Vulnerable Children and Youth Studies
Vol. 6, No. 2, June 2011, 91–102
A randomized controlled trial of home visits by neighborhood mentor
mothers to improve children’s nutrition in South Africa
Ingrid M. le Rouxa, Karl le Rouxb, Kwanie Mbeutua, W. Scott Comuladac,
Katherine A. Desmondcand Mary Jane Rotheram-Borusc*
aPhilani Child Health and Nutrition Project, Khayelitsha, Elonwabeni, Cape Town, South Africa;
bZithulele Hospital, Eastern Cape, Zithulele Village, Mqanduli District, South Africa;cSemel
Institute for Neuroscience and Human Behavior, University of California, Los Angeles, California,
Malnourished children and babies with birth weights under 2500 g are at high risk
for negative outcomes over their lifespans. Philani, a paraprofessional home visit-
ing program, was developed to improve nutritional outcomes for young children in
South Africa. One “mentor mother” was recruited from each of 37 neighborhoods
in Cape Town, South Africa. Mentor mothers were trained to conduct home visits
to weigh children under six years old and to support mothers to problem-solve life
challenges, especially around nutrition. Households with underweight children were
assigned randomly on a 2:1 ratio to the Philani program (n=500) or to a standard
care condition (n=179); selection effects occurred and children in the intervention
households weighed less at recruitment. Children were evaluated over a one-year period
(n=679 at recruitment and n=638 with at least one follow-up; 94%). Longitudinal
random effects models indicated that, over 12 months, the children in the interven-
tion condition gained significantly more weight than children in the control condition.
Mentor mothers who are positive peer deviants may be a viable strategy that is effica-
cious and can build community, and the use of mentor mothers for other problems in
South Africa is discussed.
Keywords: mentoring; motherhood; nutrition; positive deviant; South Africa
Malnutrition is a significant and growing global problem and is the leading factor in more
than one-third of deaths worldwide among young children (Black et al., 2008). Among
South African children less than five years old, the national prevalence of stunting (low
height for age) is 27%, and at least 12% of babies are underweight (UNICEF, n.d.). About
7% of South African children die before their fifth birthday (UNICEF, n.d.), and more
than half of South African households experience hunger (Labadarios et al., 2005). In the
longer term, poor nutrition results in shorter adult height, reduced economic productivity
and lifelong impairments in neurocognitive and socioemotional development (Grantham-
McGregor et al., 2007; Mason et al., 2005; Stanfield, 1993). Nutritional challenges at birth
and during childhood result in successive generations of unhealthy adults who, in turn,
place their children at risk (Horta, Gigante, Osmond, Barros, & Victora, 2009). The Philani
*Corresponding author. Email: CCHPublications@mednet.ucla.edu
ISSN 1745-0128 print/ISSN 1745-0136 online
© 2011 Taylor & Francis
I.M. le Roux et al.
Project was established in the outskirts of Cape Town, South Africa in 1979 to combat
these odds by providing basic child health and nutrition services. The goal of this article
is to evaluate the effectiveness of this community-developed service model in improving
nutritional outcomes and child health.
The Philani program contains elements found in several successful international mod-
els that have been shown to improve healthy development of children in resource-poor
settings. The first is the Positive Deviance/Hearth model to target childhood malnutrition
(Marsh & Schroeder, 2002; Sternin, Sternin, & Marsh, 1998; Wollinka, Keeley, Burkhalter,
& Bashir, 1997) developed in Haiti in the 1980s (Berggren, Alvarez, Genece, Amadee-
Gedeon, & Henry, 1984) and replicated worldwide (Sternin et al., 1998; Wollinka et al.,
1997). Using this approach, “positive deviant” (PD) mothers, who are raising healthy
and well-nourished children despite living in the same poor conditions as their peers, are
recruited to lead gatherings in their homes attended by small groups of local malnourished
children and their mothers. The PD/Hearth method has been demonstrated to improve
health behaviors, increase nutrition knowledge and rehabilitate undernourished children
(Berggren et al., 1984; Marsh & Schroeder, 2002; Marsh, Schroeder, Dearden, Sternin, &
Sternin, 2004; Sternin et al., 1998; Wollinka et al., 1997).
