood mothers by CHWs may be a feasible strategy for enhancing maternal/child outcomes. However, visits likely must extend over several years for persistent benefits. TRIAL REGISTRATION ClinicalTrials.gov NCT00996528.
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Affiliation(s)
- Mary Jane Rotheram-Borus
- Department of Psychiatry and Biobehavioral Medicine, Semel Institute, University of California Los Angeles, Los Angeles, California, United States of America
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Ingrid M. le Roux
- Philani Maternal, Child Health and Nutrition Programme, Elonwabeni, Cape Town, South Africa
| | - Jessica M. Harwood
- Department of Psychiatry and Biobehavioral Medicine, Semel Institute, University of California Los Angeles, Los Angeles, California, United States of America
| | - Scott Comulada
- Department of Psychiatry and Biobehavioral Medicine, Semel Institute, University of California Los Angeles, Los Angeles, California, United States of America
| | - Mary J. O'Connor
- Department of Psychiatry and Biobehavioral Medicine, Semel Institute, University of California Los Angeles, Los Angeles, California, United States of America
| | - Robert E. Weiss
- Department of Biostatistics, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America
| | - Carol M. Worthman
- Department of Anthropology, Emory University, Atlanta, Georgia, United States of America
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Tsai AC, Tomlinson M, Dewing S, le Roux IM, Harwood JM, Chopra M, Rotheram-Borus MJ. Antenatal depression case finding by community health workers in South Africa: feasibility of a mobile phone application. Arch Womens Ment Health 2014; 17:423-31. [PMID: 24682529 PMCID: PMC4167933 DOI: 10.1007/s00737-014-0426-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 03/04/2014] [Indexed: 12/13/2022]
Abstract
Randomized controlled trials conducted in resource-limited settings have shown that once women with depressed mood are evaluated by specialists and referred for treatment, lay health workers can be trained to effectively administer psychological treatments. We sought to determine the extent to which community health workers could also be trained to conduct case finding using short and ultrashort screening instruments programmed into mobile phones. Pregnant, Xhosa-speaking women were recruited independently in two cross-sectional studies (N = 1,144 and N = 361) conducted in Khayelitsha, South Africa and assessed for antenatal depression. In the smaller study, community health workers with no training in human subject research were trained to administer the Edinburgh Postnatal Depression Scale (EPDS) during the routine course of their community-based outreach. We compared the operating characteristics of four short and ultrashort versions of the EPDS with the criterion standard of probable depression, defined as an EPDS-10 ≥ 13. The prevalence of probable depression (475/1144 [42 %] and 165/361 [46 %]) was consistent across both samples. The 2-item subscale demonstrated poor internal consistency (Cronbach's α ranged from 0.55 to 0.58). All four subscales demonstrated excellent discrimination, with area under the receiver operating characteristic curve (AUC) values ranging from 0.91 to 0.99. Maximal discrimination was observed for the 7-item depressive symptoms subscale: at the conventional screening threshold of ≥10, it had 0.97 sensitivity and 0.76 specificity for detecting probable antenatal depression. The comparability of the findings across the two studies suggests that it is feasible to use community health workers to conduct case finding for antenatal depression.
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Affiliation(s)
- Alexander C. Tsai
- Center for Global Health and Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, US,Harvard Medical School, Boston, MA, US,Address correspondence to: Alexander Tsai, Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street, 15th floor, Boston, MA 02114 USA.
