Lending a hand: developing a support structure for young migrants in South Africa and Uganda

A significant proportion of young people in sub-Saharan Africa migrate to towns or cities, where they hope to find work and build their livelihood. Our aim is to develop and test the acceptability and feasibility of a protective support structure for young migrants (aged 14-24 years old) in urban settings in South Africa and Uganda as means of early intervention to reduce the harm of patterns of risk behaviour (sexual risk and violence) associated with youth migration. Specifically we will 1) establish a small peer supporter network in three sites (a small town in Uganda (Lukaya) and in South Africa (Mtubatuba) and an urban area (Mengo) in Kampala city in Uganda) to provide advice and support over the telephone to young migrants; 2) offer a drop-in centre or hub (a small rented shop or similar) staffed by a peer-supporter during the day and early evening who can provide information and onward referral to local health and social services, free condoms, access to a counsellor/nurse for advice and the use of a computer and printer for word processing (for letters and job applications) and 3) identify local (adult) champions and local resources/safe spaces to enable a supportive environment for the well-being adolescent and young people who are migrants.

Our plans draw from our evidence base, gained through prior research in the two settings, and a Theory of Change which draws on a `protection-risk' conceptual framework. Our focus will be all young people who have migrated, with particular attention to new migrants (who are within six months of their move to the new location and particularly vulnerable to health-related risk and sexual exploitation) while still providing advice to migrants of longer standing, who may be planning a further move or trying to make a change in their employment.

We will use mixed-methods to adapt, implement and evaluate the feasibility of an intervention. We will use participatory methods working with youth advisory groups in both countries already engaged in the design of this project, to develop and implement the intervention. Then we will conduct a mixed-methods process evaluation to assess which facets of the package are valued and test our assumptions about the challenges young migrants face and the appropriateness of the intervention offered. Finally, we will design a full-scale evaluation of the effectiveness and cost effectiveness of the feasible and acceptable elements of the intervention, which we anticipate will go on to be tested in a randomised control trial.

The intervention is intended to support an individual migrant's ability to manage and adapt to their place of migration and identify the ways in which the key components of our intervention (positive role models/ "good" social network, safer environment, health and social support) may afford protection, supporting young migrants to demonstrate resilience with tangible impacts on health (e.g. safer sexual and reproductive health behaviours) and well-being (e.g. hope for the future).

The work will be divided into four phases across 30 months: Phase 1 (months 1-3): recruitment of staff and other preparations; Phase 2 (months 4-9): Baseline assessment and co-designing the intervention with young people and other stakeholders; Phase 3 (months 10-21): Implementation of the intervention; Phase 4 (months 22-30): Analysis, dissemination and discussions on refinement of the intervention and, if the intervention is feasible, the design of a full-scale trial. On completion of the project we expect to have a contextually adapted, community-based, peer-delivered intervention, predicated on demonstrated resilience to improve health and well-being of mobile adolescents. We anticipate that this intervention will be scalable and reproducible in other settings in sub-Saharan Africa to reduce teenage pregnancy and the burden sexually transmitted infections including HIV-related morbidity and mortality in adolescent and young people.

We will develop and test the acceptability and feasibility of a protective support structure for young migrants (aged 14-24 years old) in urban settings in South Africa and Uganda as means of early intervention to reduce the harm of patterns of risk behaviour (sexual risk and violence) associated with youth migration. We will 1) establish a peer-supporter network in three sites (a small town in Uganda and in South Africa and part of the capital city in Uganda) to provide advice and support over the telephone to individual young migrants; 2) offer a drop-in centre (a rented shop or similar) staffed by a peer-supporter during the day and early evening who can provide information and onward referral to local health and social services, free condoms, access to a counsellor/nurse for advice and the use of a computer/printer; 3) identify local champions and resources to enable a more supportive environment for youth. Our plans draw from evidence gained through prior research in the two settings, and a Theory of Change which draws on a `protection-risk' conceptual framework. Our focus is young people who have migrated, particularly new migrants within six months of their move to the new location, while still providing advice to migrants of longer standing, who may be planning a further move or change in their employment. We will use mixed-methods to adapt, implement and evaluate the feasibility of an intervention. We will use participatory methods working with youth advisory groups in both countries already engaged in the design of this project, to develop and implement the intervention. We will assess which facets of the package are valued and test our assumptions about the challenges young migrants face and the appropriateness of the intervention offered. Finally, we will design a full-scale evaluation of the effectiveness and cost effectiveness of the feasible and acceptable elements of the intervention, which we anticipate will be a randomised control trial.

The long-term impact of the project is to improve the health and broader quality of life of young migrants in resource-constrained urban settings through addressing health system and social services, community and individual challenges. For the study participants, the interventions will have an immediate impact on aspects of their health and wellbeing as the intervention packages is designed to address key barriers to general support and advice and health service access.

Our study will contribute to the limited evidence available on the feasibility of targeted interventions for young migrants. Our study aligns with global HIV targets: by 2020, UNAIDS has called for the achievement of the ambitious 90-90-90 target: 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART); and 90% of all people receiving ART will have viral suppression. This project will contribute to that goal among one of the groups that UNAIDS has characterised as among the most vulnerable to being left out of HIV prevention and care (the recently published `Miles to Go' UNAIDS report highlights the needs of both adolescents and migrants http://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf) and will thus contribute to social justice and equity, acknowledging the importance of supporting young people to live safe and fulfilled lives.

While we support the UNAIDS' 90-90-90 targets, we believe that achieving viral suppression should not be the sole goal of treatment scale-up. We argue that a fourth '90' should be added to ensure that 90% of people with viral suppression also report good quality of life. This project links quality of life/well being to access to protective factors, including social connections to provide support and advice.

The initial geographical scope of the proposed project in two sites in Uganda and one site in South Africa will focus on testing the feasibility of the intervention package, which has been co-designed with young people engaged in our recent preparatory work. This project will, in time, have a broader impact through the demonstration effect of our work. Through stakeholder engagement, the intervention outcomes will potentially affect practice in other areas, through our close working relations with national and local government, and NGOs.

Our intervention design explicitly aims to provide the training and skills to the youth advisors and peer-supporter staff that will build their capacity to engage with research, advocate for their own health and social welfare, and ultimately build their social and political capital and improve their employability,

Furthermore, by interacting and providing skills development in youth engagement for health staff and `adult champions' we will support the capacity building of staff who will come into contact with the interventions. In addition, through our active engagement with health centres, local government as well as local non-governmental organisations and community groups, we will ensure that information about the on-going progress of the study and the findings will be packaged appropriately for dissemination.

Despite the critical need for harm reduction interventions which engage with adolescent risk behaviour before these risks translate into the acquisition of HIV and/ or problematic substance use or unplanned pregnancy, the benefits of investing in such interventions are often under-mined by the inherent challenges in providing evidence to demonstrate their efficacy. A further intellectual impact of this research will be the development of qualitative and quantitative measures to more effectively evaluate the impact of early prevention contextually orientated interventions to capture and assess complex outcomes, including the avoidance/ reduction of risk and the development of resilience.