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

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.