From Stop to Go! Overcoming barriers to healthcare utilisation for high-risk adolescent mothers and their children in Southern Africa.

  • Sherr, L. (CoPI)
  • Tomlinson, Mark M. (CoPI)
  • Cluver, L. D. (PI)
  • Hodes, Rebecca Jane R.J. (CoPI)
  • Toska, Elona E. (CoPI)
  • Bungane, Nontuthuzelo Vuyelwa N.V. (CoPI)

Project: Research

Grant Details

Description

This project will identify barriers and facilitators of healthcare utilization among high-risk adolescent mothers and their children in South Africa. Research questions and methods were co-developed by a South-North research team, policymakers, NGOs and an adolescent parents Advisory Group. We will build local capacity in adolescent health research among South Africa-based early-career academics, doctoral students and government officials. Together we have a proven track-record of ethical research with vulnerable adolescents and high-impact programmatic engagement.

WHO guidelines view adolescent healthcare utilization within a socio-ecological framework. But there are major evidence gaps for adolescent mothers and their children in Africa, where one in three adolescent mothers live. Little is known about how healthcare, family, school and economic factors block or promote use of antenatal, maternal and child health services, especially in the context of HIV. There is limited evidence on adolescent fathers: the potential merits of their involvement in antenatal and early childhood care. This study combines quasi-experimental cohort data with qualitative participatory research to address this pressing evidence gap. The findings will directly contribute to regional policy and programming.

Stage 1 (2017-18) CO-CREATION AND PILOTING. The study was co-created with policymakers, adolescents and healthcare workers. We conducted consultations and reviewed draft questionnaires with adolescent parents, UN, government partners and frontline workers. From April 2018, we will supplement this with preliminary qualitative fieldwork. With co-funding from UNICEF, we are currently piloting questionnaires and developmental assessment tools with adolescent mother-child dyads.

Stage 2 (2018-19) FIELDWORK. We will conduct primary research to determine predictors of maternal healthcare use amongst high-risk adolescents in South Africa. This new research will capitalise on existing cohort data from 1589 adolescents followed from 2015-2017, with high rates of HIV, TB and poverty. By 2019 this cohort will include 450 adolescent mothers, and 450 of their children receiving care in 72 healthcare facilities. This provides an unprecedented opportunity to test prior and current predictors of healthcare utilisation, and its impacts on maternal and child health. We will collect i) medical records for adolescent mothers and their children (including standardised child development assessments); ii) detailed service provision data from all healthcare facilities; iii) self-reported adolescent healthcare experiences, violence exposure, alcohol use, support, schooling, parenting, father involvement, poverty and social protection access; and iv) in-depth qualitative and ethnographic data from adolescent mothers and fathers.

STAGE 3 (2019-20) DATA ANALYSIS AND ALLOCATIVE EFFICIENCY MODELS. We will merge this new study with prior longitudinal adolescent data, and use techniques such as propensity-score matching, multi-level structural equation modelling and marginal effects modelling to examine barriers and facilitators to healthcare utilisation. Findings will identify solutions that are feasible within government and NGO-provided health and social services. With government partners, we will identify 'best buys' through cost-effectiveness analyses for combinations of effective provisions for optimal impact on health outcomes.

STAGE 4 (2021-22) CO-CREATION OF EVIDENCE-BASED SOLUTIONS. We will co-create high-impact dissemination materials with our policy and adolescent partners. Through our programming partner's training fora, we will conduct skills training with frontline workers with regional reach. We will engage in extensive impact strategies with international agencies, donors and national governments.

This project combines innovative partnership with rigorous evidence to promote survival and thriving for adolescent mothers and their children.

Technical Summary

Adolescent parents in Africa persistently under-utilise healthcare: antenatal care, PMTCT and child services. This increases maternal mortality and morbidity, birth complications, pre-term birth, neonatal and under-5 mortality, HIV-transmission, childhood illness and risk of developmental delay. Systematic reviews of African research find limited evidence of modifiable barriers or facilitators to healthcare utilisation in this group. There is no known research on potential impact of adolescent fathers. Policy partners have identified a need for high-quality research alongside cost-effectiveness models to inform programming.

This study combines new data from maternal-child dyads in South Africa with prior data from pre-conception to pregnancy. It is powered to examine moderated and mediated pathways to healthcare uptake through multilevel structural equation models. It allows testing of combinations of interventions through marginal effect and propensity-score models.

We will merge medical records, socio-economic surveys with standardised child developmental assessments from 450 mother-child dyads with service delivery information collected at 72 healthcare facilities. This complex multi-year dataset will be analysed using multi-level models to account for repeated measures and nested effects within facilities. After identification of facilitators (and potential interactive/additive effects), allocative efficiency analysis will compute the cost of these provisions under different budgetary models. Findings will be informed by qualitative research, by adolescent and policy advisory groups.

Targeted activities will maximise ODA impact. The study was co-created with high-level policymakers at international and national level, and fills a clearly identified need in the Global South. Findings will be integrated into policies, programming and health facilities via a training module for healthcare practitioners delivered through our implementation partners.

StatusFinished
Effective start/end date07/1/1812/31/21

Funding

  • Medical Research Council: $931,021.00

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