Feasibility and pilot study of a complex community intervention to improve rural adolescent health

Lead Research Organisation: University of the Witwatersrand
Department Name: Faculty of Health Sciences

Abstract

Throughout the world the numbers of people with non-communicable (NCDs) diseases, like type 2 diabetes and high blood pressure, are increasing. The risk of developing diabetes is associated with being poorly nourished as a child and then becoming obese later in life, being inactive, having a poor quality diet, as well as with genetic inheritance and poor growth in the womb. Low- and middle-income countries, like South Africa, have particularly fast-growing numbers of people with NCDs and have health systems already struggling to manage the burden of infectious diseases. We have shown that in rural South Africa a third of girls have growth faltering at one year of age, and a third of adolescents and young women are overweight or obese by 20 years of age. Five percent of 7 to 15 year olds already show early warning signs for the development of diabetes.

To combat the problem of an increasing prevalence of NCDs, it has been suggested that improving adolescent nutritional status may be a successful strategy, and that developing and evaluating pre-pregnancy interventions that promote healthy behaviours in poor communities where childbearing tends to start at a younger age, may be part of the solution. Sub-Saharan Africa is the only region worldwide where the number of adolescents is predicted to grow, but it also has the worst adolescent health profile. To date, we are still unclear about how best to intervene to improve nutritional status in adolescents in low- or middle-income countries.

Our extensive research over the last five years, has informed the development of an intervention targeting adolescent girls and boys. It will employ trained adolescent-focused community health workers (AHWs) to work with adolescents to address both underweight and obesity by: (i) promoting healthy behaviours and increasing their use of adolescent health services; (ii) encouraging better caregiver and friend support and increasing opportunities in the community to become more healthy; and (iii) supporting adolescent girls who become pregnant to use antenatal health services earlier in their pregnancies and more frequently.

This intervention aims to identify and reduce NCD risk in adolescents, and increase their use of health services through supporting behaviour change. AHWs will be trained in 'Healthy Conversation Skills', a set of skills to support behaviour change specifically developed and tested for use with socioeconomically disadvantaged women to improve their confidence that they can achieve their health goals. AHWs will use these skills as the basis for their work in rural SA villages over two years, building relationships with adolescents and their families to encourage social support for healthier adolescent lifestyles. The intervention is flexible in its approach and will focus on the most relevant area of difficulty for each participant. AHWs will also involve their adolescent peer group in the village to promote health literacy. Health literacy will both increase adolescent access to health information and develop their ability to use this information effectively. AHWs will mobilise village community leaders to create greater opportunities to promote and support healthier lifestyles. Adolescents who become pregnant will be further supported by AHWs to access and regularly attend antenatal services, facilitate caregiver involvement, and reinforce optimal individual health (including weight gain) during pregnancy. Through these interventions we aim to reduce the incidence of low of high birthweight in the infants, as these have been associated with diabetes risk in later life.

The proposed development grant will enable us to complete a feasibility and pilot study in two villages to provide critical data to inform both the design and implementation of the trial.

Technical Summary

The proposed intervention is already informed by extensive formative research (over 5 years; 25 publications) based on UK MRC Guidelines for Complex Interventions and supported by PI Norris' MRC/DfID African Research Leader award2. The formative evidence base includes: (i) a needs assessment with local stakeholders from multiple sectors, including adolescents; (ii) studies describing youth-friendly health services, and adolescent perceptions and use of these services, (iii) barriers to and facilitators of physical activity and dietary practices; (iv) child and adolescent growth, nutrition and metabolic disease risk surveys; (v) literature reviews and scoping of best practice interventions; (vi) analyses of Agincourt HDSS longitudinal surveillance data on fertility and childbearing patterns; (vii) formulation of behaviour change objectives; (viii) selection of theory-based methods and practical strategies appropriate for encouraging behaviour change in the target group; (ix) training of lay community workers in "healthy conversation skills"; (x) field studies to document variance in BMI across the target villages to inform power calculations.

However, the proposed pilot study will enable us to further identify important factors which may be important in assessing the feasibility (consenting, recruitment rates, protocol delivery, data collection processes, tracking metabolic and pregnancy outcomes), the acceptability of the intervention components (intervention material; AHWs) to the control and intervention populations and the villages, and to use this information to refine and strengthen the future trial design and implementation of the study.

Planned Impact

South Africa's evolving burden of disease is complex due to: (i) persisting malnutrition (infant stunting reaching 40% in some rural areas); (ii) the highest prevalence of obesity in Sub-Saharan Africa; and (iii) rising rates of type 2 diabetes (T2D) - 14% of black adult women live with T2D. Efforts to address the paradoxical challenges of stunting in early childhood and escalating obesity, particularly in black South African women, have been largely unsuccessful.