Peer education programs have also been shown to improve nutritional outcomes.
The US Department of Agriculture’s Expanded Food and Nutrition Education Program
(EFNEP) enrolls more than 500,000 new participants annually to receive personal nutrition
education, delivered by trained peer educators, who usually live in the communities where
they work. EFNEP increases consumption of fruits and vegetables, knowledge of nutrition
basics,foodstorageandpreparation safetyandnutritionper dollarspentonfood(Arnold&
Sobal, 2000; Burney & Haughton, 2002; National Institute of Food and Agriculture, n.d.).
The peer nutrition education model has also been successful in small-scale programs, such
as La Cocina Saludable in Colorado (Taylor, Serrano, Anderson, & Kendall, 2000) or the
Peer Nutrition Program of the Toronto Public Health Department (Moscovitch, n.d.).
Philani also incorporates elements of nurse home visiting for infants and young chil-
dren, which has been highly beneficial for children in the United States (Olds et al., 2002,
2004a, b). Such programs provide social support, health education and practical assistance
during an important period of early childhood, and result in significant improvements in
developmental and psychosocial outcomes (Gomby, Culross, & Behrman, 1999).
By pulling together elements from these models of child health and nutrition interven-
tions – PD mothers, nutrition education provided by local peers and home visits during
children’s early years – the Philani program aims to build community relationships and
encourage mothers to engage in healthy practices each day to improve nutrition and
health outcomes. The arrival of a child creates unique opportunities for behavior change.
Verplanken and Wood (2006) have demonstrated that it is far easier to shift behaviors dur-
ing periods of life transition compared to periods of stable living. Early childhood opens a
window of opportunity to instill positive health behaviors into the daily life of the family.
In all cultures, rewarding daily routines that promote consistent care for children’s health
and encouraging parents’ bonds with their children are associated with healthy develop-
mental outcomes (Weisner, 1998, 2002). In this article we evaluate whether the Philani
program was successful in one specific outcome: rehabilitating underweight children to
recommended weights within one year of enrollment into the program.
In the Xhosa townships surrounding Cape Town, 37 neighborhoods of about 500
households each were identified to participate in the project. The neighborhoods contain
Vulnerable Children and Youth Studies
a variety of housing, including formal settlements (government housing with onsite water
and sewage connections), site-and-service plots (plots of land where residents can build a
home, with some access to water and sanitation facilities) and informal settlements (shacks
or temporary structures that rarely have water on the premises and are not on a specified
plot of land). For each neighborhood, a Mentor Mother (MM) was screened, recruited and
trained. Recruitment and training of MMs is described below.
MMs canvassed their neighborhoods, entering each household and inquiring if there
were any children under six years of age living in the home. When children were present,
the MM weighed each child and plotted the weight on a growth chart that was shown and
explained to the parent(s). If the MM identified a child whose weight indicated malnourish-
ment, the household was eligible to participate in the study. Malnourishment was defined
as having a weight more than two standard deviations below the World Health Organization
(WHO) normative mean weight for the child’s age. Children in this range are in the bottom
2% in weight for age.
From November 2002 to July 2004, the 37 MMs recruited 684 mothers with malnour-
ished children under the age of six years; if there was more than one malnourished child,
only one was selected to be followed for this study. The mother–child unit in each house-
hold is referred to as a dyad. Dyads recruited into the study were scheduled for a baseline
assessment, after which they were randomized to either the intervention or control arm
of the study. Figure 1 displays the flow of participants through the study. Assignment to
the treatment condition was based on a random sequence decided a priori for every three
households enrolled into the study. MMs were provided with randomly sequenced num-
bered folders containing the randomization assignments. Once a dyad was enrolled the
MM selected the next folder in her possession, and assigned the dyad accordingly. Two
out of each three households were assigned to the Philani intervention condition (n=500).