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Sarah Dewing
- Health Systems Research Unit, Medical Research Council of South Africa, Tygerberg, South Africa
| | - Ingrid M. le Roux
- Philani Child Health and Nutrition Project, Khayelitsha, Elonwabeni, Cape Town, South Africa
| | - Jessica M. Harwood
- Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry, University of California at Los Angeles, Los Angeles, CA, US
| | - Mickey Chopra
- Health Section, United Nations Children’s Fund, New York, NY, US
| | - Mary Jane Rotheram-Borus
- Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry, University of California at Los Angeles, Los Angeles, CA, US,Global Center for Child and Families, University of California at Los Angeles, Los Angeles, CA, US
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le Roux IM, Rotheram-Borus MJ, Stein J, Tomlinson M. The impact of paraprofessional home visitors on infants' growth and health at 18 months. Vulnerable Child Youth Stud 2014; 9:291-304. [PMID: 25342956 PMCID: PMC4203669 DOI: 10.1080/17450128.2014.940413] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Paraprofessional home visitors trained to improve multiple outcomes (HIV, alcohol, infant health, and malnutrition) have been shown to benefit mothers and children over 18 months in a cluster randomised controlled trial (RCT). These longitudinal analyses examine the mechanisms which influence child outcomes at 18 months post-birth in Cape Town, South Africa. The results were evaluated using structural equation modelling, specifically examining the mediating effects of prior maternal behaviours and a home visiting intervention post-birth. Twelve matched pairs of neighbourhoods were randomised within pairs to: 1) the control condition, receiving comprehensive healthcare at community primary health care clinics (n=12 neighbourhoods; n=594 pregnant women), or 2) the Philani Intervention Program, which provided home visits by trained, paraprofessional community health workers, here called Mentor Mothers, in addition to clinic care (n=12 neighbourhoods; n=644 pregnant women). Recruitment of all pregnant neighbourhood women was high (98%) with 88% reassessed at six months and 84% at 18 months. Infants' growth and diarrhoea episodes were examined at 18 months in response to the intervention condition, breastfeeding, alcohol use, social support, and low birth weight, controlling for HIV status and previous history of risk. We found that randomisation to the intervention was associated with a significantly lower number of recent diarrhoea episodes and increased rates and duration of breastfeeding. Across both the intervention and control conditions, mothers who used alcohol during pregnancy and had low birth weight infants were significantly less likely to have infants with normal growth patterns, whereas social support was associated with better growth. HIV-infection was significantly associated with poor growth and less breastfeeding. Women with more risk factors had significantly smaller social support networks. The relationships among initial and sustained maternal risk behaviours and the buffering impact of home visits and social support are demonstrated in these analyses.
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Affiliation(s)
- Ingrid M le Roux
- Philani Maternal, Child Health and Nutrition Project, Cape Town, South Africa
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Dewing S, Tomlinson M, le Roux IM, Chopra M, Tsai AC. Food insecurity and its association with co-occurring postnatal depression, hazardous drinking, and suicidality among women in peri-urban South Africa. J Affect Disord 2013; 150:460-5. [PMID: 23707034 PMCID: PMC3762324 DOI: 10.1016/j.jad.2013.04.040] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 04/26/2013] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although the public health impacts of food insecurity and depression on both maternal and child health are extensive, no studies have investigated the associations between food insecurity and postnatal depression or suicidality. METHODS We interviewed 249 women three months after they had given birth and assessed food insecurity, postnatal depression symptom severity, suicide risk, and hazardous drinking. Multivariable Poisson regression models with robust standard errors were used to estimate the impact of food insecurity on psychosocial outcomes. RESULTS Food insecurity, probable depression, and hazardous drinking were highly prevalent and co-occurring. More than half of the women (149 [59.8%]) were severely food insecure, 79 (31.7%) women met screening criteria for probable depression, and 39 (15.7%) women met screening criteria for hazardous drinking. Nineteen (7.6%) women had significant suicidality, of whom 7 (2.8%) were classified as high risk. Each additional point on the food insecurity scale was associated with increased risks of probable depression (adjusted risk ratio [ARR], 1.05; 95% CI, 1.02-1.07), hazardous drinking (ARR, 1.04; 95% CI, 1.00-1.09), and suicidality (ARR, 1.12; 95% CI, 1.02-1.23). Evaluated at the means of the covariates, these estimated associations were large in magnitude. LIMITATIONS The study is limited by lack of data on formal DSM-IV diagnoses of major depressive disorder, potential sample selection bias, and inability to assess the causal impact of food insecurity. CONCLUSION Food insecurity is strongly associated with postnatal depression, hazardous drinking, and suicidality. Programmes promoting food security for new may enhance overall psychological well-being in addition to improving nutritional status.