Impact of project on problem: Planned intervention during adolescence for girls and boys, and in particular, before young women become pregnant in settings where childbearing is common before age 20y provides the best opportunity to impact effectively on an adolescent's future health and that of the mother's offspring. The project team has engaged fully with target communities, adolescents, and various stakeholders, including the health sector, to ensure buy-in, collaboration, affordability and sustainability. We envisage that this intervention will substantially reduce the risk of suboptimal or excessive weight gain in adolescents and contribute to lessening the present and future NCD burden in South Africa.

Trial will produce rigorous evidence: Including process and economic evaluations, which can inform potential later scale-up based on primary health care systems. Adolescents are a highly vulnerable and at-risk population for the onset of obesity, with potential lasting effects for themselves and on the next generation. Early interventions to improve adolescent nutritional status and health are likely to have a significant impact and be more cost-effective than intervening later in life.

The intervention has great potential to impact on and strengthen the public health system (collaboration and co-production): Rigorous evaluation using hard endpoints will provide evidence for intervention scale-up within primary health care systems in South Africa, regionally and in other middle- and low-income countries undergoing complex health and nutrition transitions. In particular, we aim to work with and support the current national health system to adapt to these new and unfamiliar challenges. Thus the partnership with the South African Department of Health (DOH) was initiated early in the intervention development and needs assessment to ensure the project's relevance, with co-creation and input, and importantly to lay the basis for potential take-up of the evidence to shape policy and practice. The findings, experience and insight from the process evaluation will, we expect, prove instrumental in informing the DOH's Primary Health Care Re-engineering initiatives with AHWs and form an essential part of the pathway towards economic and societal impact. Notably, findings from this trial should translate into current adolescent health practice. Key local and national members of the DOH are part of the established Community Advisory Group and Scientific Committee.

The planned development grant is crucial to provide pilot, feasibility and acceptability information to assist in the development of the trial and how the complex community intervention will be implemented.

In summary: impact of the trial will be through: (i) advancing our understanding on how to improve the nutritional status and health of adolescents living in poor communities; (ii) understanding how a pre-pregnancy intervention during adolescence may leverage health benefits for adolescent women and their offspring if they become pregnant; (iii) shaping Department of Health policy and practice around AHWs; and (iv) enabling bi-directional knowledge transfer between UK and SA researchers and students involved in the study.

Publications

10 25 50
 
Description Wellcome Trust Intermediate Fellowship
Amount £800,000 (GBP)
Funding ID Conduct disorders, violence and executive function as potential intervention targets to improve child and adolescent mental health in South Africa 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 02/2019 
End 01/2024
 
Title Database 
Description The study is currently generating a database of data on all adolescents from two rural South African villages that form part of this pilot study. 
Type Of Material Database/Collection of data 
Year Produced 2018 
Provided To Others? No  
Impact The research database is still be developed as the current study has not yet completed. 
 
Description 1000DaysPlus Global Nutrition Research Group 
Organisation University of Southampton
Country United Kingdom 
Sector Academic/University 
PI Contribution I am a co-investigator with Professor Newell (PI) on a NIHR Research Group application, which was successful. Sub-Saharan Africa (SSA) has persistently high rates of intrauterine growth restriction, pre- term birth, low birthweight, underweight and child stunting, but also rapidly increasing rates of overweight and obesity. Further, communities across SSA now have a 'double burden' of malnutrition, where under-nutrition in infancy is followed by over-nutrition in terms of macronutrients, but with enduring deficiencies in micronutrients (iron, folic acid and other vitamins). Of particular concern is that from Developmental Origins of Health and Disease (DOHaD) research, early life under-nutrition coupled with excessive weight gain in later life ncreases risk for adult obesity, diabetes and hypertension. Given that non- communicable diseases (NCD) are major causes of death and disability globally and are now increasing most rapidly in low- and middle-income countries (LMICs), optimising the nutritional status of future parents, and thus tackling the double burden of malnutrition may in the short-term improve growth and neurodevelopment of their offspring, and in the longer- term could set up healthier trajectories that reduces the risk for NCDs in later life. To address the double burden of malnutrition we will establish a group of researchers to develop a framework focussing on our 1000 DaysPlus concept (optimise nutrition before, during and after pregnancy). We envisage that implementing supportive "double-duty" nutritional interventions to tackle both aspects of the double burden of malnutrition will require engagement of critical multi-sectoral stakeholder groups, including target population groups along with policy-makers and health care professionals (HCPs), to co-create opportunities and services to allow vulnerable populations to adopt healthy diets. HCPs have an important role in motivating men and women to change eating behaviours; in LMICs the case for such policy action has not yet been made, and HCPs lack knowledge and skills to assist motivation. I contributed the the conceptualisation and writing of the grant application and subsequently I will be leading the research in South Africa.
Collaborator Contribution Professor Newell lead the grant application and she will be providing leadership and mentorship across the group.
Impact The group's first meeting took place in Johannesburg, South Africa in May 2018. A follow-up meeting then was convened in Southampton in October 2018. Five work packages were formulated and are currently being implemented, which involved Lancet mini-series, qualitative data collection, economic modelling, stakeholder engagement, and analyses of historical data collected in South Africa, Burkina Faso and Ghana.
Start Year 2018
 