Mentor Mothers (MMs) hired and trained
n = 37
Each assigned to a different neighborhood
MMs visit households in their neighborhoods looking for families with at least one malnourished child
under 6 years old. n = 684 identified and recruited for the study, across all 37 neighborhoods.
In a pre-determined 2:1 random allocation sequence, MMs assign families to treatment or
control arm of the study. If > 1 malnourished child, 1 is randomly selected to be followed.
Philani treatment arm
n = 500 mother–child dyads
MM provides intervention via home
visits over the course of one year
MM weighs child at intervention
visits, including at 6 and 12 months
Lost to follow-up
n = 19
Lost to follow-up
n = 20
analysis due to
n = 5
n = 154
n = 184 mother–child dyads
No intervention visits
MM returns to weigh child at 6 and
12 months after baseline
n = 481
Figure 1.Outline of flow of participants in the study.
I.M. le Roux et al.
The third household became a control case (n=184). Five dyads were assigned initially to
the control condition but were removed from the analysis and were provided services for
ethical reasons because the child’s life was endangered; the final sample size in the control
condition was thus n=179.
growth monitoring to those dyads randomized to receive it. Dyads in the control arm of the
study did not receive these visits. In addition, MMs conducted follow-ups with control
dyads approximately every six months, at which time they weighed the children. After
their final weighing, dyads in the control condition were given the option to receive the
Philani nutrition intervention program. The follow-up period ended in September 2005.
The study was approved by the Institutional Review Board at UCLA and was registered
with ClinicalTrials.gov (NCT00995592).
Mentor Mothers were nominated initially by local community leaders or by open appli-
cation. Criteria included having thriving babies, demonstrating good communication and
strong interpersonal skills, being committed to community service and showing a disci-
plined personal and professional lifestyle. The nominees were interviewed and trained by
the Philani outreach supervisors and received home visits to observe routines and con-
firm that the households met the criterion of “thriving” (i.e. the home was organized,
children were monitored, healthy food was available). Only about 50% of potential MMs
remained after this process; these MMs were engaged to recruit participants and deliver the
home-based interventions. They received a stipend of $US 130/month and were expected
to work for four hours per day.
Mentor Mothers received four phases of training: (1) watching experienced MMs
implement the intervention in an inspiring manner; (2) attending training sessions cov-
ering nutrition, basic child health, weighing babies and completion of growth charts, how
to recognize danger signs and crisis situations and how to encourage depressed mothers
to be more active and engaged with their children; (3) learning how to build trust with
mothers and use the relationship to improve the consistency of healthy daily routines; and
(4) implementing the first round of home visits independently in their neighborhoods. The
intervention supervisor visited at least one day per month on a random schedule to ensure
that the implementation was proceeding as planned. The supervisor collaborated with the
MM in problem-solving and generating action plans when problems occurred in the field.
The quality of implementation was monitored by reviewing the forms completed at each
home visit, monitoring visitation patterns, collecting observations by outreach supervisors
and brief ratings of home visits by the outreach supervisors.
The frequency of MM visits was based upon need. For example, if there was a very
small low-birth weight baby, the family might be visited two to three times a week for a
week or two until the MM was confident that the child’s mother was coping well. If a child
was improving and gaining weight that dyad could be visited every two–three weeks. When
the child was almost fully rehabilitated visits might occur once a month. Typical MM home
visits lasted from 20 minutes to one hour. During the visits, the MM weighed the child and
discussed developmental progress with the mother. The MM also ensured that the mother
had applied for appropriate social grants and understood proper nutrition and hygiene.
MMs stressed the importance of breastfeeding, the proper time to introduce solid food, fre-
quent feeding and a mixed diet that includes fruits and vegetables. The MMs checked that
immunizations were up to date and that the child had been dewormed. Among the families
Vulnerable Children and Youth Studies
in each MM’s caseload there was likely to be one emergency per week; for example, a
child with a high fever, difficulty breathing or appearance of severe dehydration. These
cases were brought to the Philani health clinic or the local public health clinic to receive
immediate attention. As part of the intervention program, MMs established neighborhood
meetings where mothers gathered to discuss child health and nutrition issues.
