A trial of nurturing care among children who are HIV-exposed and uninfected in eSwatini.

INTRODUCTION: Children who are HIV-exposed and uninfected (CHEU) are a growing population at potential risk of poor neurocognitive development. We tested a nurturing care intervention on children's neurocognitive development and maternal depressive symptoms (primary) with mediation through caregiving activities (secondary). METHODS: This study was conducted among six intervention and nine comparison antenatal-care/prevention of vertical transmission (ANC/PVT) HIV clinics in eSwatini. We enrolled pregnant women and measured infant development at 9 and 18 months. mothers2mothers (m2m) designed and implemented the clinic-home-community-based intervention. We measured infants' neurodevelopment, maternal depressive symptoms and caregiving activities with the Mullen Scales of Early Learning (MSEL), Edinburgh Postnatal Depression Scale, HOME Inventory and Family Care Indicators. We fitted linear mixed effects regression models with clinic random effects to compare intervention versus comparison arms, and generalised structural equation models to evaluate mediation, adjusting for confounders. RESULTS: Mother-infant pairs (n = 429) participated between January 2016 through May 2018. Socio-demographic characteristics were balanced between arms except for higher rates of peri-urban versus rural residence and single versus married mothers in the comparison group. The 18 month retention was 82% (180/220) intervention, 79% (166/209) comparison arm, with 25 infant deaths. Intervention MSEL scores were significantly, and modestly, higher in receptive language (55.7 [95% CI 54.6, 56.9] vs. 53.7 [95% CI 52.6, 54.8]), expressive language (42.5 [95% CI 41.6, 39.8] vs. 40.8 [95% CI 39.8, 41.7]) and composite MSEL (85.4 [95% CI 83.7, 84.5] vs. 82.7 [95% CI 81.0, 84.5]), with no difference in maternal depressive symptoms or in observations of mother-child interactions. Intervention book-sharing scores were higher (0.63 vs. 0.41) and mediated the effect on MSEL scores (indirect effect, p-values ≤ 0.024). The direct effects on visual reception and expressive language scores were significantly higher in the intervention compared to the comparison arm (coefficients 1.93 [95% CI 0.26, 3.60] and 1.66 [95% CI 0.51, 2.79, respectively]). CONCLUSIONS: Nurturing care interventions can be integrated into ANC/PVT clinic-home-community programmes. The intervention, mediated through interactive caregiving activities, increased language development scores among CHEU. Partnering with a local team, m2m, to design and implement a culturally relevant intervention illustrates the ability to impact parent-child play and learning activities that are associated with children's neurodevelopment.

Community surveillance and response to maternal and child deaths in low- and middle-income countries: A scoping review.

BACKGROUND: Civil registration and vital statistics (CRVS) systems do not produce comprehensive data on maternal and child deaths in most low- and middle-income countries (LMICs), with most births and deaths which occur outside the formal health system going unreported. Community-based death reporting, investigation and review processes are being used in these settings to augment official registration of maternal and child deaths and to identify death-specific factors and associated barriers to maternal and childcare. This study aims to review how community-based maternal and child death reporting, investigation and review processes are carried out in LMICs. METHODS: We conducted a scoping review of the literature published in English from January 2013 to November 2020, searching PubMed, EMBASE, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews, Scopus, and Web of Science databases. We used descriptive analysis to outline the scope, design, and distribution of literature included in the study and to present the content extracted from each article. The scoping review is reported following the PRISMA reporting guideline for systematic reviews. RESULTS: Of 3162 screened articles, 43 articles that described community-based maternal and child death review processes across ten countries in Africa and Asia were included. A variety of approaches were used to report and investigate deaths in the community, including identification of deaths by community health workers (CHWs) and other community informants, reproductive age mortality surveys, verbal autopsy, and social autopsy. Community notification of deaths by CHWs complements registration of maternal and child deaths missed by routinely collected sources of information, including the CRVS systems which mostly capture deaths occurring in health facilities. However, the accuracy and completeness of data reported by CHWs are sub-optimal. CONCLUSIONS: Community-based death reporting complements formal registration of maternal and child deaths in LMICs. While research shows that community-based maternal and child death reporting was feasible, the accuracy and completeness of data reported by CHWs are sub-optimal but amenable to targeted support and supervision. Studies to further improve the process of engaging communities in the review, as well as collection and investigation of deaths in LMICs, could empower communities to respond more effectively and have a greater impact on reducing maternal and child mortality.

Engaging community health workers in maternal and infant death identification in Khayelitsha, South Africa: a pilot study.

