Implementing SafeCare Kenya to Reduce Noncommunicable Disease Burden: Building Community Health Workers' Capacity to Support Parents with Young Children - Worldwide, the most common forms of non-communicable diseases (NCD) among children and adolescents are mental health disorders and injuries/violence. Ample research supports the causal pathway between early childhood adversity—in particular child maltreatment—and vulnerability to a range of NCDs in later life through toxic stress and biological embedding. Consequently, childhood maltreatment represents a major risk factor for NCDs; up to 70% of Kenyans report experiencing maltreatment during childhood, typically by parents due to lack of appropriate parenting skills, misunderstanding of child development, failure to provide proper medical attention, and systemic obstacles to securing basic needs and adequate supervision. Evaluating these behavioral and implementation mechanisms in Kenya offers a uniquely efficient, compressed timeline that is directly relevant to vulnerable, low-resourced populations in the United States (U.S.). While testing implementation pathways in the U.S. is frequently stalled by lower baseline maltreatment reporting rates, Kenya’s high prevalence of parental maltreatment yields the statistical power necessary to rapidly identify intervention effectiveness. Furthermore, Kenya provides an optimal, highly centralized ecosystem to study task-shifted delivery; its formalized national network of Community Health Workers (CHWs) allows for rapid, high-fidelity evaluation of workforce scaling that would otherwise require years and prohibitive costs to coordinate across disparate U.S. state health systems. While evidence-based parenting programs are a proven strategy to remedy risk factors for NCDs, scaling these interventions in the U.S. via traditional, degreed professionals is economically and structurally unattainable. The purpose of this R01 proposal is to conduct a Hybrid Type 2 study to examine the implementation and effectiveness of the evidenced-based program, SafeCare (SC), as a primary prevention approach to address NCD burden. SC has a strong evidence base demonstrating that it improves parenting skills, thereby reducing the likelihood of child maltreatment and subsequent NCD risk. This project leverages Kenya’s CHWs—the well-established, primary workforce for maternal and child physical health in the region—to implement the intervention. This project will sustain a six-year partnership among the Africa Mental Health Research and Training Foundation (AMHRTF; Nairobi-based partner), Pacific University, Georgia State University and its National SafeCare Training and Research Center (NSTRC; SafeCare developers), and key country and regional stakeholders—including families, practitioners, government entities, and researchers—to scale up and disseminate SC. Because NSTRC leads SC implementation across the U.S., findings from this study will create a rapid, bi-directional pipeline that will directly inform and be disseminated to more than 100 U.S.-based SafeCare implementations, including numerous rural communities. Virtual and in-person delivery modes will be examined to identify the optimal methods for sustainability. Three specific aims will be accomplished in this 5-year study: (1) Determine clinical effectiveness of SC delivered by CHWs using a parallel group multilevel-randomized trial. (2) Determine feasibility and probable utility of SC implementation by CHWs. (3) Initiate efforts to scale up and sustain SC with CHWs across Kenya, alongside parallel expansion efforts in the U.S. We will recruit 312 families paired with 24 CHW randomly assigned to deliver SC (16 Providers; 208 families) or care as usual (8 Providers; 104 families). Child maltreatment is a critical social determinant of NCDs, and primary prevention is essential to mitigating long-term disease burden. The utilization of a CHW model establishes a scalable, sustainable workforce infrastructure capable of meeting this demand, particularly within low-resource contexts such as the rural U.S. where severe shortages of degreed professionals p
