Unlocking potential: developing innovative adolescent screening visits for health promotion, prevention and treatment in low-resource settings

In adolescence, health-related behaviours are adopted that will have substantial positive or negative impacts on the individual's short- and long-term health, educational attainment, and employment prospects. However, in most low-income countries few adolescents have any contact with health services, especially for health promotion and disease prevention, and services are not always appropriate for their needs. Due to resource constraints there is often limited capacity to provide high-quality youth-friendly health services. Technological advances provide opportunities to deliver services and information away from traditional clinical settings, hence reducing barriers such as cost or confidentiality. Adolescents may be particularly receptive to digital platforms that allow them to self-manage their health and well-being.

What is A-CHECK? The programme will screen and treat/refer adolescents for common conditions through health check-ups in younger (10-13y) and older (16-19y) adolescents. Adolescents will only be screened for conditions with an accurate and acceptable test and a locally accessible effective intervention e.g. mental health, HIV, vision and hearing, anaemia.

What exactly will be done? I will develop, pilot-test, implement and evaluate the innovative A-CHECK programme and an accompanying digital platform in Zimbabwe. Check-up visits will take place at schools for younger and in the community for older adolescents. The platform will reduce the workload of staff by allowing adolescents to self-screen using questionnaires (e.g. mental health, risk behaviours) and pre-existing apps (to test hearing, eyesight, body composition), and will help the team to keep in touch with adolescents and provide information on referral appointments. I will analyse the data collected through the A-CHECK programme to improve its future acceptability and cost-effectiveness.

What are the main outcomes? Answers to the following questions - Do adolescents attend the screening and referral appointments? What impact do visits have on their health and education? How much does it cost for an adolescent to be screened and to obtain the recommended care for a condition? Is this a good value for money?

What is innovative about this study? The approach is innovative and novel, because, few LMICs currently provide check-up visits for adolescents and in countries where they are provided, the visits don't always meet the needs of adolescents e.g. don't include mental health screening. This proposal takes the innovative and bold step of moving from condition-specific health programmes towards an adolescent-centred approach focusing on what matters most to adolescents. This is the first empirical study to have investigated the effectiveness and cost-effectiveness of multi-component adolescent health check-ups. Specific innovations:
- Youth Researchers will participate in a human-centred design approach to intervention development
- Digital platform on which adolescents will complete some of the health screening activities, saving consultation time and improving the quality and efficiency of data collection
- Novel adolescent engagement activities including crowdsourcing contests and a reward system in the digital platform with adolescents gaining points when they complete screening and/or attend referral visits
- Machine learning and innovative data analysis to maximise A-CHECK efficiency and engagement by providing targeted messages and services

Why Zimbabwe? Zimbabwe is an ideal location for A-CHECK with great potential for scale-up given the close collaboration between BRTI and the Ministries of Health and Education, the emphasis on prevention within the 2018 School Health Policy, and the absence of other good ways to screen and refer adolescents. In other African settings, there is considerable interest in adolescent check-ups and potential for the Zimbabwean model to be adapted elsewhere.

Youth: The immediate benefit of this research will be adolescents living in Harare and Chitungwiza cities in Zimbabwe who participate in this study. They will benefit from health screening, health services/referrals, and increased information on how to improve their health and well-being. If A-CHECK is not an appropriate way of delivering health services for adolescents, then there will be limited immediate benefit of this research. However, the knowledge gained during the project will inform the improvement of the content and/or the implementation of youth friendly health services in this area. The small number of adolescents and young people who participate in our Youth Advisory Group will gain an understanding of research, and may benefit from an increased sense of empowerment. If A-CHECK is effective and scaled-up in Zimbabwe and/or implemented in other LMICs, then many more adolescents will benefit from improved health and educational outcomes.

Families and the wider local community: Any benefit for adolescents in terms of improved health and well-being may benefit their partners and families by improving trust and/or engagement with healthcare services, and by improving overall well-being in the family. Short-term community-wide benefits would be minimal but if the intervention were to be implemented on a larger scale (based on the results of this work) then we would anticipate economic and societal impacts because of a more effective public health service, and improved health, prosperity, and quality of life for adolescents and their families.

Primary health care providers: This research will benefit primary health care providers by engaging with adolescents who are slipping through the net of existing preventive and treatment services. In the longer-term the use of a digital platform as a tool to facilitate more efficient screening, treatment and referral may reduce the workload of clinic staff and increase overall efficiencies in the health service.

Policy makers/programmers: This study is designed to inform practice, and we anticipate that the findings will be used to inform the design and implementation of adolescent check-up visits. If effective, check-up visits can be used as a strategy to achieve the goals of the 2018 School Health Policy. The findings e.g. on integration of services, self-screening etc. may also be transferrable to other population groups. In addition to data on the acceptability, feasibility and impact of the A-CHECK intervention, we will also be able to provide policy makers/programmers with data on the marginal cost of this approach. This intervention, if effective, would contribute to the international and national goal of universal healthcare.

International public health community: This research is aligned with relevant international and national commitments on improving the uptake of promotive, preventive and curative health care by adolescents, and by exploring the use of digital interventions within programmes. The results will be of interest to other regions and countries who are considering implementing digital interventions to improve adolescent health. The findings will feed directly into WHO guidelines on check-up visits for adolescents.

Academics & other collaborative staff: There is a paucity of research data on adolescents worldwide, as informed consent requirements often deter researchers from including those <18 years of age. This research will advance our understanding of the acceptability and feasibility of check-up visits and digital interventions for adolescents in LMICS, and the feasibility of engaging and interacting through a digital platform including through the use of self-screening questionnaires and screening apps. The A-CHECK team in Zimbabwe, and the LSHTM-based postdoc will have several capacity building opportunities including a significant on-the-job training and mentoring, and the opportunity to present at international conferences.