BACKGROUND: Engaging community health workers in a formalised death review process through verbal and social autopsy has been utilised in different settings to estimate the burden and causes of mortality, where civil registration and vital statistics systems are weak. This method has not been widely adopted. We piloted the use of trained community health workers (CHW) to investigate the extent of unreported maternal and infant deaths in Khayelitsha and explored requirements of such a programme and the role of CHWs in bridging gaps. METHODS: This was a mixed methods study, incorporating both qualitative and quantitative methods. Case identification and data collection were done by ten trained CHWs. Quantitative data were collected using a structured questionnaire. Qualitative data were collected using semi-structured interview guides for key informant interviews, focus group discussions and informal conversations. Qualitative data were analysed thematically using a content analysis approach. RESULTS: Although more than half of the infant deaths occurred in hospitals (n = 11/17), about a quarter that occurred at home (n = 4/17) were unreported. Main causes of deaths as perceived by family members of the deceased were related to uncertainty about the quality of care in the facilities, socio-cultural and economic contexts where people lived and individual factors. Most unreported deaths were further attributed to weak facility-community links and socio-cultural practices. Fragmented death reporting systems were perceived to influence the quality of the data and this impacted on the number of unreported deaths. Only two maternal deaths were identified in this pilot study. CONCLUSIONS: CHWs can conduct verbal and social autopsy for maternal and infant deaths to complement formal vital registration systems. Capacity development, stakeholder's engagement, supervision, and support are essential for a community-linked death review system. Policymakers and implementers should establish a functional relationship between community-linked reporting systems and the existing system as a starting point. There is a need for more studies to confirm or build on our pilot findings.

Effect of a Mentor Mother Programme on retention of mother-baby pairs in HIV care: A secondary analysis of programme data in Uganda.

BACKGROUND: Community healthcare workers (CHWs) play an important role in promoting HIV-care retention. Notwithstanding inconsistencies in the outcomes of CHW programmes, these programmes are known to have a positive effect on retention of mother-baby pairs in HIV-care in sub-Saharan Africa. AIM: The aim of this analysis was to assess the effect of mothers2mothers (m2m) Ugandan Mentor Mother (MM) programme on the retention of mother-baby pairs in HIV-care. METHODS: We conducted a secondary analysis of data obtained from the m2m Uganda MM programme in nine East Central districts. The primary data was generated through a quasi-experimental study of women attending prevention of mother to child transmission of HIV (PMTCT) clinics in Uganda between January 2011 and March 2014; where those who were enrolled at PMTCT sites with the MM intervention (n = 1161) were compared with those who received standard PMCTCT services without the MM intervention (n = 1143). Frequencies and descriptive statistics were calculated for categorical and continuous measures respectively. Risk factors for retention in care were determined by clustered generalised estimating equations and reported as adjusted odds ratios (AOR) with 95% confidence intervals (95% CI). RESULTS: Retention in the PMTCT cascade was significantly higher for mother-baby pairs in the intervention arm compared to those in the control arm across all measured time points (96.7% vs 65.8% at 6 weeks after birth, p<0.001; 81.5% vs 42% at 6 weeks after cessation of breastfeeding, p<0.001; and 71.2% vs 20.6% at 18 months after birth, p<0.001). Relative to the control group, women in the intervention group were less likely to be lost to follow up following treatment initiation (AOR 0.05, 95% CI: 0.02, 0.15). There was no difference in the proportion of the retained mother-baby pairs who received prescribed PMTCT interventions at different time points but a significantly higher number of mother-baby pairs in the intervention arm were retained at different time points. CONCLUSION: HIV positive mothers and their HIV exposed children in the mothers2mothers Ugandan Mentor Mother programme had higher retention in HIV care at every step along the PMTCT cascade. We therefore recommend adoption of this peer-to-peer model in sub-Saharan Africa to complement retention in care strategies and health system interventions especially among priority and key populations.

Impact of lay health worker programmes on the health outcomes of mother-child pairs of HIV exposed children in Africa: A scoping review.

