Example page from the CHW job aid.
The content and structure of the job aid were developed over the course of the year that preceded the start of the trial through a process that included several steps. Content development was informed by a robust body of evidence demonstrating that home visits covering a diversity of topics, including child health, nutrition, and play-based stimulation, can generate significant positive effects on child development [Two versions of the job aid were developed that differed only with respect to the suggested play-based activities and the approach to how caregivers interacted with their child during play. The first version emphasized caregiver-directed interactions focused on developing and reinforcing skills within the child’s zone of proximal development [Participants in the control arm received the local standard of care throughout the study period. CHWs in the study area are responsible for making monthly home visits for all children under the age of 2 and for providing a broad range of services during those visits, including health screening, immunization monitoring, and nutrition counselling. The Road to Health Booklet served as a guide for control CHW visits as well as a record of the child’s growth and vaccination status. It also provided caregivers with important information on child health, nutrition, and common developmental milestones. Intervention CHWs continued to use the Road to Health Booklet to record child growth and vaccination status, and the key health promotion messages in the Road to Health Booklet were integrated into the job aid. The intervention job aid expanded the content of home visits but was designed to be effort neutral by restructuring the time CHWs were already responsible for allotting.CHWs were trained on the job aid prior to the start of the intervention period and were provided with refresher trainings every 6 months thereafter, amounting to 4 trainings in total over the 2-year intervention period. The first training lasted 4 days, while the subsequent refresher trainings lasted 2 days each. Trainings were conducted by members of the research team with logistical support from a local nongovernmental organization that specialized in training CHWs for the Limpopo Department of Health. Each training also included an overview of key topics related to child development, a subject that was not part of standard CHW training in South Africa at the time of the study. Trainings employed didactic learning methods, which sought to build on and improve the baseline knowledge that CHWs had. Training included live demonstrations of aspects of the curriculum, particularly recommended play-based activities. All CHWs were proficient in English, though many preferred to communicate in their home language (Xitsonga or Sepedi). Trainings were conducted in Sepedi and Xitsonga, which also prepared CHWs to use the job aid in the caregiver’s home language. In the 6 months that followed the first training, each CHW was accompanied on a home visit by one of the trainers, who provided additional support and feedback to strengthen CHW knowledge around delivering the intervention.