Asili Evaluation in the Democratic Republic of Congo
Condition: Diarrhea; Cough; Fever; Malnutrition, Child
MeSH terms: Malnutrition; Child Nutrition Disorders; Diarrhea
Study type: Interventional

Summary: 
      The South Kivu province of DRC has experience continuous armed conflict over the last several
      decades; as a result, livelihoods and health metrics are uniformly poor. Thus, the objective
      of this study is to determine if an integrated set of social enterprises can improve child
      health while offering viable and scalable new business opportunities for the community.
      Specific research questions include the impact of the individual enterprises on (1) child
      health, (2) access to clean water, and (3) economic opportunities in the region.
    

Detailed description: 
      The South Kivu province of DRC has experience continuous armed conflict over the last several
      decades; as a result, livelihoods and health metrics are uniformly poor. Thus, the objective
      of this study is to determine if an integrated set of social enterprises can improve child
      health while offering viable and scalable new business opportunities for the community.

      Asili ("foundation" in Swahili) is an innovative initiative that aims to implement a suite of
      social enterprises to provide basic services and employment opportunities in South Kivu, DRC.
      Asili was co-created by the American Refugee Committee (ARC), an independent non-profit, and
      IDEO.org using a methodology known as human-centered design (HCD); based on the process, a
      model of multiple businesses to meet multiple needs was developed, linked under the Asili
      membership system and coordinated through a centralized database. The Asili model is unique
      in bringing self-sustaining social enterprises together on a common operational platform to
      improve both health and economic opportunity in the region. These enterprises are 1) clean
      water and 2) high quality healthcare clinics.

      The team at Stanford University has been recruited as the external evaluator to conduct an
      impact evaluation of Asili in order to determine whether or not the project goals of reduced
      child disease as well as increased economic capacity are met. The primary outcome of this
      impact evaluation study is to determine the effect of the Asili intervention on improving the
      health of children under five from baseline. Secondary outcomes of this study are to
      determine the impact of the intervention on enhanced economic activity, food security, and
      maternal self-esteem and self-efficacy. The investigators hypothesize that under-five
      children in Asili households will have lower incidence of diarrhea, fever, and cough/short,
      rapid breathing as well as a higher incidence of vaccination rates.

      There is little research on the effects of social enterprise/HCD interventions on health,
      child health in particular, especially in areas recovering from recent conflict. Therefore,
      the investigators' aim is to determine if a multi-sectoral approach that can improve
      livelihoods in DRC can also improve family and child health.

      This study will use household surveys at two time points (baseline and endline) to collect
      information on key indicators from the target populations. For Zones 3 and 4, encouragement
      design will be used to provide an instrumental variable to analyze the difference in outcomes
      between the households that enroll in Asili and those that do not. Specific research
      questions include the impact of the individual enterprises on (1) child health, (2) access to
      clean water, and (3) economic opportunities in the region.

      Encouragement design, a variation on the more commonly known randomized control trial (RCT),
      is a useful alternative for interventions where it is impractical to require adherence by
      participants or in situations where offering the intervention to a portion of the population
      is not possible or ethical. Encouragement involves randomly assigning participants to the
      "opportunity" or encouragement arm, where efforts are made to motivate participants to take
      part in an intervention or receive a particular treatment, but are allowed to choose whether
      or not they actually participate.

      Because Asili services will be offered and available to all members of the community and
      controlling access to services is not possible, encouragement design will be utilized to
      measure uptake of Asili. Families will be randomly sampled based on location, and a team of 2
      local community champions/data collectors (hired from within the community) will visit each
      of the encouragement arm homes, supervised by a community outreach liaison. Community
      champions will be responsible for visiting each home, going door-to-door and speaking with
      each family individually in order to avoid contamination/cross-over with control households.

      Champions will spend between 25-45 minutes with members of each household, during which they
      will explain how Asili works, what the intervention encompasses, and the benefits of joining
      Asili. The investigators hope to foster a sense of trust in the participants randomized to
      the encouragement arm by engaging data collectors from the community for these one-on-one
      exchanges with each household. Control households will also have equal access to Asili
      services; however, those households will not be visited by community champions individually.

      The study populations in the two Zones include families surveyed from the catchment area of
      the Asili project intervention site in South Kivu. Each of these zones has a population of
      approximately 10,000 individuals; approximately 850 households were recruited at baseline in
      each of Zones 3 and 4. Baseline data was completed in Zones 3 and 4 in August 2016 and July
      2017, respectively, and follow-up is anticipated in April/May 2018.
    

Intervention name(s): Encouragement
Intervention type(s): Behavioral
Intervention description(s): Households will be visited and encouraged to enroll in Asili
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: As part of the encouragement intervention, participants (households) will be randomly assigned to the "opportunity" or encouragement arm, where they will be incentivized to participate in the Asili intervention, but are allowed to choose whether or not they actually participate.
Families will be randomly sampled based on location, and a team of 2 local community champions/data collectors (hired from within the community) will visit each of the encouragement arm homes, supervised by a community outreach liaison. Control households will not receive an individualized home visit.
Due to numerous factors, including political instability and program implementation delays, our local research team was unable to deploy encouragement as planned.
Masking: None (Open Label)
Primary purpose: Health Services Research