Innovative approaches to developing scalable and sustainable adolescent maternal mental health interventions in Kenya and Mozambique

The majority of the 20,000 babies born to adolescent mothers in low and middle-income countries live in sub-Saharan Africa. Efforts to achieve the UN Sustainable Development Goals have focused on preventing teenage pregnancy, leaving adolescent mothers with limited support to overcome the specific challenges they face. Adolescent girls are particularly vulnerable with 1 in 2 experiencing a mental disorder during pregnancy or the year after birth. The adverse effects on their physical health, social networks, educational achievements and employment opportunities and well as the developmental, emotional, behavioural and physical health outcomes of their children are significant. Despite this inequity, no interventions focused on adolescent maternal mental health have been evaluated in these low-resource settings. This is the challenge this Fellowship will address.

To support adolescent mothers and their children to survive and thrive, it is necessary to engage stakeholders in the development of mental health interventions and identify how to leverage the surrounding structures and forces to optimise interventions for both front-line use and local and national implementation through the combination of human-centred design and systems thinking approaches. Through this fellowship I will use human-centred, systems-minded design to partner with adolescent girls, their families, and health providers to design, implement, and evaluate interventions to improve the mental health of adolescents during pregnancy and the year after birth in Mozambique and Kenya.

A seven-year, three-phase, mixed-method design will be used to develop and evaluate a mental health prevention intervention for pregnant and new mothers aged 15-19 living in Mozambique and Kenya. In Phase 1 (months 2-18) a human-centred, system-minded design approach will be used to partner with adolescents, their families, local service providers and policymakers to identify, adapt and prototype an intervention to improve adolescent maternal mental health outcomes in each country. In Phase 2 (months 14-48), the intervention will be piloted within each country to assess feasibility, appropriateness, and acceptability and collect mental health, process and resource data to prepare for a trial. Lastly, in Phase 3 (months 49-84), a randomised controlled trial evaluating clinical effectiveness and delivery outcomes compared to usual care/basic mental health literacy intervention will be conducted.

The research will result in the development of an intervention(s) that supports adolescent maternal wellbeing and gives adolescent mothers the hope and skills to build a better life for them and their children by packaging what we know are the risk and protective factors for maternal mental disorders in a way that is attractive to young mothers, their families and service providers. By using human-centred, systems-minded design to understand the needs and priorities of young mothers and the health and community systems in which they live, the resulting intervention(s) and approach to contextual adaptation has significant potential for international transferability and impact beyond Mozambique and Kenya, and beyond Africa. In addition, the work undertaken will provide a foundation for the development of approaches to adaptation and implementation of mental health interventions which can be used by providers of mental health interventions across the lifespan.

My research introduces the human-centred, systems-minded design to the field of global mental health to develop interventions to improve the mental wellbeing of adolescent mothers living in Mozambique and Kenya giving them the hope and skills to make a better life for them and their children. Together with my collaborators I have identified four impact goals which we will work towards over the duration of the Fellowship.

Impact Goal #1: Provide evidence of the impact of an adolescent-specific maternal mental health intervention on maternal wellbeing during pregnancy and the year after birth in low and middle-income countries (LMIC) to influence health policy in Kenya and Mozambique
Stakeholders: Kenyan and Mozambican Ministries of Health
Impact: The identification of an intervention which improves adolescent maternal wellbeing within a LMIC context will provide an evidenced way in which national governments can support adolescent mothers.

Impact Goal #2: Provide evidence of the clinical and implementation effectiveness for mental health interventions developed using human-centred, systems-minded design to support the efforts of national and international advocacy groups and influence mental health practices in international development
Stakeholders: United for Global Mental Health; African Alliance for Maternal Mental Health; UK Department for International Development (DFID); World Health Organization; Unicef; United Nations Population Fund
Impact: An intervention developed through meaningful and long-term engagement of adolescent mothers, their families, and local service providers which has proven clinical effectiveness and strong implementation qualities can be used by advocacy groups to support their emphasis on stakeholder engagement in the development of mental health interventions and services. Furthermore, national development programmes may be influenced to require human-centred approaches to the development and delivery of mental health interventions they support in partner countries.

Impact Goal #3: Provide practitioners around the world with a development guide for the identification, adaptation, and implementation of evidence-based mental health promotion and prevention interventions for adolescents using human-centred, systems-minded design
Stakeholders: National and International NGOs (e.g. The Perinatal Mental Health Project; The MHPSS Collaborative; Save the Children); Tete District Health Director (Mozambique); Kilifi County Chief Officer of Health (Kenya)
Impact: The development of a guide for the adaptation and implementation of existing evidence-based interventions specifically for practitioner use will provide practical assistance to service providers to improve the mental health services and care offered to adolescents.

Impact Goal #4: Increase participation of professionals outside the field of mental health in collaboration to improve the development of scalable and sustainable mental health interventions
Stakeholders: Social entrepreneurs, educators, technologists, ang other non-mental health professionals
Impact: By engaging with individuals not traditionally included within the identification and development of interventions to promote adolescent wellbeing we hope to increase their agency and participation in identifying solutions to increase the availability and access to mental health interventions.

Achievement of these goals will also raise awareness of adolescent maternal mental health issues within the communities where the project is conducted. We hope this increases demand for appropriate, tailored interventions and the likelihood of intervention adoption/implementation. Ultimately the project will help to increase the availability of an intervention which provides practical and desired support to maintain positive wellbeing during pregnancy and after childbirth.