Can Community Health Workers improve lives? Hope pervades HIV - - PowerPoint PPT Presentation

Can Community Health Workers improve lives?

Hope pervades HIV community

Yet, there are many hurdles; South Africa Tx cascade.

24.7% tested for HIV & know results 83% linked to care

• vs. 41% in Eastern & Southern Africa

62% have achieved viral suppression

• vs. 25% in sub-Saharan Africa

71% of HIV patients adherent

• vs. 77% in sub-Saharan Africa

Fickle global donor community that recognizes the role

• f non-communicable diseases.

87% of global funding = HIV 200,000 AIDS-related deaths (< 40%) 66% of deaths worldwide = NCDs

Behavioral interventions which have failed to be Cost-effective Useful Realistic Evolve with time Sustainable.

Our current scientific norms limit ability to provide CURES.

PI driven models Manual-based training Not responsive to context Replication with fidelity Female models of tend/befriend Interpersonal

Prevention scientists are often like architects who design custom houses, unique for each setting.

Each EBI builds its own structure, process, & content.

Each existing EBI is unique & special, “over-serving the needs” of families.

Disruptive Innovations are simpler, cheaper, & good enough solutions.

Foundational Skills Content Tailoring Local Adaptation Cultural Tailoring Ethnicity, Language, Income, Education Shared processes: Frame issue Apply knowledge Build skills Remove barriers Build social support Dom ains (anxiety, obesity); Situations (enter new school); Developm ental challenges (parenting 0-5, 6-9, 10-12) Practice Elem ents (n=14) utilized to implement a set of Com m on Principles (10)

A model for conceptualizing a training model to diffuse evidence-based interventions.

4 million Community Health Workers (CHW) are poorly trained & provide inconsistent care.

Philani founded in 1 9 7 9 in the Cape Tow n tow nships

Accountability Visit all homes Connect with families Carry entre task Community ties & decision making Weak: Behavior change theory

CHW ( Mentor Mothers) are at the core of Philani’s program .

Three innovations Build our MM’s skills & quality: Selection Training Monitoring

Com m unity health w orkers ( CHW ) are at the core of Philani’s program .

Mobile phones are used throughout all aspects

• f the project.

Collect research data Monitor place, time, & content

• f intervention delivery

Provide MM & their supervisor data

• n content, process, & outcome.

Mobile phones help CHW to provide effective support & monitoring.

Mentor Mothers visit every household, clicks her phone on entry, indicates content, & gives feedback at end.

Target challenge: 14% underweight; 30%, HIV+; 6.5% Fetal Alcohol Syndrome.

Assessm ents at Baseline, Post- Birth, 6 , 1 8 , and 3 6 m onths

• 5 com pleted: 8 0 .6 %
• 4 com pleted: 9 1 .4 %
• 3 com pleted: 9 5 .6 %
• 2 com pleted: 9 8 .9 %

10 20 30 40 50 60 70 80 90 100 2-Weeks Post- birth 6 month 18 month 36 month

%

Follow-up Rates (N=1238)

Randomization worked well. Neighborhoods were highly similar. Shebeens Size Density Water sources Formal / informal housing Rates of HIV Migration history

Mothers were highly similar across conditions. Age, Education Income Number of previous children Low Birth Weight previously HIV status Partnerships

5 10 15 20 25 30 35

Alcohol AUDIT > 2 %

Baseline Characteristics of MLH and MWOH

HIV + HIV -

Linked to Care

• Perinatal 8 3 .5 %
• 6 m onths 4 6 .5 % ( 6 8 % ARV)
• 1 8 m onths 5 4 .5 % ( 8 7 % ARV)
• 3 6 m onths 6 6 % ( 8 0 % ARV)

Disturbing

• HI V + Status ( control group)

–Antenatal 3 2 % –3 6 m onths + 5 %

• Deaths

–Maternal ( 3 5 / 1 4 0 ) 2 5 % –I nfant 8 .9 %

SC PIP

Significant at the 10% level, adjusted for neighborhood clustering.

27.7% 16.9% 24.6% 17.9% 8.4% 13.2%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% Weight-for-age z-score ≤ -1* Height-for-age z-score ≤ -2* Treated at clinic: High fever*

HIV+ Mothers: Infant Health At 18 Months

SC PIP

*Significant at the 5% level.

Intervention work??

Baby nutrition outcom es for the I ntervention Condition

• 1.00
• 0.50

0.00 0.50 1.00 1.50 2.00

Post birth 6 months post birth

Mean weight for length

Time

Predicted Weight for length z-score of Intervention Infants by Mother's antenatal depression status

EPDS > 18 EPDS ≤ 18

• 1.40
• 1.20
• 1.00
• 0.80
• 0.60
• 0.40
• 0.20

0.00 0.20 0.40 0.60 Post Birth 6 Months 18 Months

Height-for-age Z-scores Over Time, Stratified by Severe Antenatal Depression (EPDS>18)

SC Not Depressed SC Depressed PIP Not Depressed PIP Depressed Among the SC, infants of mothers depressed antenatally have significantly lower HAZ scores at 6 months (p=<0.01); however, among the PIP, infants of mothers depressed at baseline do not have significantly different HAZ scores. Looking within mothers depressed during pregnancy, PIP infants have significantly higher HAZ at 6 months (p<0.01), and a significantly more positive change in HAZ between post-birth and 6 months (p=0.04). Note that for n=94 late-entry participants, depression during pregnancy was not assessed. Depression at the time of the late-entry assessment is used as a proxy for antenatal depression.

SC PIP

Significant at the 10% level, adjusted for neighborhood clustering.

49.2% 30.5% 28.6% 15.7%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% Child had cough last two weeks* Since birth child admitted to hospital*

Mothers Depressed Antenatally (EPDS>18): Infant Health At 18 Months

SC PIP

*Significant at the 5% level.

2.7% 2.6 7 8.6% 3.3 4

1 2 3 4 5 6 7 8 9 10 Percent breastfed exclusively first 6 months* Mean months breastfed exclusively * Median count of non-breast-milk food items * Percent / Mean / Median

Feeding Habits Among Mothers Ever Severely Depressed

Control

SC PIP

Significant at the 10% level, adjusted for neighborhood clustering.

8.1% 24.8% 4.1% 17.2%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% Mother currently diagnosed with hypertension* Child had diarrhoea last two weeks*

Among All Subjects: Maternal And Infant Health At 18 Months

SC PIP

*Significant at the 5% level.

SC PIP

Significant at the 10% level, adjusted for neighborhood clustering.

62.0% 31.5% 76.6% 46.6%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% Condom use 10 out of last 10 times* Method family planning: Condom*

HIV+ Mothers: Condom Use At 18 Months

SC PIP

*Significant at the 5% level.

CHW hom e visitors significantly I m prove m aternal & child health.

W e have been reinventing the w heel; w hat has w orked has been the sam e across EBI .

W e know of five innovations w hich w e think consistently im prove im plem entation of CHW

Case assignment Training model Contact strategy Phone & in-person contact Length of intervention

Healthy families will require:

Synthesize common elements, practices, principles Experiment with delivery formats Market strategies to diffuse Adopt continuous quality improvement

MEN ?????

Not In Women’s Settings With Women’s Norms

Men are not going to be engaged in fem ale oriented structures. W ORK & PLAY

The Philani Plus Team thanks you.