An RCT to Improve the South African Government's Community Health Workers' Capacities to Deliver Evidence-based Interventions for Optimizing HIV Outcomes and Reducing its Comorbidities

摘要 非洲的保健服务，特别是社区保健服务的特点是效率低下， 能力有限，人员缺乏培训。这些系统中的护理质量在很大程度上取决于 关于人员：培训、监测和持续的执行质量。南非正在部署 65，000名社区卫生工作者（CHW），然而，目前几乎没有任何系统， 系统尚未计划如何培训，监测和确保这些CHW提供高质量的护理。以试点 在南非的东开普省，过去六个月里，我们发现25%的CHW没有上班 在任何时候，当监督第一次外包时。这种表现和失败的监测 表现，与谴责不出勤的后果，往往是典型的CHW服务提供， 低收入和中等收入国家（LMIC）在联合国成功开展成效研究的基础上， 南非开普敦的乡镇，我们的目标是表明，培训，监测和数据知情 监督将导致CHW在孕产妇和儿童健康（MCH）方面比前两个方面有显着的好处 特别是感染艾滋病毒的母亲、抑郁的母亲和少龄母亲。的支持下 省政府，Philani的创新培训和监测战略旨在表明，我们 可以缩小我们所知道的（基于科学）和我们所做的改善农村健康之间的差距 目前缺乏问责制和效率。 加州大学洛杉矶分校、斯泰伦博斯大学、齐图莱医院和菲拉尼妇幼保健和营养信托基金 将合作进行由政府资助的CHW提供的第二次家访效果RCT。 加州大学洛杉矶分校将随机选择24个匹配的地区，每个地区都有政府资助的CHW：1）接受家访培训， 监督，并定期监测（即，Philani干预模式[PIM]，n=420名妇女，12个地区）;或2） 标准护理（SC）控制家庭访问由CHW谁接受当前标准的培训，监测， 监督（n=420名妇女，12个地区）。在样本中，25%将是未成年母亲; 30%将是MLH; 25%的人会在怀孕期间饮酒; 22%的人会感到抑郁。将进行独立评估 斯泰伦博斯大学在怀孕期间，出生后两周内，6，15和24个月后。我们 将构建一个全面的分析测试，同时检查多个结果与综合测试。 我们将监测MLH的艾滋病毒检测，与护理的联系，治疗的坚持和保留;孕产妇健康 指标（体重、糖尿病、心理健康状况、伴侣关系、酒精使用和伴侣暴力）;以及 儿童的身体发育、认知、情感和行为适应。我们预计PIM将显著改善 结果总体和高风险亚组（MLH，抑郁，青少年，饮酒）。分析 实时过程从CHW（持续时间、频率、内容区域、使用的技能、电话联系人）测量 收集到的信息将使我们能够设计和重新设计实施战略。

Abstract Health services and especially community-based health services in Africa are characterized by inefficiency, limited capacity, and poorly-trained personnel. The quality of care in these systems is dependent most heavily on personnel: training, monitoring, and ongoing quality of the implementation. South Africa is deploying 65,000 community health workers (CHW), however, there are almost no systems currently, nor are the systems yet planned for how to train, monitor, and ensure quality care is delivered by these CHW. In a pilot over the last six months in the Eastern Cape of South Africa, we found 25% of CHW not showing up for work at any time, when supervision was out-sourced for the first time. Such performance and failures to monitor performance, with consequences of censuring non-attendance, are often typical of CHW service delivery in low and middle income countries (LMIC). Building on the results of a successful effectiveness study in the townships of Cape Town, South Africa, we aim to show that training, monitoring, and data-informed supervision will result in CHW having significant benefits in maternal and child health (MCH) over the first two years of life, particularly mothers living with HIV, depressed mothers, and teenage mothers. With support from the provincial government, Philani's innovative training and monitoring strategies aim to demonstrate that we can decrease the gap between what we know (based on science) and what we do to improve health in rural communities that currently lack accountability and efficiency. UCLA, Stellenbosch University, Zithulele Hospital, and the Philani Maternal, Child Health and Nutrition Trust will collaborate on this second effectiveness RCT of home visiting delivered by government-funded CHW. UCLA will randomize 24 matched areas, each with government-funded CHW to either: 1) home visiting trained, supervised, and routinely monitored (i.e., the Philani Intervention Model [PIM], n=420 women, 12 areas); or 2) a standard care (SC) control home visiting by CHW who receive current standards of training, monitoring, and supervision (n=420 women, 12 areas). Within the sample, 25% will be adolescent mothers; 30% will be MLH; 25% will drink alcohol in pregnancy; and 22% will be depressed. Independent assessments will be conducted by Stellenbosch University during pregnancy, within two weeks of post-birth, 6, 15, and 24 months later. We will construct an overall analytic test which examines multiple outcomes simultaneously with an omnibus test. We will monitor MLH's HIV testing, linkage to care, treatment adherence and retention; maternal health indicators (weight, diabetes, mental health status, partnerships, alcohol use, and partner violence); and, the child's physical growth, cognitive, affective, and behavioral adjustment. We expect PIM to significantly improve outcomes overall and for the high risk subgroups (MLH, depressed, adolescents, alcohol-using). Analyses of the real-time process measures from CHW (duration, frequency, content area, skill used, phone contacts) collected on mobiles will allow us to design and redesign implementation strategies.