A Pilot Study of Improving Outcomes in Teenage Pregnancy Using a Combined Tailored M- Health Program and Motivational Interviewing Intervention
Lead Research Organisation:
Human Sciences Research Council
Department Name: Pop Health, Health Systems & Innovation
Abstract
Mortality among pregnant teenagers in South Africa (SA) is very high: institutional Maternal Mortality Ratio (iMMR) of 67.1 deaths per 100,000 live births in teenagers; with 71.7% of deaths resulting from four causes: hypertension (22.8%); non-pregnancy related infections (21.1%) (HIV/AIDS-related, such as TB or pneumonia); obstetric haemorrhage (14.2%); and medical and surgical disorders (13.6%). Risk factors for these include poor antenatal clinic (ANC) attendance, lack of adherence to antiretroviral therapy, poor compliance to treatment for tuberculosis, inadequate management of preeclampsia, and slow referral of high risk pregnancies to secondary and tertiary centres. Changing the health-related behaviour of pregnant teenagers, using an m-health intervention combined with motivational interviewing (MI), could reduce the prevalence of these risk factors and, thus reduce mortality. This pilot study will test the feasibility, user acceptability and preliminary efficacy of an enhanced version of MomConnect - an m-Health program developed by our partners, the Praekelt Foundation and the SA National Department of Health (NDOH).The enhancements include adding tailored content to the SMS messaging platform; and an MI counselling intervention (4 sessions) delivered face to face by trained healthcare workers. The SMS messages will be tailored by age (13 - 19 years), motivational variables, appointment adherence, language and culture. Messages will be designed, pretested, and refined through formative evaluation procedures, under direction of our health communications expert. The revised program, Teen-MomConnect, will integrate both the enhanced SMS messages and the MI counselling for each pregnant teenager. For example, the MI counsellors will have access to the survey question responses, as well as ANC appointment-keeping status obtained via the cell phone. The MI clinical behavioural counselling training and implementation will be designed by, and pilot tested with health workers, who will deliver the counselling. Starting from week 12 of their pregnancy, the teenagers will receive 4 MI sessions delivered face to face (or via cell phone) at the ANC by a healthcare worker. The study has two phases. Phase 1 aims to develop, test, refine, and then pilot the major program enhancements (SMS and MI) to MomConnect. Phase II is the pilot field test and its aims are:1) to demonstrate whether pregnant teenagers can be recruited and retained in the study; 2) whether the causes of 71.7% of mortality in pregnant teenagers can be measured, 3) to establish uptake rates (both SMS use and completion of MI visit) for the enhanced Teen-MomConnect intervention; 4) evaluate if the integrated motivational behavioural face to face counselling, and the tailored health SMS intervention, impact pregnant teenagers ANC attendance (primary outcome), and the other risk factors for teenage maternal mortality. For the Phase II field pilot study, 200 pregnant teenagers will be recruited through clinics, schools and community organisations - 100 will be randomised to the behavioural intervention of Teen-MomConnect plus MI; and 100 will be given "usual care" with MomConnect alone. The study will take 18 months to complete at a cost of £150,000.The results of the pilot will be used to design a randomised controlled trial (RCT) to test the effectiveness of the Teen-MomConnect in a fully powered cohort of pregnant teenagers. The RCT will also include a cost effectiveness analysis. The products from this grant will include the Teen-MomConnect App and SMS messages; an MI training program for health workers; research instruments that have been designed and validated for the larger RCT; recruitment and retention protocols and a partnership between an international collaboration of scientists, Praekelt Foundation and the NDOH. This grant application has received the support of the NDOH who have issued a letter of support.
Technical Summary
Objectives: 1) Develop the Teen-MomConnect intervention, which enhances the existing MomConnect SMS messaging content and adds MI counselling, delivered by trained healthcare workers to the pregnant teenagers, 2) Test the feasibility and user acceptability of Teen- MomConnect in a pilot study. Methodology: Phase I: Formative research for intervention development comprises design, pretesting and refinement of intervention content. Development of tailored SMS content: 1) focus groups of 8-10 eligible pregnant teenagers to determine behavioural drivers, 2) develop SMS messages tailored by age, motivational variables, appointment adherence, language, culture, 3) pretest messages in one on one interviews with a new set of teenagers, 4) message refinement. Development of the MI content delivered by health workers to teenagers comprises similar 4-stage procedures to the development of SMS content. Phase II: Piloting. Pregnant teenagers will be recruited and screened for eligibility from clinics, communities and schools. Eligibility criteria: 13-19 years, <20 weeks pregnant, speak Afrikaans, English or Xhosa, registered on the MomConnect system. 200 enrolled participants will be randomised to receive either usual care MomConnect (control) or Teen- MomConnect with MI (intervention). The intervention group will receive tailored messages and counselling based on characteristics established from baseline assessment. Questionnaires and clinic records will measure pre and post test. Outcome measures: ANC attendance, uptake rates of SMS use and MI, HIV testing, treatment compliance for those with TB and HIV, preeclampsia identified and treated, and referral of high risk pregnancies to specialist centres. The pilot will inform a large scale RCT to test the effectiveness of the Teen-MomConnect. Products include the Teen-MomConnect intervention, MI training program for health workers, and designed and validated research instruments for the larger RCT.
Planned Impact
The maternal mortality among South African teenagers is 67.1 deaths per 100 000 live births annually; twice that of other upper middle income countries such as Mexico, and six times that of USA. A key priority of the National Department of Health of SA (NDOH) is to substantially reduce maternal mortality (one of the MDG goals of the United Nations), including teenage pregnancy deaths.
The majority of deaths of pregnant teenagers (71.7%) result from four causes: hypertension (22.8%); non-pregnancy related infections (21.1%) (HIV/AIDS-related, such as TB or pneumonia); obstetric haemorrhage (14.2%); and medical and surgical disorders (13.6%). Changing the health-related behaviour of pregnant teenagers, using an m-health intervention combined with motivational interviewing, is hypothesised to reduce the prevalence of these four causes and thus reduce mortality. This is because the behavioural intervention would reduce risk factors for mortality such as poor antenatal clinic (ANC) attendance, lack of adherence to antiretroviral therapy, poor compliance to treatment for tuberculosis, inadequate management of preeclampsia, and slow referral of high risk pregnancies to secondary and tertiary centres.
