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, self- efficacy and practice? What is the effect on infant feeding practices, and uptake of PMTCT and MCH services?

Setting and Design 3 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

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 Baseline 6 Months12 Months CHW: Mothers: Pre- Intervention Post- Intervention

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 CharacteristicsIntervention CHW N=60 Control CHW N=60 P-value Age (years), Median (IQR) 39.3 ( )38.5 ( )0.91 Female98.3%100%0.91 Education – completed secondary school 31.67%31.66%0.92 Experience as CHW: 4+ years 63.3%61.7%0.88

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 Percent Correct P=0.28 P<0.0001

Participant Characteristics: Mothers Pre-Intervention 23 April 2012 to 3 August 2012 Post-Intervention 4 November 2013 to 31 March 2013 Control catchment Intervention catchment TotalControl catchment Intervention catchment Total N=370N=366N=736N=310N=296N=606 Age, Median (IQR) 25 years (21 years to 30 years) 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) P value = 0.48P value = 0.93 At least some secondary level education 289 (78.1%)272 (74.3%)561 (76.2%)255 (82.3%)220 (71.0%)475 (78.4%) P value = 0.65P value = 0.83 Employed32 (8.7%)28 (7.8%)60 (8.2%)25 (8.1%)22 (7.5%)47 (7.8%) P value = 0.67P value = 0.83 HIV- positive 30.0%27.4%28.7%27.5%28.3%27.8% P value = 0.48P value = 0.86

Mother report about CHW visits

Exclusive Breastfeeding in First 6 Weeks P = 0.15P = 0.02 N=305N=298N=231N=256

Care Seeking P=0.16P=0.02 P=0.33 P=0.02 Did not seek care for self when needed in prior 6 months Did not seek care for child when needed in prior 6 months

Receipt of ANC, PNC, HIV and PMTCT services (post-intervention)

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