Description GDAR: Global network in Diet and physical Activity Research 
Organisation University of Cambridge
Department MRC Epidemiology Unit
Country United Kingdom 
Sector Multiple 
PI Contribution I am a co-investigator with Professor Nick Wareham (PI) on a NIHR Global Health Research Network grant application, which was successful. The network aims to achieve the following: 1. Investigating the determinants of diet and physical activity in LMICs; 2. Understanding 'lived experiences' shaping diet and physical activity; 3. Mapping the policy environments relevant to the determinants of NCDs; 4. Identification and evaluation of natural experiments; and 5. Development and testing of methods for use across the GDAR sites, including pilot data collection. I contributed to the conceptualisation and writing of the application and subsequently I am leading the second aim across the network of countries.
Collaborator Contribution Professor Wareham with Professor Unwin lead the grant application and is stewarding the network to ensure we achieve the goals set out.
Impact The first network meeting took place in Cambridge in 2017 and we are currently implementing the research agenda. The partnership has harmonised data collection across two sites in South Africa (Cape Town and Soweto), Jamaica, Cameroon, Kenya and Ghana.
Start Year 2017
 
Description TALENT Network: Transforming Adolescent Lives Through Nutrition 
Organisation University of Southampton
Department MRC Lifecourse Epidemiology Unit
Country United Kingdom 
Sector Public 
PI Contribution I participated as a co-investigator with Professor Caroline Fall (PI) on a GCRF pump priming grant in global nutrition, which was successful. This grant will form a consortium of researchers in the UK, sub-Saharan Africa and India who have a special interest in adolescent health and the ability to work together to conduct major population-based nutrition research in diverse LMIC settings. We aim to fill large knowledge gaps about the dietary behaviour, food security, nutritional status and physical activity of adolescents in LMICs, the factors that influence these and how they change through the course of adolescence. We will use this new knowledge and understanding to develop and assess context-specific interventions to improve adolescent nutrition, engaging with adolescents themselves, their communities, and policy-makers to ensure impact and scalability. We will also build within-country capacity for quantitative and qualitative nutrition research, and intervention development, in the adolescent age group. My contribution was in the conceptualisation of the application and planned activities and writing of the application. Subsequently, I am leading the stakeholder engagement research theme in this network across the sites.
Collaborator Contribution Professor Caroline Fall as PI provided the overall leadership in the preparation of the grant application and subsequent to its success is coordinating the research activities of this network that consists of 10 African and Indian research sites.
Impact We have had our first network workshop in Dervan, India and have completed the implementation of the research activities planned during the workshop. We are currently analysing data and preparing papers, and seeking new grant opportunities
Start Year 2018
 
Title Adolescent intervention package 
Description Intervention package and tools designed to be delivered by community health workers in either urban or rural communities to adolescents to optimise their physical and mental health. 
Type Preventative Intervention - Behavioural risk modification
Current Stage Of Development Initial development
Year Development Stage Completed 2019
Development Status Under active development/distribution
Impact The package (resources) and training material have all been developed for testing 
 
Description Followup Stakeholder Engagement Meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The original 15 stakeholders from South African national departments of health and nutrition, international agencies (UNICEF and Save the Children), NGO (Lovelife) professional practitioners, and community leaders convened in Johannesburg at the School of Public Health (University of the Witwatersrand) to address current research, practices, and policies in South Africa governing adolescent nutrition were invited to the follow up meeting. The stakeholder engagement workshop was particularly pertinent to the planned activities around the current MRC grant with good dialogue that is useful to the intervention piloting but also in terms of data needed by government departments to influence policy and practice.
Year(s) Of Engagement Activity 2019
 
Description Stakholder engagement workshop 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact 15 stakeholders from South African national departments of health and nutrition, international agencies (UNICEF and Save the Children), NGO (Lovelife) professional practitioners, and community leaders convened in Johannesburg at the School of Public Health (University of the Witwatersrand) to address current research, practices, and policies in South Africa governing adolescent nutrition. The stakeholder engagement workshop was particularly pertinent to the planned activities around the current MRC grant with good dialogue that is useful to the intervention piloting but also in terms of data needed by government departments to influence policy and practice.
Year(s) Of Engagement Activity 2018