The trial development study will result in an m-health behavioural intervention for pregnant teenagers that is age and cognitively appropriate and culturally and socially sensitive to the social aspects of teenage pregnancy.
The trial development study alone will provide useful information to policy makers on how tailored, culturally specific health care SMS messages can be delivered to young people to influence their healthcare seeking behaviour.
Cost effectiveness analysis (CEA) will demonstrate whether it is economically feasible to roll this intervention throughout the healthcare system, in an upper middle income country such as SA. Specifically, it will evaluate whether 1) the tailored health education messages can be cost effectively rolled out nationwide on the MomConnect ICT backbone and 2) whether it is cost effective to train midwives and nurses in MI techniques; or whether a special cadre of healthcare workers could be recruited and trained for this purpose. These will be expressed in cost per life saved and other indices of CEA. If the intervention is found to be efficacious and cost-effective, Teen-MomConnect with MI can be up scaled nationally. Uptake rates among teenagers are expected to be fast, given that 50% of all women giving birth (503 500) between August 2014 to 2015 had registered on MomConnect.
Pregnant teenagers who participate in the pilot study will gain knowledge on better health practises for the future, to avoid future pregnancies and better manage current and future pregnancies. The study will impact upon midwives and nurses in improving the quality of service they provide; and equip them with skills in MI and behavioural interventions that they can use in other areas of their professional practice.
Other health programmes, and social and educational development programmes in SA will benefit from this demonstration of how m-health technology and tailored behavioural interventions can be used to improve health, and possibly augment social and educational development. The results will create an evidence base to inform the future work of maternal health experts at NDOH. Useful data and lessons learned will be provided for the global m-health movement, and for informing the work of practising obstetricians and academics in cognitive behavioural research.
This study will impact on the development agenda of the UK Government, as reducing maternal mortality in developing countries is a priority for the Government and UKaid.
Many of these impacts will accrue after the pilot study ends in late 2017. More convincing evidence for implementation of the intervention will be marshalled upon RCT completion in 2019; potentially increasing the impacts outlined above, both in SA and globally.
The majority of deaths of pregnant teenagers (71.7%) result from four causes: hypertension (22.8%); non-pregnancy related infections (21.1%) (HIV/AIDS-related, such as TB or pneumonia); obstetric haemorrhage (14.2%); and medical and surgical disorders (13.6%). Changing the health-related behaviour of pregnant teenagers, using an m-health intervention combined with motivational interviewing, is hypothesised to reduce the prevalence of these four causes and thus reduce mortality. This is because the behavioural intervention would reduce risk factors for mortality such as poor antenatal clinic (ANC) attendance, lack of adherence to antiretroviral therapy, poor compliance to treatment for tuberculosis, inadequate management of preeclampsia, and slow referral of high risk pregnancies to secondary and tertiary centres.
The trial development study will result in an m-health behavioural intervention for pregnant teenagers that is age and cognitively appropriate and culturally and socially sensitive to the social aspects of teenage pregnancy.
The trial development study alone will provide useful information to policy makers on how tailored, culturally specific health care SMS messages can be delivered to young people to influence their healthcare seeking behaviour.
Cost effectiveness analysis (CEA) will demonstrate whether it is economically feasible to roll this intervention throughout the healthcare system, in an upper middle income country such as SA. Specifically, it will evaluate whether 1) the tailored health education messages can be cost effectively rolled out nationwide on the MomConnect ICT backbone and 2) whether it is cost effective to train midwives and nurses in MI techniques; or whether a special cadre of healthcare workers could be recruited and trained for this purpose. These will be expressed in cost per life saved and other indices of CEA. If the intervention is found to be efficacious and cost-effective, Teen-MomConnect with MI can be up scaled nationally. Uptake rates among teenagers are expected to be fast, given that 50% of all women giving birth (503 500) between August 2014 to 2015 had registered on MomConnect.
Pregnant teenagers who participate in the pilot study will gain knowledge on better health practises for the future, to avoid future pregnancies and better manage current and future pregnancies. The study will impact upon midwives and nurses in improving the quality of service they provide; and equip them with skills in MI and behavioural interventions that they can use in other areas of their professional practice.
Other health programmes, and social and educational development programmes in SA will benefit from this demonstration of how m-health technology and tailored behavioural interventions can be used to improve health, and possibly augment social and educational development. The results will create an evidence base to inform the future work of maternal health experts at NDOH. Useful data and lessons learned will be provided for the global m-health movement, and for informing the work of practising obstetricians and academics in cognitive behavioural research.
This study will impact on the development agenda of the UK Government, as reducing maternal mortality in developing countries is a priority for the Government and UKaid.
Many of these impacts will accrue after the pilot study ends in late 2017. More convincing evidence for implementation of the intervention will be marshalled upon RCT completion in 2019; potentially increasing the impacts outlined above, both in SA and globally.
