Department of Pediatrics, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Eneas de Carvalho Aguiar, 647, Cerqueira Cesar, São Paulo, SP 05403-000, Brazil.
Caribbean Institute for Health Research, University of West Indies (TMRI), Mona, Kingston 7, Jamaica.
Health Policy Plan. 2021 Apr 21;36(3):288-297. doi: 10.1093/heapol/czaa195.
Home visiting programmes are increasingly recognized as one of the most effective interventions to improve child health and development in low-income settings. However, the best platforms to deliver such programmes remain unclear. We conducted a randomized controlled trial to test the relative effectiveness of child development agents (CDAs) and community health workers (CHWs) as two possible delivery platforms for early childhood development (ECD) focused home visiting intervention in São Paulo, Brazil. A total of 900 children aged 9-15 months were screened for potential study inclusion between January and March 2015. Children who did not attend crèches at enrolment were included in the trial. Children were randomly assigned to control or to receive biweekly home visits either through a CHW in the areas covered by the Brazilian Family Health Strategy (FHS) or by a newly hired cadre of CDAs in the areas not covered by the FHS. The primary study outcome was children's development (cognition, motor, language and social emotional skills) assessed after 12 months of intervention with the PRIDI and Caregiver-Reported Early Development Instruments tools. A total of 826 mother-child dyads were enrolled in the trial. In intention-to-treat analysis, neither intervention arm improved study outcomes. In per-protocol (PP) analysis, the CDA programme resulted in a 0.22 standard deviation increase in children's development (95% confidence interval [0.01-0.43]). The results presented in this study suggest that home visiting programmes have the potential to improve child development among poor urban families in Brazil. However, delivering home visiting interventions through already active CHWs may not be feasible in the Brazilian context and coordination across sectors is essential to effective ECD policies.
家庭访视项目越来越被认为是改善低收入环境下儿童健康和发育的最有效干预措施之一。然而，最佳的服务平台仍不清楚。我们进行了一项随机对照试验，以测试儿童发展代理（CDA）和社区卫生工作者（CHW）作为两种可能的交付平台，在巴西圣保罗为幼儿发展（ECD）重点家庭访视干预提供服务的相对有效性。共有 900 名 9-15 个月大的儿童在 2015 年 1 月至 3 月期间接受了潜在研究纳入的筛查。未在入组时参加托儿所的儿童被纳入试验。儿童被随机分配到对照组或接受每两周一次的家庭访视，访视者是在巴西家庭健康战略（FHS）覆盖地区的 CHW，或在 FHS 未覆盖地区新雇佣的 CDA。主要研究结果是儿童在干预 12 个月后使用 PRIDI 和照顾者报告的早期发育工具评估的发育（认知、运动、语言和社会情感技能）。共有 826 对母婴对被纳入试验。意向治疗分析中，两种干预组都没有改善研究结果。在按方案（PP）分析中，CDA 方案使儿童发育提高了 0.22 个标准差（95%置信区间为 0.01-0.43）。本研究的结果表明，家庭访视项目有可能改善巴西贫困城市家庭的儿童发育。然而，在巴西背景下，通过已经活跃的 CHW 提供家庭访视干预可能不可行，部门间的协调对于有效的 ECD 政策至关重要。