BACKGROUND: Increased demand for healthcare services in countries experiencing high HIV disease burden and often coupled with a shortage of health workers, has necessitated task shifting from professional health workers to Lay Health Workers (LHWs) in order to improve healthcare delivery. Maternal and Child Health (MCH) services particularly benefit from task-shifting to LHWs or similar cadres. However, evidence on the roles and usefulness of LHWs in MCH service delivery in Sub-Saharan Africa (SSA) is not fully known. OBJECTIVES: To examine evidence of the roles and impact of lay health worker programmes focusing on Women Living with HIV (WLH) and their HIV-exposed infants (HEIs). METHODS: A scoping review approach based on Arksey and O'Malley's guiding principles was used to retrieve, review and analyse existing literature. We searched for articles published between January 2008 and July 2018 in seven (7) databases, including: MEDLINE, Embase, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews and Web of Science. The critical constructs used for the literature search were "lay health worker", "community health worker", "peer mentor", "mentor mother," "Maternal and Child health worker", "HIV positive mothers", "HIV exposed infants" and PMTCT. RESULTS: Thirty-three (33) full-text articles meeting the eligibility criteria were identified and included in the final analysis. Most (n = 13, 39.4%) of the included studies were conducted in South Africa and used a cluster RCT design (n = 13, 39.4%). The most commonly performed roles of LHWs in HIV specific MCH programmes included: community engagement and sensitisation, psychosocial support, linkage to care, encouraging women to bring their infants back for HIV testing and supporting default tracing. Community awareness on Mother to Child Transmission of HIV (MTCT), proper and consistent use of condoms, clinic attendance and timely HIV testing of HEIs, as well as retention in care for infected persons, have all improved because of LHW programmes. CONCLUSION: LHWs play significant roles in the management of WLH and their HEIs, improving MCH outcomes in the process. LHW interventions are beneficial in increasing access to PMTCT services and reducing MTCT of HIV, though their impact on improving adherence to ART remains scanty. Further research is needed to evaluate ART adherence in LHW interventions targeted at WLH. LHW programmes can be enhanced by increasing supportive supervision and remuneration of LHWs.

Realizing the Promise of the Global Plan: Engaging Communities and Promoting the Health and Human Rights of Women Living With HIV.

The Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive highlighted the need to put the health and well-being of women and mothers at the center of efforts to prevent vertical transmission. This article will examine a selection of community engagement practices in 3 key areas: (1) as an accountability tool, (2) in service delivery, and (3) as a facilitator of human rights. The lived experiences of women living with HIV as recipients of and participants in services for the prevention of vertical transmission provide both the framework for an exploration of best community engagement practices and suggestions for the way forward.

Understanding the role of the OneLove campaign in facilitating drivers of social and behavioral change in southern Africa: a qualitative evaluation.

In the wake of the HIV and AIDS pandemic, health communication has played an important role in social and behavior change in HIV prevention and treatment efforts. Despite this significant role, it is not always clear how health communication influences individuals and communities to facilitate social and behavior change. Guided predominantly by Lewin's theory of change in the context of complexity thinking, and supported by qualitative evidence from Soul City Institute's midterm evaluation of the OneLove multimedia campaign in 9 southern African countries, this article illustrates how carefully designed health edutainment communication materials facilitate drivers of social and behavior change. Thus, researched and theory-based health communication aimed at behavior and social change remains an important pillar in HIV prevention and treatment, where personal and social agency remain key.

Risk factors for domestic physical violence: national cross-sectional household surveys in eight southern African countries.

BACKGROUND: The baseline to assess impact of a mass education-entertainment programme offered an opportunity to identify risk factors for domestic physical violence. METHODS: In 2002, cross-sectional household surveys in a stratified urban/rural last-stage random sample of enumeration areas, based on latest national census in Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia and Zimbabwe. Working door to door, interviewers contacted all adults aged 16-60 years present on the day of the visit, without sub-sampling. 20,639 adults were interviewed. The questionnaire in 29 languages measured domestic physical violence by the question "In the last year, have you and your partner had violent arguments where your partner beat, kicked or slapped you?" There was no measure of severity or frequency of physical violence. RESULTS: 14% of men (weighted based on 1,294/8,113) and 18% of women (weighted based on 2,032/11,063) reported being a victim of partner physical violence in the last year. There was no convincing association with age, income, education, household size and remunerated occupation. Having multiple partners was strongly associated with partner physical violence. Other associations included the income gap within households, negative attitudes about sexuality (for example, men have the right to sex with their girlfriends if they buy them gifts) and negative attitudes about sexual violence (for example, forcing your partner to have sex is not rape). Particularly among men, experience of partner physical violence was associated with potentially dangerous attitudes to HIV infection. CONCLUSION: Having multiple partners was the most consistent risk factor for domestic physical violence across all countries. This could be relevant to domestic violence prevention strategies.

Communicating HIV and AIDS, what works? A report on the impact evaluation of Soul City's fourth series.

This article describes the evaluation of the HIV/AIDS communication aspect of the multi media Soul City health promotion intervention in South Africa. The intervention consists of a television and radio drama and print material. The evaluation was multifaceted with a before and after national survey and a national qualitative study. In the before and after survey change was measured and then multiple regression analysis was performed to assess the variables associated with the change. The qualitative study consisted of focus group discussions, which were analysed thematically. The studies show that there are numerous instances of community change and how the change is mediated at the community level. The studies also describe the change at a number of levels of the described behaviour change model for individuals.