The following measures were assessed:
rMaternal and household characteristics. At recruitment, mothers reported their age,
status and housing conditions (classified as formal, site and service or informal).
Interviewers reported two subjective assessments of the mothers’ living conditions:
overall smell (classified as pleasant, neutral or poor) and hygiene (classified as good,
average or poor).
number of years they had been in Cape Town, number of living children, marital
rChildren’s characteristics. At recruitment, mothers reported on several characteris-
the child’s meals had been reduced in size or skipped in the past year due to lack of
money and whether or not the child was already enrolled in a nutrition program. At
recruitment and follow-ups, child weight was measured in kilograms. In addition,
a weight-for-age Z-score (WAZ) was calculated and standardized according to ref-
erence weights from the Centers for Disease Control and Prevention growth charts
(Kuczmarski, Ogden, & Grummer-Strawn, 2000).
tics of the child enrolled in the study, including: age, gender, birth weight, whether
We compared demographic and household characteristics of the dyads across intervention
conditions at recruitment. We also compared dyads followed over time versus those lost
to follow-up; χ2tests and t-tests were conducted for categorical and continuous measures,
respectively. Where appropriate, Fisher’s exact test was conducted on categorical measures
with sparse cell counts and the Wilcoxon two-sample test was conducted on continuous
measures with skewed distributions.
Mixed-effect linear regression models were fitted in SAS software version 9.1 (SAS
Institute Inc., Cary, NC, USA) using the PROC MIXED procedure to evaluate the impact
of the intervention on the child’s weight (in kilograms and weight-for-age Z-score) over
the year following recruitment. Random intercepts were included for each MM and each
child to account for the hierarchical structure of the data. We also modeled an autoregres-
sive (AR) covariance structure to account for variability between repeated evaluations not
accounted for by the random intercepts. The longitudinal model estimates separate base-
line means and trajectories for each intervention condition. In doing so, the model allows
baseline and trajectory differences across intervention conditions to be disentangled and
Models included covariates for relevant background characteristics (i.e. characteris-
tics anticipated to be associated with child weight or found to differ across intervention
conditions); an intervention condition indicator to control for baseline differences in child
weight across intervention conditions; time from recruitment; and a time × intervention
condition two-way interaction to model both separate mean weights at recruitment and
weight trajectories over time for the intervention and control conditions. Based upon the
I.M. le Roux et al.
curved trajectories found in infant growth charts, we anticipated that weight would change
in a non-linear manner over the course of the year. Therefore, we also tested covariates
for a quadratic time trend to model non-linear weight changes in the overall sample and
a three-way interaction between quadratic time and intervention condition to model addi-
tional non-linear weight changes in the intervention condition; quadratic covariates were
retained if significant. The model for weight in kilograms also included age of the child at
recruitment as a covariate; weight-for-age incorporates age into the outcome measure.
Table 1 shows the demographic and background characteristics of mother–child dyads at
recruitment. Most mothers were married (70%); the average age was 29.4 years old for
mothers and 26.2 months for children. Half the dyads lived in informal housing (48%). A
majority of interviewers reported living conditions of the dyads to have a pleasant or neu-
tral smell (87%) and to have at least average hygiene (78%). Slightly fewer than a quarter
of the children were supported by a nutrition program (24%) and 41% of children were
of low birth weight, defined as less than 2500g at birth. None of the demographic and
background characteristics differed significantly across intervention conditions, although
two characteristics exhibited trends towards significance. A higher percentage of children
in the intervention condition were likely to be in a nutrition program at recruitment com-
pared to children in the control condition (26% vs. 19%; χ2=3.54, df=1, p=0.06). On
average, children in the intervention condition weighed less at recruitment (mean=8.6 vs.
9.0 kg; t=1.88, df=677, p=0.06.). WAZ was also significantly lower in the intervention
group (mean=–3.49 vs. –3.21, t=3.07, df=677, p=0.002). These potential differences
across intervention conditions were accounted for in regression analyses by the inclusion
of appropriate adjustment covariates.
by intervention condition.