Publications
Sewpaul R
(2021)
A mixed reception: perceptions of pregnant adolescents' experiences with health care workers in Cape Town, South Africa
in Reproductive Health
| Description | The TeenMomconnect mHealth intervention was successfully developed. It is a behavioural modification intervention targeting the risk behaviours for maternal morbidity and mortality in pregnant teenage girls in South Africa. An SMS message library of tailored 2-way messages was developed that addressed knowledge, attitudes and behaviours related to antenatal clinic (ANC) appointment attendance, substance use, nutrition, physical activity, HIV/TB testing and treatment, and general healthy pregnancy-related behaviours. These Teen Momconnect messages were incorporated into the MomConnect SMS platform and delivered to participants during Phase 2 of the study, the pilot RCT phase. The pilot RCT enrolled 279 pregnant girls aged 13-20 years and <=24 weeks pregnant. Many girls arrived for their first clinic appointment after 24 weeks. The late arrivals influenced the feasibility of recruiting participants from clinics. After recruitment, contacting and following up participants posed challenges, which influenced retention rates. Participants completed a baseline and endline assessment and patient records were examined. Key risk behaviour variables between the intervention and control groups are currently being analysed. The study has led to collaborations with academic partners in information technology in Sweden and in behavioural science in the US, to work on future projects and write grant applications for extensions of the TeenMomconnect intervention and mHealth interventions addressing adolescent obesity-related behaviours. The research team, as a result of working on this study, has developed skills in mHealth intervention research. The researchers continue to work in mHealth and behavioural intervention research. |
| Exploitation Route | The intervention message content can be extended/adapted and tested in other contexts, such as in other countries or in different population groups. The messages can be programmed into a mobile application instead of SMS. The lessons learned in this study can inform mHealth intervention development and testing, feasibility of studies in pregnant teenagers in South Africa, and mHealth policy in South Africa. |
| Sectors | Digital/Communication/Information Technologies (including Software),Healthcare |
| Description | Building Research skills |
| Geographic Reach | Local/Municipal/Regional |
| Policy Influence Type | Influenced training of practitioners or researchers |
| Impact | Twenty junior research staff were employed over the course of the project. They were trained in research methods specific to the project, including how to recruit pregnant teenagers, administer data collection tools, follow up participants over time and consult with nurses at the clinics. They have been thoroughly trained in motivational interviewing techniques. These skills are being implemented with pregnant teenagers during the study duration. They are now equipped with research skills that they will carry forward into their work beyond the study. MI techniques can improve the motivation and attitudes of pregnant teenage girls towards accessing healthcare and practicing improved health behaviours. Training of health care workers in MI techniques, while originally planned, was not found to be feasible in the current study due to health workers were overcommitted during the time of the study. The research team, however, aims to approach the South African Nursing Council, to explore inclusion of the behavioural MI intervention training into the curriculum of trainee midwives. The training can improve the motivation and attitudes of midwives towards providing a quality service to all patients, including teenage girls. The intervention aims to change the judgmental attitude that many healthcare workers exhibit towards pregnant teenagers. This is vital as the National Confidential Enquiries into Maternal Deaths of the past 20 years in South Africa have all shown that key to reducing maternal mortality is improving the performance of midwives and nurses with respect to adherence to protocols and guidelines, such as protocols for emergency obstetric care. |
| Description | National and Provincial Departments of Health |
| Geographic Reach | National |
| Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
| Impact | The early involvement of the National Department of Health during the design of the pilot study will prove an important pathway to impact. The Deputy Director General of Health who wrote the letter of support is responsible for policy and planning in HIV and AIDS, TB and Maternal and Child Health. This heightens the chances of adoption of the behavioural intervention in the national health system, if it is proven to be efficacious and cost effective. The study, which specifically targets teenagers, will likely form a component of the m-Health Strategy that the National Department of Health (NDOH) is implementing in South Africa. If the intervention, as shown by the RCT, is found to be efficacious and cost-effective, Teen- MomConnect with the MI component can be up scaled nationally. This can elicit large scale improvement of maternal health throughout pregnancy, better detection of risk factors for high risk pregnancy, and better adherence to treatment for risk conditions, which all result in improved maternal outcomes and saving young mother's lives. The Department of Health is building future m-health programmes. The findings from this study can inform their future programmes. The study will also provide DOH with information on the feasibility and cost effectiveness of using cell phone sms's for delivery of health promotion content for specific population groups, in this case adolescents and pregnant women. It will also assess the feasibility of using sms's over app's as the delivery platform. |
| Description | South Africa Sweden University Forum Collaborative Projects: Effectiveness of mHealth intervention for obesity and overweight prevention in school-going youth |
| Amount | R161,000 (ZAR) |
| Organisation | South Africa Sweden University Forum |
| Sector | Academic/University |
| Country | Sweden |
| Start | 10/2019 |
| End | 08/2020 |
| Title | An assessment to design and pre-test Teen-MomConnect intervention |
| Description | The assessment had a qualitative approach. In the focus group discussion with pregnant girls, they were asked about their experience, challenges, and expectations of pregnancy and thus will inform the development of SMS messages that are tailored to their needs. In the focus group discussion with health care workers, they will be asked about their experience, challenges, and expectations of working with pregnant girls at the clinics, and thus will inform the development of the health training programme that will be used in combination with the SMS intervention. During the focus groups, we also pre-tested a few example intervention messages with the pregnant girls. These intervention messages have been provisionally developed prior to the focus groups. We asked the pregnant girls to rate the quality and appropriateness of these example messages and invited them to discuss their thoughts about the messages. To be more specific, a standard set of closed-ended user response questions will be asked, such as "rate each message on a scale of 0 - 10 for how well you understand the message?"; "How much it motivates you to change?", "How well it fits your beliefs/attitudes /needs etc." These will be followed by open-ended questions; such as tell me why you chose this number?" This will allow us to pre-test the existing example messages we have developed. Moreover, to assess the health training programme, we first conducted training workshops, and then we useduse a standard set of post-training forms to rate various aspects of the trainee experience on a 0-10 scale, including the content and format of the exercises as well as the lead trainer. This allowed us to shape the content of the health programme based on their thoughts. |
