Nompilo Study: Results of Evaluation
Lisa M. Butler, PhD, MPH
Division of General Pediatrics, Boston Children’s Hospital
Department of Pediatrics, Harvard Medical School
Presenting on behalf of the Nompilo Study Team:
C. Horwood, W. Ngidi, M. Grant, J. Reddy, P. Barker, and N. Rollins
Research Questions
Implementing integrated community case management
training & QI support to CHWs:
•
Is it feasible?
•
Does it lead to gains in CHW knowledge, selfefficacy
and practice?
•
What is the effect on infant feeding practices, and
uptake of PMTCT and MCH services?
Setting and Design
Setting:
• Ugu District, KwaZulu Natal, South Africa
Design:
• Cluster randomized controlled trial
• CHW supervisors (N=30), CHWs (N=120)
• Mothers: ~8 mothers per CHW pre & post intervention
3
Participants and Timelines
• CHW:
• > 18 years old
• Grade 9 education or greater
• Employed by Department of Health to provide home support to
pregnant women, mothers and children in Ugu District, SA
• Mothers
• > 18 years old
• Delivered live-born infant in past 12 months
• Reside in household assigned to participating CHW
CHW:
Baseline
Mothers:
PreIntervention
6 Months
12 Months
PostIntervention
Analytic Approach
•
Mixed-effects models
•
Interaction of treatment group with visit month tested for
differences in rate of change between groups
Results
Participant Characteristics: CHW
Characteristics
Intervention CHW
N=60
Control CHW
N=60
P-value
39.3 (34.7-44.6)
38.5 (34.1-44.5)
0.91
Female
98.3%
100%
0.91
Education –
completed secondary
school
31.67%
31.66%
0.92
Experience as CHW:
4+ years
63.3%
61.7%
0.88
Age (years), Median
(IQR)
Self Efficacy
•
Significantly improved self efficacy at 6 and 12 months
(intervention vs control CHWs):
• Talking to a pregnant woman about HIV
• Advising a pregnant woman about her own nutrition
• Assisting a mother with breastfeeding
• Explaining services available for PMTCT
• Doing a postnatal visit to check the mother’s health & newborn baby
• Recognizing danger signs in pregnancy, newborn or postpartum
mother
CHW Knowledge
80
P=0.28
P<0.0001
P<0.0001
70
Percent Correct
60
50
Control CHW
40
Intervention CHW
30
20
10
0
Baseline
6 Months
12 Months
Participant Characteristics: Mothers
Pre-Intervention
23 April 2012 to 3 August 2012
Age,
Median
(IQR)
Control
catchment
Intervention
catchment
Total
Control
catchment
Intervention
catchment
Total
N=370
N=366
N=736
N=310
N=296
N=606
24 years (20
years to 30
years)
25 years (21
years to 30
years)
23 years (20
years to 29
yeas)
23 years (20
years to 28
years)
23 years (20
years to 29
years)
25 years (21
years to 30
years)
P value = 0.48
At least
some
secondary
level
education
289 (78.1%)
272 (74.3%)
P value = 0.93
561 (76.2%)
P value = 0.65
Employed
32 (8.7%)
28 (7.8%)
30.0%
27.4%
P value = 0.48
255 (82.3%)
220 (71.0%)
475 (78.4%)
P value = 0.83
60 (8.2%)
P value = 0.67
HIVpositive
Post-Intervention
4 November 2013 to 31 March 2013
25 (8.1%)
22 (7.5%)
47 (7.8%)
P value = 0.83
28.7%
27.5%
28.3%
P value = 0.86
27.8%
Mother report about CHW visits
100
90
80
70
60
50
40
30
20
10
0
Control Catchment
Intervention Catchment
Exclusive Breastfeeding in First 6 Weeks
100
Control Catchment
Intervention Catchment
90
80
P = 0.15
P = 0.02
70
60
50
40
30
20
10
0
N=298
Time 1
N=305
N=256
Time 2
N=231
Care Seeking
35
30
Control Catchment
P=0.16
Intervention Catchment
P=0.02
P=0.33
25
P=0.02
20
15
10
5
0
Pre-Intervention
Post-Intervention
Did not seek care for self when
needed in prior 6 months
Pre-Intervention
Post-Intervention
Did not seek care for child
when needed in prior 6 months
Receipt of ANC, PNC, HIV and PMTCT services (post-intervention)
100
Control Catchment
Intervention Catchment
90
80
70
60
50
40
30
20
10
0
Attended ANC
HF birth
PNC in 1st week Offered HIV test
in pregnancy
Referred for
ART
On ART when
baby born
Baby had PCR Received PCR
test
test
Summary
Compared to CHWs in control arm, CHWs in intervention arm:
• Significantly greater level of self-efficacy
• Significantly greater level of HIV and MCH-related knowledge
• Knowledge regarding HIV/MCH content sustained over time
Compared to mothers in control catchment, mothers in intervention arm:
• Reported more frequent CHW visits and discussion about HIV/MCHN
• Significant improvement in exclusive breastfeeding in first 6 weeks
• Significant improvement in care-seeking for mothers and infants
• No change in receipt of HIV testing or receipt of PMTCT services – but
prevalence overall was very high
Conclusions
• Training approach and materials were effective in knowledge
transfer and highly appreciated even though demanding;
• QI supervision and support of CHWs was feasible and valued;
• Improved CHW knowledge, self-efficacy and practices were
sustained over time;
• Some maternal behavior change observed, despite short period of
intervention
Nompilo Study Team
20,000+ Partnership
•
Dr. Jennifer Reddy (PI-intervention)
•
Wilbroda Ngidi
•
Khumbuzile Sishi
•
Ellen Ntswe
•
Lorraine Mkhize
•
Sandra Reid
Centre for Rural Health, U. KwaZulu-Natal
•
Dr. Christiane Horwood (PI-evaluation)
•
Merridy Grant
•
Lyn Haskins
•
Sifiso Phakathi
•
Ntokozo Mntambo
•
Rosemary Brown
World Health Organization
•Dr. Nigel Rollins
Institute for Healthcare Improvement
•Dr. Pierre Barker
•Dr. Kedar Mate
Boston Children’s Hospital
•Dr. Lisa M. Butler
Acknowledgements
Lenore Spies, Nutrition Manager, KwaZulu-Natal Department of Health
Janet Dalton, KwaZulu-Natal Primary Healthcare Manager
Victoria Mubaiwa, Maternal and Child Health Director, KwaZulu-Natal Department of
Health
Dr. Charles McCulloch, University of California San Francisco
Dr. Henry Feldman, Boston Children’s Hospital
Funders:
•US Centers for Disease Control and Prevention
•World Health Organization