Demographic and background characteristics of mothers and their children at recruitment
Mean age of caregiver
Mean years of
residence in Cape
Mean number of living
10.3(7.6) 10.0 (7.2) 10.1(7.3)0.73
2.7(1.7)2.6(1.6) 2.6(1.6) 0.29
(70.4)Married vs. single
Presence of fatherc
Vulnerable Children and Youth Studies
Table 1. (Continued).
Mean birth weight in
Mean weight at
recruitment in kgd
Mean age at
9.0 (2.5)8.6 (2.4)8.7(2.4) 0.06
–3.21(0.87) –3.49(1.09) –3.41(1.04)
Low birth weight,
Supported by a
Cut size of child’s meal
in past 12 months
32(18.6) 120 (25.8)152 (23.8)0.06
71(41.8) 213(44.6) 284(43.8) 0.53
Site and service
Access to water
Tap on site
Notes:an=325 (48% of possible responses).
bn=417 (61% of possible responses).
cn=at least 530 (at least 78% of possible responses).
dn=679 (full sample).
For remaining measures, total n=635 or greater (at least 93% of responses).
et-Test or Wilcoxon test for means; χ2test or Fisher’s exact test for percentages.
I.M. le Roux et al.
We compared characteristics from Table 1 between mothers we were unable to follow
after recruitment (6%; 39 of 679) and mothers with at least one follow-up assessment.
Mothers in the control condition were more likely to be lost to follow-up compared to those
in the intervention (11% vs. 4%; χ2=13.24, df=1, p< 0.01). Mothers lost to follow-up
were also likely to have lived in Cape Town for fewer years compared to mothers who
were followed successfully (mean=6.1 vs. 10.3; t=–2.46, df=415, p=0.01). None of
the other demographic or background characteristics differed significantly by whether or
not mothers were lost to follow-up. All observations were included in regression analyses;
dyads lost to follow-up contributed only to weight estimation at the recruitment timepoint.
Analyses on weight in kilograms and WAZ led to the same conclusions; therefore, we
present results on WAZ only. We included children’s gender and a dichotomous indicator
for enrollment in a nutrition program at recruitment as covariates; both were signifi-
cant predictors of WAZ (both p<0.01). Children in a nutrition program weighed less at
baseline. Males also weighed less, consistent with research indicating that male infants
thrive less successfully than females (Khoury, Marks, McCarthy, & Zaro, 1985; Naeye,
Burt, Wright, Blanc, & Tatter, 1971; VanDenBosch, Huygen, VanDenHoogen, & VanWeel,
1992; Waldron, 1983; Wells, 2000). The quadratic time trend was significant and retained
in the model; the quadratic time × intervention condition interaction was not. WAZ tra-
jectories for each intervention condition as estimated by the regression model are shown
in Figure 2. Across both conditions, WAZ increased over the one-year follow-up period,
initially at a faster rate (linear time slope=0.11 and quadratic time slope = –0.0040,
t=10.95 and –7.63, df=5176, both p< 0.01). At recruitment, WAZ was estimated to be
0.22 points lower in the intervention condition compared to the control condition (t=2.11,
df=5176, p=0.04). In the intervention condition, WAZ increased linearly over one year
compared tothe control condition (slope difference=0.018, t=2.25, df=5176, p=0.02).
The Philani program resulted in significantly greater weight gain among malnourished
children enrolled in the intervention program, compared to controls, in 37 neighborhoods
in South African townships in the vicinity of Cape Town. Poor nutrition is one of the
major determinants of child health and survival and is linked consistently to poor cognitive
and developmental outcomes over the lifespan (Grantham-McGregor, Powell, Walker, &
Himes, 1991; Mason et al., 2005; Stanfield, 1993). As demonstrated by programs such as
EFNEP and PD/Hearth, and now by Philani, peer educators and role models can be used
successfully to improve nutrition practices in low-resource communities.