| Type Of Material | Model of mechanisms or symptoms - human |
| Year Produced | 2017 |
| Provided To Others? | No |
| Impact | Using this method, several advantages can be expected: 1. this instrument allows to gather information from participants and engage them in developing TeenMomConnect intervention. Community participation is essential to develop a tailored intervention. 2. this instrument allows to pre-test the SMS messages and evaluation the health programme before the pilot test in phase II. 3. this method will be able to provide personalised intervention to the pregnant girls, which is believed to be more effective to change behaviours. 4. this method can be replicated in other studies that aim to develop a tailored programme/intervention. |
| URL | https://www.ncbi.nlm.nih.gov/pubmed/18401673 |
| Title | Development of message content |
| Description | The research tools that have been produced include qualitative instruments and recruitment and retention protocols. Enhancing the existing MomConnect messages entailed a multistage qualitative process that we have used in numerous prior health communication studies: 1) initial formative research with the target audience to determine key drivers, local language as well as native cognitive and behavioural strategies, 2) message development, 3) message pretesting with the target audience, and 4) message refinement. To maximize our ability to create messages that are age, culturally, cognitively and health status appropriate, our stage I formative research explored concepts such as roles, goals, values, and aspirations among pregnant teenagers and how they can be used to motivate positive health behaviours. We conducted an initial formative research with the target audience to determine key drivers, local language as well as native cognitive and behavioural strategies. This entailed conducting focus groups and individual in-depth interviews with pregnant teenagers (between ages 13-20). During the focus groups, we also pre-tested a few example intervention messages with the pregnant girls. These intervention messages have been provisionally developed prior to the focus groups. We asked the pregnant girls to rate the quality and appropriateness of these example messages and invited them to discuss their thoughts about the messages. To be more specific, a standard set of closed-ended user response questions will be asked, such as "rate each message on a scale of 0 - 10 for how well you understand the message?"; "How much it motivates you to change?", "How well it fits your beliefs/attitudes /needs etc." These were followed by open-ended questions; such as tell me why you chose this number?" This allowed us to pre-test the existing example messages we have developed. Moreover, to assess the health training programme, we first conducted training workshops, and then we used a standard set of post-training forms to rate various aspects of the trainee experience on a 0-10 scale, including the content and format of the exercises as well as the lead trainer. This allowed us to shape the content of the health programme based on their thoughts. Moreover, we conducted focus groups with health care workers (HCWs) who work with pregnant women (e.g. nurses, doctors, health educators, midwives) and these findings were used to inform the design of Motivational Interviewing intervention content and structure.The findings of the qualitative data were used to design, pretest, and refine the content of the Teen-MomConnect SMS's. |
| Type Of Material | Model of mechanisms or symptoms - human |
| Year Produced | 2017 |
| Provided To Others? | No |
| Impact | Using this method, several advantages can be expected: 1. this instrument allows to gather information from participants and engage them in developing Teen-MomConnect intervention. Community participation is essential to develop a tailored intervention. 2. this instrument allows to pre-test the SMS messages and evaluate the health programme before the pilot test in phase II. 3. this method is used to provide a personalised intervention to the pregnant girls, which is believed to be more effective to change behaviours. 4. this method can be replicated in other studies that aim to develop a tailored programme/intervention. |
| Title | Motivational Interviewing content for pregnant teenage girls |
| Description | Research assistants conducted motivational interview (MI) sessions with the participants. The aim of the MI was to motivate and encourage the participants to improve their health behaviours. Motivational Interviewing is a patient-centered style of counselling that has been used to modify health behaviours in young adults, including substance use, nutrition, and HIV/STIs. MI differs from other counselling in that, instead of providing information and directive advice, the participants are encouraged to reflect on and express their own reasons for and against change, how their current behaviour impacts their life and family goals or core values, and explore possible options for making change. Thereby ambivalence and resistance are explored prior to moving toward action. Development of the motivational interviewing content was informed by: the key themes that emerged from the formative interviews previously conducted with pregnant teenage girls, the focus group interviews with research assistants who worked with the girls, and the behaviours, social norms and attitudes reported in the baseline questionnaire. The key themes of appointment keeping, substance use, HIV and TB testing, medication adherence, nutrition and overall health pregnancy behaviours formed the basis of the MI content. The MI session was tailored to a pregnant teenage girl, to be relevant to her specific behaviours and questions. The research assistants attended a 2 day MI training workshop which included techniques such as reflective listening and eliciting change talk. They were taught how to balance the expression of empathy with the need to build room for change. |
| Type Of Material | Model of mechanisms or symptoms - human |
| Year Produced | 2018 |
| Provided To Others? | No |
| Impact | The research assistants have been thoroughly trained in Motivational Interviewing (MI) techniques, thereby contributing to research capacity development in South Africa. This is relevant given that there are relatively few people professionally trained in MI in the country. To our knowledge, this is the first study to administer MI to pregnant women in South Africa. The pregnant girls receiving the MI were able discuss their behaviours and viewpoints with a counsellor and elicit change talk, an opportunity that is not available to adolescents consulting public health facilities in South Africa. |
| Title | Randomised control trial |
| Description | Pregnant teenagers who are willing to participate will complete a baseline questionnaire that assesses their sociodemographics, life style behaviours, and motivation and efficacy to attend ANC appointments. Research assistants will collect the baseline data from each participant using tablets connecting to Wi-Fi or bandwidth and the data collected will be instantly transferred and stored to the central database. Once the participants in cohort 1 complete the baseline questionnaire, we will use simple randomisation to assign a participant to either control or intervention group. We will do the same for cohort 2, 3, etc. The intervention group will receive TeenMomConnect SMS intervention and a subset will receive the MI intervention delivered by the research team. The Control group will receive the MomConnect intervention with the usual care delivered by the HCWs. We will repeat this recruitment process until we reach N=100 girls in intervention group and N=100 in control group. Participants will be blinded to the condition in which they are assigned to. This means that they do not know whether they are in the control or intervention group. We will conduct follow up assessments with the same participants who completed the baseline questionnaire. The same questionnaire will be administered to the intervention and control groups at the end of their pregnancy. The follow up times may vary for different cohorts of participants, as they are recruited at different times. The time that they are enrolled in the study will affect the time that the follow up questionnaires are administered. |