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Affiliation(s)
- Sarah Dewing
- Health Systems Research Unit, Medical Research Council of South Africa, Tygerberg, South Africa
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Ingrid M. le Roux
- Philani Child Health and Nutrition Project, Khayelitsha, Elonwabeni, Cape Town, South Africa
| | - Mickey Chopra
- Health Section, United Nations Children's Fund, NY, United States
| | - Alexander C. Tsai
- Center for Global Health and Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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le Roux IM, Tomlinson M, Harwood JM, O'Connor MJ, Worthman CM, Mbewu N, Stewart J, Hartley M, Swendeman D, Comulada WS, Weiss RE, Rotheram-Borus MJ. Outcomes of home visits for pregnant mothers and their infants: a cluster randomized controlled trial. AIDS 2013; 27:1461-71. [PMID: 23435303 PMCID: PMC3904359 DOI: 10.1097/qad.0b013e3283601b53] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effect of home visits by community health workers (CHWs) on maternal and infant well being from pregnancy through the first 6 months of life for women living with HIV (WLH) and all neighborhood mothers. DESIGN AND METHODS In a cluster randomized controlled trial in Cape Town townships, neighborhoods were randomized within matched pairs to either standard care, comprehensive healthcare at clinics (n=12 neighborhoods; n=169 WLH; n=594 total mothers); or Philani Intervention Program, home visits by CHWs in addition to standard care (PIP; n=12 neighborhoods; n=185 WLH; n=644 total mothers). Participants were assessed during pregnancy (2% refusal) and reassessed at 1 week (92%) and 6 months (88%) postbirth. We analyzed PIP's effect on 28 measures of maternal and infant well being among WLH and among all mothers using random effects regression models. For each group, PIP's overall effectiveness was evaluated using a binomial test for correlated outcomes. RESULTS Significant overall benefits were found in PIP compared to standard care among WLH and among all participants. Secondarily, compared to standard care, PIP WLH were more likely to complete tasks to prevent vertical transmission, use one feeding method for 6 months, avoid birth-related medical complications, and have infants with healthy height-for-age measurements. Among all mothers, compared to standard care, PIP mothers were more likely to use condoms consistently, breastfeed exclusively for 6 months, and have infants with healthy height-for-age measurements. CONCLUSION PIP is a model for countries facing significant reductions in HIV funding whose families face multiple health risks.
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Affiliation(s)
- Ingrid M le Roux
- Philani Maternal, Child Health and Nutrition Project, Cape Town, South Africa
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Rotheram-Borus MJ, le Roux IM, Tomlinson M, Mbewu N, Comulada WS, le Roux K, Stewart J, O'Connor MJ, Hartley M, Desmond K, Greco E, Worthman CM, Idemundia F, Swendeman D. Philani Plus (+): a Mentor Mother community health worker home visiting program to improve maternal and infants' outcomes. Prev Sci 2011; 12:372-88. [PMID: 21850488 PMCID: PMC3907085 DOI: 10.1007/s11121-011-0238-1] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Pregnant mothers in South African townships face multiple health risks for themselves and their babies. Existing clinic-based services face barriers to access, utilization, and human resource capacities. Home visiting by community health workers (CHW) can mitigate such barriers. The Philani Plus (+) Intervention Program builds upon the original Philani CHW home-visiting intervention program for maternal and child nutrition by integrating content and activities to address HIV, alcohol, and mental health. Pregnant Mothers at Risk (MAR) for HIV, alcohol, and/or nutrition problems in 24 neighborhoods in townships in Cape Town, South Africa (n = 1,239) were randomly assigned by neighborhood to an intervention (Philani Plus (+), N = 12 neighborhoods; n = 645 MAR) or a standard-care control condition of neighborhood clinic-based services (N = 12 neighborhoods; n = 594 MAR). Positive peer deviant "Mentor Mother" CHWs are recruited from the township neighborhoods and trained to deliver four antenatal and four postnatal home visits that address HIV, alcohol, nutrition, depression, health care regimens for the family, caretaking and bonding, and securing government-provided child grants. The MAR and their babies are being monitored during pregnancy, 1 week post-birth, and 6 and 18 months later. Among the 1,239 MAR recruited: 26% were HIV-positive; 27% used alcohol during pregnancy; 17% previously had low-birthweight babies; 23% had at least one chronic condition (10% hypertension, 5% asthma, 2% diabetes); 93% had recent sexual partners with 10% known to be HIV+; and 17% had clinically significant prenatal depression and 42% had borderline depression. This paper presents the intervention protocol and baseline sample characteristics for the "Philani Plus (+)" CHW home-visiting intervention trial.
