Strengthening the quality of adolescent primary healthcare in South Africa: preliminary work on a complex public health intervention

Adolescence is a formative phase of life which shapes the health and well-being of an individual for adulthood. In South Africa, adolescents are experiencing large and growing burdens of disease with high rates of communicable diseases (like HIV and TB), pregnancy, obesity, mental illness and trauma. Government policies to support adolescent healthcare have been widely implemented, however, challenges remain in how such policies are operationalised to strengthen adolescent healthcare: primary care clinics report low attendance of adolescents and school health reviews show low service provision. The Knowledge Translation Unit in Cape Town has developed the PACK Adolescent guide and training programme to support primary care clinicians (nurses and doctors) with tools to meet the needs of adolescents.

The aim of this study is to understand the status of adolescent healthcare in primary care clinics and schools in order to refine and adapt PACK Adolescent to meet the needs of adolescents and the challenges faced by clinicians in providing care to this underserved grouped. Once refined, we shall pilot and evaluate PACK Adolescent in schools and clinics to see what more we need to do to optimise PACK Adolescent and what we need to alter about the delivery of adolescent healthcare to enable its use in primary care clinics and schools in other settings.

From the outset, the design of this study involved the input of adolescents themselves, primary care clinicians and policymakers in health and education sectors during a stakeholder workshop. Throughout the grant's duration, stakeholder input and co-production will characterise the study through theory of change workshops and an advisory board. The study seeks to assess adolescent primary health care in six clinics and twelve schools in the Western Cape province of South Africa through a facility questionnaire to determine various aspects of adolescent healthcare services and the clinical characteristics of adolescents using these services. We shall observe the processes that adolescents follow to receive health care, including their consultations with clinicians. Focus group discussions with school and clinic managers, clinicians, community-based organisations, policymakers and adolescents will provide a broad understanding of existing adolescent health care. We shall then refine the PACK Adolescent guide and training programme following a theory of change workshop (a workshop intended to develop a system of ideas to explain how we think change happens in the area we want to address, and how we intend to work to influence these changes) with key stakeholders. The adapted intervention will then be piloted and evaluated in the six clinics and twelve linked schools (primary and secondary). Through observations of the use of PACK Adolescent and resultant changes to the clinical pathway for adolescents as well as interviews with adolescents, clinic clinicians and school health nurses we will see how PACK Adolescent meets the needs of adolescents and clinicians along with the challenges to its use. A survey questionnaire completed by clinicians in schools and clinics along with routine health data will help us to assess its impact.

The outcomes of the study will provide an understanding of adolescent primary healthcare across schools and clinics. It will allow us to identify the minimum system strengthening components needed to support adolescent healthcare in an integrated way in both health and education sectors. We shall share these outcomes with participating schools and clinics, as well as the Departments of Health and Education in the province and nationally. They will inform the design of a future study evaluating whether PACK Adolescent leads to improved outcomes for young people.

Over half the world's adolescents live in countries like South Africa, with high levels of communicable and non-communicable diseases, obesity, high adolescent fecundity and unmet need for contraception. Although at increased risk, adolescents are marginalised and face barriers in accessing healthcare. In South Africa many policies set out to right this, nevertheless, adolescent-specific service provision is lacking especially with regards to inter-sectoral collaboration. The Knowledge Translation Unit has developed a PACK Adolescent health systems strengthening intervention which covers the comprehensive and integrated primary healthcare of a 10 to 19 year old. At 6 clinics and 12 schools in South Africa, we will conduct a situational analysis of adolescent primary healthcare using observations of non-clinical healthcare processes and clinical consultations, interviews with policymakers and community-based organisations and focus groups with managers, clinicians and adolescents. Two theory of change workshops with key stakeholders will help adapt the intervention using minimum components that incorporate an understanding of adolescent health needs across clinics and schools. The customised intervention will then be piloted in 6 schools and 12 clinics. A parallel, mixed methods process evaluation will include observations of consultations and interviews with adolescents and clinicians. A survey questionnaire will be completed by end-users 6 months after implementation to assess the intervention's reach. Impact will be assessed through monitoring routine data of adolescents accessing healthcare in schools and clinics. We will engage with stakeholders in the design, adaptation, pilot and implementation phases through an advisory board of national and provincial stakeholders in health, education and social services, as well as adolescents themselves, to ensure that the study and the intervention speak to the needs of adolescents and their healthcare providers.

We have identified eight stakeholder categories and outlined strategies and tools for their continuous engagement throughout the duration of the project in the Pathways to Impact: [1] local and national policymakers; [2] regional and global policymakers; [3] training providers; [4] clinicians responsible for the delivery of adolescent primary care in clinics and school health service; [5] adolescents and parents/guardians; [6] research participants; [7] academics and [8] potential funders of future work.

Local and national stakeholders are committed to implementing PACK Adolescent in South Africa to complement PACK Adult (which is already well embedded throughout primary care) thereby promoting life course and family-orientated approaches in keeping with the WHO's strategy of Survive, Thrive and Transform for children, adolescents and women (http://www.who.int/life-course/partners/global-strategy/global-strategy-at-a-glance/en/). They are most concerned with how to optimise implementation. Co-production of the implementation components of PACK Adolescent and research findings from this Grant will provide important lessons and insights in this regard as well as opportunities for continuous engagement. The value of embedded research are that stakeholders are more likely to use evidence when there has been dialogue and exchange between researchers and potential "users" including policy-makers, health providers, citizens.

Regional and global policymakers will want to understand whether PACK Adolescent is able to strengthen the processes and outcomes of adolescent primary care services in resource-constrained settings. Inclusion of them at the
Grant stage in development of this application and the diagnostic phase of the situational analysis and the adaptation of the intervention is critical to understanding what they would consider compelling and policy-important outcomes, and securing their participation in a future Advisory Board and dissemination of activities.

We need to engage with end-users throughout the situational analysis, intervention adaptation and evaluation process to design a health systems intervention that is highly acceptable and relevant, and likely to result in uptake of PACK
Adolescent into daily practice. Training providers and health care workers responsible for the delivery of adolescent primary care in clinics and schools will be included in the co- production of the intervention from the start, and their preferences and concerns systematically elicited and addressed through the parallel process evaluation.
Adolescents and their families are the ultimate beneficiaries of the PACK Adolescent health systems intervention, and may have different views on what they consider to be important outcomes to those of the researchers or policymakers, which should be considered at the time of intervention.

This Grant proposes several research participants including health care workers, managers, policymakers, training providers, and adolescents and their parents/guardians. It is important that their welfare not be compromised in any way by their participation in the research process and that they be informed of the research findings. Measures to ensure their protection and fair treatment are described in Ethical Information. A wide range of academics would be interested in the findings of this Grant, including health systems and implementation science researchers, methodologists and clinicians.