| Type Of Material | Model of mechanisms or symptoms - human |
| Year Produced | 2018 |
| Provided To Others? | No |
| Impact | Pregnant teenagers who participate in the pilot study will gain knowledge on better health practices for the future, avoid future pregnancies and better manage current and future pregnancies. The research will provide evidence of the efficacy of the Teen Momconnect intervention (which includes tailored two-way messaging) in comparison to the existing sms message system used by the South African government. Other health programmes, and social and educational development programmes in South African will benefit from this demonstration of how m-health technology and tailored behavioural interventions can be used to improve health, and possibly augment social and educational development. The results will create an evidence base to inform the future work of maternal health experts at NDOH. Useful data and lessons learned will be provided for the global m-health movement, and for informing the work of practicing obstetricians and academics in cognitive behavioural science. |
| Title | Baseline and post evaluation interview data |
| Description | Participants completed a baseline questionnaire at recruitment into the study (at <24 weeks pregnant) and then completed a post evaluation questionnaire after the duration of their pregnancy. The baseline and post evaluation datasets are still in the process of being cleaned by the research team. Each participant is assigned a unique identifier to ensure accurate merging of the two data records per participant. Items in the database include socio-demographic characteristics, social support variables, attitudes and behaviours relating to clinic appointment keeping, and health risk behaviours. |
| Type Of Material | Database/Collection of data |
| Year Produced | 2019 |
| Provided To Others? | No |
| Impact | The database will be analysed in 2019/2020. The data will be used to test the efficacy of the TeenMomconnect intervention. |
| Title | Qualitative dataset |
| Description | The data were collected by means of individual interviews and focus groups with pregnant teenagers in the Western Cape Province of South Africa. We have data on participants' experiences with the maternal health care workers and their experiences of antenatal clinic attendance. |
| Type Of Material | Database/Collection of data |
| Year Produced | 2017 |
| Provided To Others? | No |
| Impact | We have the data collected in this phase to develop a scientific paper on the influence of health care workers' stigma on pregnant teenager's health seeking behaviours. The results of the paper have clinical implications and may sensitise health professionals to provide better and sensitive maternal health care to teenagers in South Africa's public health sector. The paper is in its final draft and will soon be submitted to a peer reviewed scientific journal. The qualitative data will also be used to inform the randomised control trial (RCT) design to evaluate the efficacy and cost-effectiveness of a tailored health intervention, namely, Teen-MomConnect, in reducing the key risk factors that contribute to maternal mortality in pregnant teenagers. |
| Title | SMS Message library |
| Description | We have developed a set of SMS's that are cognitively tailored, age and culturally appropriate for pregnant teenage girls. Formative research was used to design, pretest, and refine the Teen-MomConnect SMS messages using qualitative methods such as focus groups and individual interviews. The message library aims to provide pregnant teenage girls with health promotion and risk behavior change messages related to the mothers well-being and the well-being of their unborn child. The messages target the following behaviours: appointment keeping, attitude towards pregnancy, clinic attendance, general health information, illegal drugs, nutrition, self-care/Hygiene, smoking, social stigma, social support, STD and tuberculosis. Rapidpro is used to disseminate the SMS's to pregnant teenage girls. Rapidpro is a computer generated messaging platform that is designed to distribute tailored messages according to the participants pregnancy week and is tailored to their SMS responses. |
| Type Of Material | Database/Collection of data |
| Year Produced | 2018 |
| Provided To Others? | No |
| Impact | The partnerships formed with the NDOH and the Praekelt Foundation will enable the successful completion of the Teen-Momconnect pilot study, and possible implementation of this intervention to national level. |
| Description | Partnership with Praekelt.org (JHB, SA), Michigan University (USA), and National and Provicial Department of Health |
| Organisation | Government of South Africa |
| Department | Department of Health |
| Country | South Africa |
| Sector | Public |
| PI Contribution | The PI at the Human Sciences Research Council (HSRC) is responsible for the initiation, administration and coordination of all aspects of this grant, including formulating and maintaining partnerships and collaborations. Constructive and regular meetings have been held with our technical partner praekelt, health experts from Michigan University and administrators from the National Department of Health. The HSRC has been responsible for gaining ethics approval (REC2/17/08/16) to conduct the study. We have also obtained permission from Provincial Department of Health to collect data at various community health centres and clinics in Cape Town.Enhancing the existing MomConnect messages entailed a multistage qualitative process which has been successfully completed. We conducted an initial formative research with the target audience to determine key drivers, local language as well as native cognitive and behavioural strategies. This entailed conducting focus groups and individual in-depth interviews with pregnant teenagers (between age 13-20). We have done 2 Xhosa speaking in-depth interviews, 4 Afrikaans in-depth interviews, 2 Xhosa speaking focus groups, and 1 Afrikaans focus group with pregnant girls. The findings of the qualitative data were used to design, pretest, and refine the content of the TeenMomConnect SMS's. Moreover, we conducted focus groups with health care workers (HCWs) who work with pregnant women (e.g. nurses, doctors, health educators, midwives). In total, 4 focus groups with HCWs were conducted. We used the findings to inform the design of Motivational Interviewing (MI) intervention content and structure as well as enhance the momconnect messages to be more cognitively and culturally appropriate for teenage pregnant girls. The HSRC in partnership with Michgan University and Praekelt are now in the process of implementing the intervention. The intervention group will receive 1) TeenMomConnect SMS's; and 2) MI counselling intervention. The MI will be delivered by the HCWs to the pregnant girls face-to-face (or via cell phone), therefore, we will provide them training so that they can deliver the MI intervention on their own. We have the data collected in this phase to develop a scientific paper on the influence of health care workers' stigma on pregnant teenager's health seeking behaviours. The results of the paper have clinical implications and may sensitise health professionals to provide better and sensitive maternal health care to teenagers in South Africa's public health sector. The paper is in its final draft and will soon be submitted to a peer reviewed scientific journal. |
