There are four intersecting epidemics among pregnant women in South Africa: hazardous alcohol use (30%), HIV (27%), TB (60% of HIV+), and malnutrition (24% of infants). Unless the prevention programs for these epidemics are horizontally integrated, there will never be adequate resources to address these challenges and stigma will dramatically reduce program utilization. Furthermore, while clinics are the typical sites for treating each of these health problems, this proposal will examine a home-visiting prevention program delivered by neighborhood Mentor Mothers (MM) as an alternative to clinic-based interventions to reduce the consequences of hazardous alcohol use, HIV, TB, and poor nutrition. A two phase project is proposed. In Phase 1, we will prepare and finalize the support materials, personnel, procedures, and training for the implementation of a randomized controlled trial (RCT). In Phase 2, we will conduct a RCT evaluating the MM home visiting program, Philani Intervention Project (PIP), on maternal and child outcomes over 18 months. All Mothers at Risk in 20 neighborhoods will be identified (N=600) and randomly assigned by geographic neighborhood to either:1) standard care (SC), mothers and infants with access to clinic-based health care and educational materials;or 2) the PIP. The PIP will encourage mothers to care for their own health, parent well, maintain their mental health, and, if the mother is living with HIV (HIV+ MAR), reduce HIV transmission and/or reduce alcohol use and abuse. The impact of the intervention on a comprehensive composite outcome, the mediating, and background predictors of healthy family routines will be monitored during pregnancy, at the child's birth, and 6 and 18 months later. The results begin to inform the optimal delivery strategy for next generation of preventive interventions in order to be feasible and sustainable for broad dissemination immediately following an efficacy trial.The health and well-being of South Africa's children depends on effectively intervening with the intersecting epidemics of alcohol, HIV,TB, and child malnutrition. South Africa (SA) is distinguished by having both the highest number of persons living with HIV (PLH) (5 million PLH;40% of pregnant women are HIV+) as well as the highest documented rate of children with fetal alcohol syndrome (FAS;6.5% at first grade) (Viljoen et al., 2005). Concurrently, 6% of children die by first grade, and 8.5% of children are malnourished. Alcohol abuse, in addition to its direct effect on children, is consistently related to parents'premature death and child abuse (Frontline, 2006). While clinics are the typical sites for treating each of these health problems, this proposal will examine a home-visiting model as an alternative to clinic-based interventions. Positive results could lead to large scale implementation in South Africa.
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