August 12, 2013 in Uncategorized
Community health workers can help improve the well-being of poor and vulnerable mothers and children, writes Mark Tomlinson in this guest post:
In 2011, 6.91 million children under five years of age died globally. While this is a significant reduction from the 11.97 million children under five dying in 1990, most of these deaths continue to occur from preventable causes and almost all in low- and middle-income countries.
In 2005 South Africa was one of only four countries in the world where the under-five mortality rate was higher than the baseline rate established by the Millennium Development Goals initiative in 1990. This was primarily related to the HIV epidemic, with more than half of child deaths attributed to HIV/AIDS, but about 30% of under-five deaths in South Africa are newborns dying in the first 28 days of life (20,000 deaths each year). Since 2005, as a result the scaling up of effective programmes to prevent mother-to-child transmission (PMTCT) of HIV and to some extent the roll out of antiretroviral therapy, South Africa has been making considerable progress towards reducing under-five mortality.
While the death of children is the most commonly used metric to illustrate the dire state health systems in many poor countries, more than 200 million children under the age of five (who survive) fail to reach their developmental potential. This has been linked to multiple risks such as poverty, poor nutrition, a lack of educational opportunities, maternal depression and under-stimulating home environments. Jack Shonkoff and colleagues from Harvard University have used the term ‘toxic stress’ to describe a form of stress that occurs when a child’s stress response system is activated for a prolonged period of time, together with an absence of a supportive caregiving relationship that can buffer the stress.
If this early toxic stress is not reduced it can lead to irreversible changes in brain function and structure. We are talking here of environments where children are exposed to chronic levels of violence, alcohol abuse, drug use, and unresponsive care. But we are also talking about environments where children are beaten by caregivers and where their attempts at exploration and play are thwarted. In the same vein, chronic poverty in the absence of nurturing environments and relationships might be termed ‘toxic poverty’.
To ensure that South Africa improves the health of its entire population and achieves a more equitable distribution of resources, we need effective community-based programmes that focus on pregnancy and the first two years of life – what is now called the first 1000 days of development. The South African government is currently in the process of re-engineering the primary health care system. One component of this is teams of community health workers (CHWs), professional nurses and other medical professionals who will deliver interventions at the community level.
Over the last five years, my colleagues and I have implemented a randomised controlled trial sto examine the impact of community health workers conducting home visiting in order to improve maternal, infant and child health in Cape Town. Our project is a partnership between the Department of Psychology at Stellenbosch University, University of California, Los Angeles and a local NGO Philani.
Philani has been operating in Cape Town since the late 1980’s and was initially designed to focus on improving child nutrition. Philani identifies potential neighbourhood community health workers on the basis of them being women who live in the same neighbourhoods as the mothers and children that they will be serving, as well being mothers whose children are thriving, that is, mothers who are positive role models in the neighbourhoods.
They are called Mentor Mothers and they provide social support to their peers, making home visits to monitor the baby’s progress, providing alcohol, HIV/TB information and skills, as well as making referrals for clinic care on an ongoing basis. Mothers whose children thrive typically have good social skills, an ability to develop caring social relationships, and a sense of pragmatism.
The Philani + mentor-mother intervention is currently underway in Khayelitsha and Mfuleni in Cape Town. The initial study was funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in the USA, and the follow up of children at 3 years old is being funded by a local South African funder Ilifa Labantwana.
Early results indicate that mothers receiving the intervention report a significantly higher number of tasks reflecting well-being than mothers who did not, were more likely to be free of maternal birth complications, and HIV+ mothers were more likely to take anti-retrovirals during delivery.
Infants whose mothers received visits from Philani Mentor Mothers and that were experiencing depressed mood during pregnancy have improved growth and cognitive development when they are 18 months old than infants who did not receive Mentor Mother visits. These findings are important as we know from previous interventions to improve nutrition outcomes of infants and children, that early improvements in child growth suggest later cognitive, educational, social, and economic benefits.
Preventive and curative services offered by community health workers can contribute to ensuring that we avoid this loss of developmental potential in our children and adults. These community based programmes can supplement overwhelmed health-care systems that do not meet South Africa’s health needs, and certainly cannot meet the needs of the range of diseases confronting many other poor countries throughout Africa and globally.
Professor Mark Tomlinson is based in the Department of Psychology at Stellenbosch University.