These results also support the potential utility of paraprofessional MMs to deliver
in-home programs for households at high risk of other negative outcomes for their chil-
dren. The WHO has advocated successfully for the integrated management of childhood
disorders (World Health Organization [WHO], 1997) and has demonstrated that para-
professionals can be consistently good deliverers of effective programs (World Health
Organization [WHO], 2003). The work of Grantham-McGregor and colleagues in Jamaica,
for example, shows the effectiveness of home visits by community health aides to
improve the cognitive development of malnourished children (Grantham-McGregor et al.,
1991; Powell, Baker-Henningham, Walker, Gernay, & Grangham-McGregor, 2004). An
evaluation of the mothers2mothers program in KwaZulu-Natal, South Africa (Beck et al.,
Vulnerable Children and Youth Studies
Time from recruitment (months)
children in the intervention and control conditions.
Plots of model-fitted weight-for-age Z-scores (WAZ) over time for initially malnourished
2007) demonstrated the ability of MMs to improve psychosocial wellbeing, increase use
of clinical services to prevent mother-to-child human immunodeficiency virus (HIV) trans-
missionandcontinued utilizationofthehealth-caresystem,amongHIV+pregnant women.
Across geographical contexts and maternal and child health outcomes, peer mentors are an
efficacious model for health behavior and structural interventions.
It is important to recognize that these are preliminary findings. MMs implemented assign-
ment of families to the treatment condition; the nearly significant difference in child weight
at baseline between the intervention and control groups indicates that reassignment of
needier families into the intervention probably took place, and prevents this from being a
truly randomized study. The loss to follow-up was significantly greater in the control con-
dition compared to the intervention condition, suggesting that there may have been bias as
mothers in need of support and intervention dropped out of the study. In addition, because
MMs conducted the intervention as well as collected data, assessments were not blinded
as to study arm. Finally, because randomization took place within each neighborhood, with
the possibility of close neighbors being assigned to different arms of the study, it is possible
that contamination could have occurred in which women receiving the intervention shared
information and support with women in the control arm. Given these preliminary findings,
we are currently conducting a randomized controlled trial with neighborhoods assigned to
intervention and control conditions, that is, randomization occurs at the neighborhood level
rather than the individual level. Assessments are conducted by an independent team, not
I.M. le Roux et al.
MMs. This will prevent the possibility of MM bias during the condition assignment pro-
cess or during data collection, as well as preventing contamination of intervention effects
from mothers in the same neighborhood.
In the United States, home visiting programs such as that of Olds et al. have been effective
and broadly diffused (Gomby & Culross, 1999; Olds, Hill, & Rumsey, 1998; Olds, Sadler,
& Kitzman, 2007; Olds et al., 2002, 2004a, b; Sweet & Applebaum, 2004). These programs
target multiple child development and parenting outcomes, not just nutrition. Although the
US experience has shown the greatest effectiveness when home visitors are professional
nurses, paraprofessional visitors have also provided significant improvements (Olds et al.,
2002, 2004b). The huge differential in costs and the shortage of trained medical personnel
in South Africa favor implementation with paraprofessionals, especially those who are
chosen on the basis of the theory of positive peer deviants (Berggren et al., 1984; Marsh
et al., 2004; Marsh & Schroeder, 2002; Rogers, 1983; Sternin et al., 1998; Wollinka et al.,
1997). The MM model could become a vehicle for addressing a variety of conditions,
relating to nutrition, alcohol, mental health and HIV , that confront families in South Africa.
This is a significant shift from existing prevention models that do not integrate prevention
efforts vertically to target simultaneously the health behaviors that lead to major diseases
affecting African women, children and families.
This research was supported by funding from the Centre for Health and Wellbeing through Professor
Christina Paxon at the Woodrow Wilson School, Princeton University. We thank Professor Anne
Case and Dr. Alicia Menendez from the Center for Health and Wellbeing for their contribution to the
original design of the study and their advice and support throughout. We thank the Philani staff for
their work with the families and assistance in collecting the data and the families in Khayelitsha for
their participation. Drs I. M and K. leRoux and Dr. Rotheram-Borus supervised the study. Drs leRoux
supervised the intervention and the acquisition of data. Dr. Comulada designed and conducted the
statistical analyses and interpreted the results. All authors contributed to the writing of the paper.
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