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le Roux IM, le Roux K, Mbeutu K, Comulada WS, Desmond KA, Rotheram-Borus MJ. A randomized controlled trial of home visits by neighborhood mentor mothers to improve children's nutrition in South Africa. Vulnerable Child Youth Stud 2011; 6:91-102. [PMID: 22299019 PMCID: PMC3262232 DOI: 10.1080/17450128.2011.564224] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Malnourished children and babies with birth weights under 2500 g are at high risk for negative outcomes over their lifespans. Philani, a paraprofessional home visiting program, was developed to improve nutritional outcomes for young children in South Africa. One "mentor mother" was recruited from each of 37 neighborhoods in Cape Town, South Africa. Mentor mothers were trained to conduct home visits to weigh children under six years old and to support mothers to problem-solve life challenges, especially around nutrition. Households with underweight children were assigned randomly on a 2:1 ratio to the Philani program (n = 500) or to a standard care condition (n = 179); selection effects occurred and children in the intervention households weighed less at recruitment. Children were evaluated over a one-year period (n = 679 at recruitment and n = 638 with at least one follow-up; 94%). Longitudinal random effects models indicated that, over 12 months, the children in the intervention condition gained significantly more weight than children in the control condition. Mentor mothers who are positive peer deviants may be a viable strategy that is efficacious and can build community, and the use of mentor mothers for other problems in South Africa is discussed.
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Affiliation(s)
- Ingrid M. le Roux
- Philani Child Health and Nutrition Project, Khayelitsha, Elonwabeni, Cape Town, South Africa
| | - Karl le Roux
- Zithulele Hospital, Eastern Cape, Zithulele Village, Mqanduli District, South Africa
| | - Kwanie Mbeutu
- Philani Child Health and Nutrition Project, Khayelitsha, Elonwabeni, Cape Town, South Africa
| | - W. Scott Comulada
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, California, USA
| | - Katherine A. Desmond
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, California, USA
| | - Mary Jane Rotheram-Borus
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, California, USA
- Corresponding author.
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le Roux IM, le Roux K, Comulada WS, Greco EM, Desmond KA, Mbewu N, Rotheram-Borus MJ. Home visits by neighborhood Mentor Mothers provide timely recovery from childhood malnutrition in South Africa: results from a randomized controlled trial. Nutr J 2010; 9:56. [PMID: 21092178 PMCID: PMC3002292 DOI: 10.1186/1475-2891-9-56] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 11/22/2010] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Child and infant malnourishment is a significant and growing problem in the developing world. Malnourished children are at high risk for negative health outcomes over their lifespans. Philani, a paraprofessional home visiting program, was developed to improve childhood nourishment. The objective of this study is to evaluate whether the Philani program can rehabilitate malnourished children in a timely manner. METHODS Mentor Mothers were trained to conduct home visits. Mentor Mothers went from house to house in assigned neighborhoods, weighed children age 5 and younger, and recruited mother-child dyads where there was an underweight child. Participating dyads were assigned in a 2:1 random sequence to the Philani intervention condition (n = 536) or a control condition (n = 252). Mentor Mothers visited dyads in the intervention condition for one year, supporting mothers' problem-solving around nutrition. All children were weighed by Mentor Mothers at baseline and three, six, nine and twelve month follow-ups. RESULTS By three months, children in the intervention condition were five times more likely to rehabilitate (reach a healthy weight for their ages) than children in the control condition. Throughout the course of the study, 43% (n = 233 of 536) of children in the intervention condition were rehabilitated while 31% (n = 78 of 252) of children in the control condition were rehabilitated. CONCLUSIONS Paraprofessional Mentor Mothers are an effective strategy for delivering home visiting programs by providing the knowledge and support necessary to change the behavior of families at risk.
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Affiliation(s)
- Ingrid M le Roux
- Philani Child Health and Nutrition Project, Khayelitsha, PO Box 40188, Elonwabeni, Cape Town, 7791, South Africa
| | - Karl le Roux
- Zithulele Hospital, Eastern Cape Zithulele Village, Mqanduli District, 5080, South Africa
| | - W Scott Comulada
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles 360 Westwood Blvd., Los Angeles, California 90095, USA
| | - Erin M Greco
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles 360 Westwood Blvd., Los Angeles, California 90095, USA
| | - Katherine A Desmond
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles 360 Westwood Blvd., Los Angeles, California 90095, USA
| | - Nokwanele Mbewu
- Philani Child Health and Nutrition Project, Khayelitsha, PO Box 40188, Elonwabeni, Cape Town, 7791, South Africa
| | - Mary Jane Rotheram-Borus
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles 360 Westwood Blvd., Los Angeles, California 90095, USA
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