Does investment in home visitors lead to better psychological health for HIV-affected families? Results from a quasi-experimental evaluation in South Africa

Abstract

Children and families affected by HIV are at considerable risk for psychological distress. Community-based home visiting is a common mechanism for providing basic counseling and other services to HIV-affected families. While programs emphasize home visitor training and compensation as means to promote high-quality service delivery, whether these efforts result in measurable gains in beneficiaries' well-being remains largely unanswered. This study employs a longitudinal quasi-experimental design to explore whether these kinds of investments yield concomitant gains in psychological outcomes among beneficiaries. Baseline and follow-up data were collected over a two-year period from children aged 10–17 at the time of program enrollment and their caregivers, with 80% retention. In this sample of 1487 children and 918 caregivers, the psychological health outcomes of those enrolled in programs with home visitors who receive intensive training, organizational support, and regular compensation (termed “paraprofessional”) were compared to those enrolled in programs offering limited home visiting services from lay volunteers. Applying multilevel logistic regression, no measurable improvements were found among paraprofessional enrollees, and three outcomes were significantly worse at follow-up regardless of program model. Children's behavior problems became more prevalent even after adjusting for other factors, increasing from 29% to 35% in girls and from 28% to 43% in boys. Nearly one-quarter of girl and boys reported high levels of depression at follow-up, and this was a significant rise over time for boys. Rates of poor family functioning also significantly worsened over time, rising from 30% to 59%. About one-third of caregivers reported high levels of negative feelings at follow-up, with no improvements observed in the paraprofessional group. Results highlight that children's and caregivers' psychological outcomes may be relatively impervious to change even in paraprofessional home visiting models. Findings underscore the need for programs serving HIV-affected families toadd focused evidence-based psychological interventions to supplement traditional home visiting.

Community‐Based Caregiver and Family Interventions to Support the Mental Health of Orphans and Vulnerable Children: Review and Future Directions

“…Among the home visiting programs, Sherr and colleagues (2016) found CBO attenders had lower depression, suicidal ideation, and peer and conduct problems, and greater prosocial behaviors relative to a control group of non-CBO attenders. However, evaluations by Thurman et al (2014) and Visser et al (2015) found null effects for child mental health, and Zuilkowski and Alon (2015) found improvements in child psychosocial scores from Wave 1 to 2 (first year of programming) but not from Wave 2 to 3 (years 2-3 of programming). In summary, there were mixed effects for home visiting programs on child mental health.…”

“…Other evaluations evaluated outcomes post-intervention (Bell et al, 2008), 2 weeks post-intervention (Bhana et al, 2014), 1 and 3 months post-intervention (Puffer et al, 2016), 3 months post-intervention (Thurman et al, 2018), after 12-and 15-months of programming (Sherr et al, 2016), and after 2 (Thurman, Kidman, & Taylor, 2014) Local Cultural Adaptation and Community Participation. Six of ten interventions included in this review were of programs developed by researchers (Bell et al, 2008;Bhana et al, 2014;Eloff et al, 2014;Puffer et al, 2016;Thurman et al, 2018;Ward et al, 2019).…”

“…The home visiting programs included here were delivered through CBOs, and therefore located within the communities they are meant to serve, and able to access the most vulnerable families (Sherr et al, 2016). Because CBO home visitors are themselves members of the community, they are able to establish long-term relationships with families and offer culturally appropriate support (Thurman et al, 2014).…”

“…Home Visiting Programs. Evaluations of home visiting programs (Sherr et al, 2016;Thurman et al, 2014;Visser et al, 2015;Zuilkowski & Alon, 2015) were testing effects of these programs on various child mental health outcomes, including violence and abuse in the home, psychological distress, depression, resilience, self-esteem, psychosocial functioning, and social outcomes. The format of these programs varied in terms of number of visits and length of service, and all four programs included in this review offered other services in addition to psychosocial support, such as health and nutrition support, livelihood/economic support, legal services, child protection services, educational help, and access to community services.…”

“…The format of these programs varied in terms of number of visits and length of service, and all four programs included in this review offered other services in addition to psychosocial support, such as health and nutrition support, livelihood/economic support, legal services, child protection services, educational help, and access to community services. Mechanisms of change for home visiting programs vary and are not yet fully clear (Sherr et al, 2016), although some hypothesized mechanisms by which these particular programs may affect child mental health are that home visits help to reduce family stress, improve the family environment through increas-ing positive parenting and reducing abuse and violence (Yakubovich et al, 2016), provide support and counseling to parents (Thurman et al, 2014), and provide broadband services to families to help them access support and build capacity to meet their needs (Visser et al, 2015, Zuilkowski & Alon, 2015.…”