| Collaborator Contribution | From the beginning of this grant application, the HSRC set up an active partnership with the South African National Department of Health (NDOH),Michigan University and the Praekelt Foundation. The Praekelt Foundation is the main technical implementing partner of the current Momconnect programme. The HSRC, together with the Praekelt Foundation have committed to work towards co-designing and adopting the MomConnect messaging protocols to specifically target teenage girls through developing Teen-MomConnect . The use of Praekelt's open source messaging platform, adopted from MomConnect is crucial in implementing the second phase of the pilot study, which is to test the accessibility, demand, impact and competence of the Teen-MomConnect intervention. Michigan University have provided expertise in RCT intervention development. They participated in the development of instruments to assess the effectiveness of tailored messages and training programmes. The MI and health communication experts from Michigan University have designed an MI/ behaviour change counselling training for health care practitioners. The National Department of Health from the beginning of this grant has supported this pilot study. A letter of support signed by the deputy director general was provided for the feasibility study. The Deputy Director General of Health, Dr Y Pillay, adviser to the DDG Dr P Barron, Chief Director for Maternal Health D P Holela and the m-health coordinator and other senior management have all been consulted and their support obtained for this national initiative. Furthermore, the (NDoH) assisted with obtaining ethical approval from the provincial Department of Health to conduct the study. Full support has also been gained to upscale the Teen-MomConnect to national level, should the RCT be a success. |
| Impact | The products from this collaboration and this grant will include the Teen-MomConnect App and SMS message library; an MI training program for health workers; research instruments that have been designed and validated for the larger RCT; and recruitment and retention protocols. This collaboration is multidisciplinary as we have a team of experts from various fields and disciplines such as m-health, behavioural research and maternal health care. The PI, Dr Reddy has experience in conducting large, nationally representative studies, and RCTs. Dr Resnicow, MI and health communication expert has designed an MI/ behaviour change counselling training for health care practitioners, across a wide range of health care settings and content areas. He has worked in numerous studies in SA over the past 15 years. He has also designed and tested SMS-based motivational messaging in over 15 trials. Marcha Bekker works for MomConnect and the Praekelt Foundation, and will enable the MomConnect backbone to deliver the intervention. Two experienced obstetricians and gynaecologists in SA, Dr Mdaka (Head of Obstetrics and Gynaecology at Walter Sisulu University) and Dr Moja (a former Medical School Dean) will advise on clinical aspects of the study. experienced researchers from nutirition, psychology and biostatisitcs will assist with delivering the the study outcomes. |
| Start Year | 2016 |
| Description | Partnership with Praekelt.org (JHB, SA), Michigan University (USA), and National and Provicial Department of Health |
| Organisation | National Department of Health |
| Country | South Africa |
| Sector | Public |
| PI Contribution | The PI at the Human Sciences Research Council (HSRC) is responsible for the initiation, administration and coordination of all aspects of this grant, including formulating and maintaining partnerships and collaborations. Constructive and regular meetings have been held with our technical partner praekelt, health experts from Michigan University and administrators from the National Department of Health. The HSRC has been responsible for gaining ethics approval (REC2/17/08/16) to conduct the study. We have also obtained permission from Provincial Department of Health to collect data at various community health centres and clinics in Cape Town.Enhancing the existing MomConnect messages entailed a multistage qualitative process which has been successfully completed. We conducted an initial formative research with the target audience to determine key drivers, local language as well as native cognitive and behavioural strategies. This entailed conducting focus groups and individual in-depth interviews with pregnant teenagers (between age 13-20). We have done 2 Xhosa speaking in-depth interviews, 4 Afrikaans in-depth interviews, 2 Xhosa speaking focus groups, and 1 Afrikaans focus group with pregnant girls. The findings of the qualitative data were used to design, pretest, and refine the content of the TeenMomConnect SMS's. Moreover, we conducted focus groups with health care workers (HCWs) who work with pregnant women (e.g. nurses, doctors, health educators, midwives). In total, 4 focus groups with HCWs were conducted. We used the findings to inform the design of Motivational Interviewing (MI) intervention content and structure as well as enhance the momconnect messages to be more cognitively and culturally appropriate for teenage pregnant girls. The HSRC in partnership with Michgan University and Praekelt are now in the process of implementing the intervention. The intervention group will receive 1) TeenMomConnect SMS's; and 2) MI counselling intervention. The MI will be delivered by the HCWs to the pregnant girls face-to-face (or via cell phone), therefore, we will provide them training so that they can deliver the MI intervention on their own. We have the data collected in this phase to develop a scientific paper on the influence of health care workers' stigma on pregnant teenager's health seeking behaviours. The results of the paper have clinical implications and may sensitise health professionals to provide better and sensitive maternal health care to teenagers in South Africa's public health sector. The paper is in its final draft and will soon be submitted to a peer reviewed scientific journal. |
| Collaborator Contribution | From the beginning of this grant application, the HSRC set up an active partnership with the South African National Department of Health (NDOH),Michigan University and the Praekelt Foundation. The Praekelt Foundation is the main technical implementing partner of the current Momconnect programme. The HSRC, together with the Praekelt Foundation have committed to work towards co-designing and adopting the MomConnect messaging protocols to specifically target teenage girls through developing Teen-MomConnect . The use of Praekelt's open source messaging platform, adopted from MomConnect is crucial in implementing the second phase of the pilot study, which is to test the accessibility, demand, impact and competence of the Teen-MomConnect intervention. Michigan University have provided expertise in RCT intervention development. They participated in the development of instruments to assess the effectiveness of tailored messages and training programmes. The MI and health communication experts from Michigan University have designed an MI/ behaviour change counselling training for health care practitioners. The National Department of Health from the beginning of this grant has supported this pilot study. A letter of support signed by the deputy director general was provided for the feasibility study. The Deputy Director General of Health, Dr Y Pillay, adviser to the DDG Dr P Barron, Chief Director for Maternal Health D P Holela and the m-health coordinator and other senior management have all been consulted and their support obtained for this national initiative. Furthermore, the (NDoH) assisted with obtaining ethical approval from the provincial Department of Health to conduct the study. Full support has also been gained to upscale the Teen-MomConnect to national level, should the RCT be a success. |
