The effect of supervision on community health workers' effectiveness with households in rural South Africa: A cluster randomized controlled trial.

Autor: Rotheram-Borus MJ; Dept. of Psychiatry and Biobehavioral Sciences, Semel Institute, University of CA, Los Angeles, California, United States of America., le Roux KW; Institute for Life Course Health Research, Dept. of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.; Dept. of Family Medicine, Walter Sisulu University, Mthatha, South Africa.; Primary Health Care Directorate, Old Main Building, Groote Schuur Hospital, Cape Town, South Africa.; Zithulele Training and Research Centre, Zithulele Hospital, Mqanduli District, Eastern Cape, South Africa., Norwood P; Dept. of Psychiatry and Biobehavioral Sciences, Semel Institute, University of CA, Los Angeles, California, United States of America., Stansert Katzen L; Institute for Life Course Health Research, Dept. of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa., Snyman A; Zithulele Training and Research Centre, Zithulele Hospital, Mqanduli District, Eastern Cape, South Africa., le Roux I; Philani Maternal, Child Health and Nutrition Trust, Khayelitsha, Cape Town, South Africa., Dippenaar E; Zithulele Training and Research Centre, Zithulele Hospital, Mqanduli District, Eastern Cape, South Africa., Tomlinson M; Institute for Life Course Health Research, Dept. of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.; School of Nursing and Midwifery, Queens University, Belfast, United Kingdom.
Jazyk: angličtina
Zdroj: PLoS medicine [PLoS Med] 2023 Mar 02; Vol. 20 (3), pp. e1004170. Date of Electronic Publication: 2023 Mar 02 (Print Publication: 2023).
DOI: 10.1371/journal.pmed.1004170
Abstrakt: Background: Community health workers (CHWs) can supplement professional medical providers, especially in rural settings where resources are particularly scarce. Yet, outcomes of studies evaluating CHWs effectiveness have been highly variable and lack impact when scaled nationally. This study examines if child and maternal outcomes are better when existing government CHWs, who are perinatal home visitors, receive ongoing enhanced supervision and monitoring, compared to standard care.
Methods and Findings: A cluster randomized controlled effectiveness trial was conducted comparing outcomes over 2 years when different supervision and support are provided. Primary health clinics were randomized by clinic to receive monitoring and supervision from either (1) existing supervisors (Standard Care (SC); n = 4 clinics, 23 CHWs, 392 mothers); or (2) supervisors from a nongovernmental organization that provided enhanced monitoring and supervision (Accountable Care [AC]; n = 4 clinic areas, 20 CHWs, 423 mothers). Assessments were conducted during pregnancy and at 3, 6, 15, and 24 months post-birth with high retention rates (76% to 86%). The primary outcome was the number of statistically significant intervention effects among 13 outcomes of interest; this approach allowed us to evaluate the intervention holistically while accounting for correlation among the 13 outcomes and considering multiple comparisons. The observed benefits were not statistically significant and did not show the AC's efficacy over the SC. Only the antiretroviral (ARV) adherence effect met the significance threshold established a priori (SC mean 2.3, AC mean 2.9, p < 0.025; 95% CI = [0.157, 1.576]). However, for 11 of the 13 outcomes, we observed an improvement in the AC compared to the SC. While the observed outcomes were not statistically significant, benefits were observed for 4 outcomes: increasing breastfeeding for 6 months, reducing malnutrition, increasing ARV adherence, and improving developmental milestones. The major study limitation was utilizing existing CHWs and being limited to a sample of 8 clinics. There were no major study-related adverse events.
Conclusions: Supervision and monitoring were insufficient to improve CHWs' impact on maternal and child outcomes. Alternative strategies for staff recruitment and narrowing the intervention outcomes to the specific local community problems are needed for consistently high impact.
Trial Registration: Clinicaltrials.gov, NCT02957799.
Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: MT is an Academic Editor on the PLoS Medicine Editorial Board.
(Copyright: © 2023 Rotheram-Borus et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)
Databáze: MEDLINE
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