| Impact | The products from this collaboration and this grant will include the Teen-MomConnect App and SMS message library; an MI training program for health workers; research instruments that have been designed and validated for the larger RCT; and recruitment and retention protocols. This collaboration is multidisciplinary as we have a team of experts from various fields and disciplines such as m-health, behavioural research and maternal health care. The PI, Dr Reddy has experience in conducting large, nationally representative studies, and RCTs. Dr Resnicow, MI and health communication expert has designed an MI/ behaviour change counselling training for health care practitioners, across a wide range of health care settings and content areas. He has worked in numerous studies in SA over the past 15 years. He has also designed and tested SMS-based motivational messaging in over 15 trials. Marcha Bekker works for MomConnect and the Praekelt Foundation, and will enable the MomConnect backbone to deliver the intervention. Two experienced obstetricians and gynaecologists in SA, Dr Mdaka (Head of Obstetrics and Gynaecology at Walter Sisulu University) and Dr Moja (a former Medical School Dean) will advise on clinical aspects of the study. experienced researchers from nutirition, psychology and biostatisitcs will assist with delivering the the study outcomes. |
| Start Year | 2016 |
| Description | Partnership with Praekelt.org (JHB, SA), Michigan University (USA), and National and Provicial Department of Health |
| Organisation | Praekelt |
| Country | South Africa |
| Sector | Private |
| PI Contribution | The PI at the Human Sciences Research Council (HSRC) is responsible for the initiation, administration and coordination of all aspects of this grant, including formulating and maintaining partnerships and collaborations. Constructive and regular meetings have been held with our technical partner praekelt, health experts from Michigan University and administrators from the National Department of Health. The HSRC has been responsible for gaining ethics approval (REC2/17/08/16) to conduct the study. We have also obtained permission from Provincial Department of Health to collect data at various community health centres and clinics in Cape Town.Enhancing the existing MomConnect messages entailed a multistage qualitative process which has been successfully completed. We conducted an initial formative research with the target audience to determine key drivers, local language as well as native cognitive and behavioural strategies. This entailed conducting focus groups and individual in-depth interviews with pregnant teenagers (between age 13-20). We have done 2 Xhosa speaking in-depth interviews, 4 Afrikaans in-depth interviews, 2 Xhosa speaking focus groups, and 1 Afrikaans focus group with pregnant girls. The findings of the qualitative data were used to design, pretest, and refine the content of the TeenMomConnect SMS's. Moreover, we conducted focus groups with health care workers (HCWs) who work with pregnant women (e.g. nurses, doctors, health educators, midwives). In total, 4 focus groups with HCWs were conducted. We used the findings to inform the design of Motivational Interviewing (MI) intervention content and structure as well as enhance the momconnect messages to be more cognitively and culturally appropriate for teenage pregnant girls. The HSRC in partnership with Michgan University and Praekelt are now in the process of implementing the intervention. The intervention group will receive 1) TeenMomConnect SMS's; and 2) MI counselling intervention. The MI will be delivered by the HCWs to the pregnant girls face-to-face (or via cell phone), therefore, we will provide them training so that they can deliver the MI intervention on their own. We have the data collected in this phase to develop a scientific paper on the influence of health care workers' stigma on pregnant teenager's health seeking behaviours. The results of the paper have clinical implications and may sensitise health professionals to provide better and sensitive maternal health care to teenagers in South Africa's public health sector. The paper is in its final draft and will soon be submitted to a peer reviewed scientific journal. |
| Collaborator Contribution | From the beginning of this grant application, the HSRC set up an active partnership with the South African National Department of Health (NDOH),Michigan University and the Praekelt Foundation. The Praekelt Foundation is the main technical implementing partner of the current Momconnect programme. The HSRC, together with the Praekelt Foundation have committed to work towards co-designing and adopting the MomConnect messaging protocols to specifically target teenage girls through developing Teen-MomConnect . The use of Praekelt's open source messaging platform, adopted from MomConnect is crucial in implementing the second phase of the pilot study, which is to test the accessibility, demand, impact and competence of the Teen-MomConnect intervention. Michigan University have provided expertise in RCT intervention development. They participated in the development of instruments to assess the effectiveness of tailored messages and training programmes. The MI and health communication experts from Michigan University have designed an MI/ behaviour change counselling training for health care practitioners. The National Department of Health from the beginning of this grant has supported this pilot study. A letter of support signed by the deputy director general was provided for the feasibility study. The Deputy Director General of Health, Dr Y Pillay, adviser to the DDG Dr P Barron, Chief Director for Maternal Health D P Holela and the m-health coordinator and other senior management have all been consulted and their support obtained for this national initiative. Furthermore, the (NDoH) assisted with obtaining ethical approval from the provincial Department of Health to conduct the study. Full support has also been gained to upscale the Teen-MomConnect to national level, should the RCT be a success. |
| Impact | The products from this collaboration and this grant will include the Teen-MomConnect App and SMS message library; an MI training program for health workers; research instruments that have been designed and validated for the larger RCT; and recruitment and retention protocols. This collaboration is multidisciplinary as we have a team of experts from various fields and disciplines such as m-health, behavioural research and maternal health care. The PI, Dr Reddy has experience in conducting large, nationally representative studies, and RCTs. Dr Resnicow, MI and health communication expert has designed an MI/ behaviour change counselling training for health care practitioners, across a wide range of health care settings and content areas. He has worked in numerous studies in SA over the past 15 years. He has also designed and tested SMS-based motivational messaging in over 15 trials. Marcha Bekker works for MomConnect and the Praekelt Foundation, and will enable the MomConnect backbone to deliver the intervention. Two experienced obstetricians and gynaecologists in SA, Dr Mdaka (Head of Obstetrics and Gynaecology at Walter Sisulu University) and Dr Moja (a former Medical School Dean) will advise on clinical aspects of the study. experienced researchers from nutirition, psychology and biostatisitcs will assist with delivering the the study outcomes. |
| Start Year | 2016 |
| Description | Partnership with Praekelt.org (JHB, SA), Michigan University (USA), and National and Provicial Department of Health |
| Organisation | University of Michigan |
| Country | United States |
| Sector | Academic/University |
| PI Contribution | The PI at the Human Sciences Research Council (HSRC) is responsible for the initiation, administration and coordination of all aspects of this grant, including formulating and maintaining partnerships and collaborations. Constructive and regular meetings have been held with our technical partner praekelt, health experts from Michigan University and administrators from the National Department of Health. The HSRC has been responsible for gaining ethics approval (REC2/17/08/16) to conduct the study. We have also obtained permission from Provincial Department of Health to collect data at various community health centres and clinics in Cape Town.Enhancing the existing MomConnect messages entailed a multistage qualitative process which has been successfully completed. We conducted an initial formative research with the target audience to determine key drivers, local language as well as native cognitive and behavioural strategies. This entailed conducting focus groups and individual in-depth interviews with pregnant teenagers (between age 13-20). We have done 2 Xhosa speaking in-depth interviews, 4 Afrikaans in-depth interviews, 2 Xhosa speaking focus groups, and 1 Afrikaans focus group with pregnant girls. The findings of the qualitative data were used to design, pretest, and refine the content of the TeenMomConnect SMS's. Moreover, we conducted focus groups with health care workers (HCWs) who work with pregnant women (e.g. nurses, doctors, health educators, midwives). In total, 4 focus groups with HCWs were conducted. We used the findings to inform the design of Motivational Interviewing (MI) intervention content and structure as well as enhance the momconnect messages to be more cognitively and culturally appropriate for teenage pregnant girls. The HSRC in partnership with Michgan University and Praekelt are now in the process of implementing the intervention. The intervention group will receive 1) TeenMomConnect SMS's; and 2) MI counselling intervention. The MI will be delivered by the HCWs to the pregnant girls face-to-face (or via cell phone), therefore, we will provide them training so that they can deliver the MI intervention on their own. We have the data collected in this phase to develop a scientific paper on the influence of health care workers' stigma on pregnant teenager's health seeking behaviours. The results of the paper have clinical implications and may sensitise health professionals to provide better and sensitive maternal health care to teenagers in South Africa's public health sector. The paper is in its final draft and will soon be submitted to a peer reviewed scientific journal. |
| Collaborator Contribution | From the beginning of this grant application, the HSRC set up an active partnership with the South African National Department of Health (NDOH),Michigan University and the Praekelt Foundation. The Praekelt Foundation is the main technical implementing partner of the current Momconnect programme. The HSRC, together with the Praekelt Foundation have committed to work towards co-designing and adopting the MomConnect messaging protocols to specifically target teenage girls through developing Teen-MomConnect . The use of Praekelt's open source messaging platform, adopted from MomConnect is crucial in implementing the second phase of the pilot study, which is to test the accessibility, demand, impact and competence of the Teen-MomConnect intervention. Michigan University have provided expertise in RCT intervention development. They participated in the development of instruments to assess the effectiveness of tailored messages and training programmes. The MI and health communication experts from Michigan University have designed an MI/ behaviour change counselling training for health care practitioners. The National Department of Health from the beginning of this grant has supported this pilot study. A letter of support signed by the deputy director general was provided for the feasibility study. The Deputy Director General of Health, Dr Y Pillay, adviser to the DDG Dr P Barron, Chief Director for Maternal Health D P Holela and the m-health coordinator and other senior management have all been consulted and their support obtained for this national initiative. Furthermore, the (NDoH) assisted with obtaining ethical approval from the provincial Department of Health to conduct the study. Full support has also been gained to upscale the Teen-MomConnect to national level, should the RCT be a success. |
| Impact | The products from this collaboration and this grant will include the Teen-MomConnect App and SMS message library; an MI training program for health workers; research instruments that have been designed and validated for the larger RCT; and recruitment and retention protocols. This collaboration is multidisciplinary as we have a team of experts from various fields and disciplines such as m-health, behavioural research and maternal health care. The PI, Dr Reddy has experience in conducting large, nationally representative studies, and RCTs. Dr Resnicow, MI and health communication expert has designed an MI/ behaviour change counselling training for health care practitioners, across a wide range of health care settings and content areas. He has worked in numerous studies in SA over the past 15 years. He has also designed and tested SMS-based motivational messaging in over 15 trials. Marcha Bekker works for MomConnect and the Praekelt Foundation, and will enable the MomConnect backbone to deliver the intervention. Two experienced obstetricians and gynaecologists in SA, Dr Mdaka (Head of Obstetrics and Gynaecology at Walter Sisulu University) and Dr Moja (a former Medical School Dean) will advise on clinical aspects of the study. experienced researchers from nutirition, psychology and biostatisitcs will assist with delivering the the study outcomes. |
| Start Year | 2016 |
| Title | Rapid Pro |
| Description | Rapid Pro is the current technology database used by our partner, Praekelt, for distributing SMS messages. Rapid Pro contains a comprehensive message library that sends a wealth of tailored messages that are appropriate for the use of pregnant teenage girls.The messaging platform is able to deal with complexities such as coding of different variables, two-way messaging, and several questions that need to be fed into the SMS delivery for personalised tailoring of messages. |
| Type Of Technology | Software |
| Year Produced | 2017 |
| Impact | Using this method, several advantages can be expected: 1. this method can provide personalised intervention to the pregnant girls. 2. Each participant receives a unique set of messages/intervention based on their characteristics, pregnancy due date, and life style (smoking, alcohol use, etc). 3. the method of using Rapid Pro to send SMS messages can be replicated to a larger population. |
| Description | Engagement with pregnant teenagers and Health care workers |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Study participants or study members |
| Results and Impact | Pregnant teenagers and health care workers are engaged from the development stages of the programme. The intervention is a health communication programme aimed at providing enhanced health messages to a large number of pregnant teenagers via SMS's and MI behavioural counselling. This information promotes early health care seeking behavior among a target group, whose lives can be saved by having this information sent to them in a sensitive and desirable manner. |
| Year(s) Of Engagement Activity | 2017 |
| Description | Meeting with Provincial Department of Health, Western Cape, South Africa |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Policymakers/politicians |
| Results and Impact | The research team reached out to the Provincial Department of Health (DoH) for two main purposes: 1) to seek support from the Western Cape Provincial Government (where the research project is taking place) for data collection, 2) to get advice from the Government regarding where to recruit girls (sampling strategy), 3) to gain insight into the National MomConnect programme (Teen-MomConnect intervention is adapted from the national programme). A detailed presentation on the project, including methods and data collection strategies, followed by a discussion on way forward. Audience: policy makers/professional officers from social development and health units at DoH. The research team has gained knowledge on the registration details of the MomConnect programme. The research team has also gained knowledge on the use of apps for health behaviour change (e.g. mobile app intervention that is being used by the Provincial DoH). Lastly, we gained support and assistance from the Provincial DoH to recruit girls from the eleven clinics located in the Western Cape Province. Policy makers furthermore referred more contacts to the research team for further inputs and advises on sampling, and electronic based intervention. |
| Year(s) Of Engagement Activity | 2016 |