Power to participants: methodological and ethical reflections from a decade of adolescent advisory groups in South Africa

Intimate Partner Violence Among Adolescent Mothers Living With and Without HIV: A Pre- and During-COVID-19 South African Cohort Analysis

PURPOSE

Adolescent mothers face heightened economic and social vulnerabilities, which can place them at increased risk of intimate partner violence (IPV), prepandemic, and during COVID-19. However, few studies examine this population, and even less disaggregate findings by HIV status.

METHODS

We analyzed data from 834 South African adolescent mothers, 35% living with HIV (LHIV), who reported on physical, psychological, and sexual IPV exposure at two interviews: 2018-2019 (prepandemic) and 2021-2022 (during COVID-19). We estimated lifetime prevalence of IPV, disaggregating by HIV status. We used inverse weighted probability multivariate mixed-effects logistic regression to examine changes in IPV between the two periods and if changes in IPV differed by HIV status.

RESULTS

A quarter of adolescent mothers had experienced any IPV during COVID-19, quadruple prepandemic levels (24.7% vs. 6.0%). The increase was driven by surges in physical (+15.7%) and psychological (+11.2%) IPV. In both periods, psychosocial and physical IPV were the most prevalent forms and the most common combination among those who had experienced multiple forms of IPV. Exposure to any IPV was significantly more prevalent among those LHIV compared to those without HIV, prepandemic (9.5% vs. 4.1%, p = .026) and during COVID-19 (31.8% vs. 20.6%, p < .001). Adjusted models revealed an 18.2% significant increase in the average predicted probability of reporting IPV during COVID-19 compared to prepandemic, with no differential effect by HIV status.

DISCUSSION

Adolescent mothers experienced a significantly higher burden of IPV during COVID-19 than prepandemic, with those LHIV experiencing the highest level. Initiatives to reduce IPV need to reach adolescent mothers, particularly those living with HIV.

Including the child's voice in research from a longitudinal birth cohort: insights from the ROLO young person's advisory group

BACKGROUND

Public and patient involvement (PPI) through Young Person's Advisory Groups (YPAG) enables children to provide guidance and insight into research activities. PPI is an important characteristic of research, however, to date, most collaboration has been with adults. Also, few YPAGs have been established within the Irish setting. The ROLO (Randomised cOntrol trial of a LOw glycaemic index diet in pregnancy to prevent macrosomia) YPAG was established in July 2020 to identify the research priorities of a group of healthy Irish children who are part of a longitudinal birth cohort. We aimed to describe this process and the key insights to date.

METHODS

The ROLO study is a longitudinal birth cohort which has followed-up mother-child dyads at multiple timepoints over 10 years. Mothers actively involved in the study were contacted by the research team to invite their ROLO child and older sibling to participate in the YPAG. Meetings were conducted virtually between July 2020 and February 2022. Researchers encouraged free expression of views amongst the children regarding their research interests. Meetings were recorded, transcribed verbatim and analysed for themes based on the topics most frequently discussed and considered important to participants.

RESULTS

In all, seven ROLO children and six older siblings attended four ROLO YPAG meetings. Participants were aged between nine to fifteen years old. Four key themes were identified; study children viewed their identity as part of a longitudinal birth cohort as positive and unique; study children considered the fitness test and body measurements as fun aspects related to their participation; all children considered the impact and use of social media as an important form of communication; and all participants expressed interest in attaining new health-related information and learning opportunities. Children suggested topics such as mental health, future viruses, organ transplants, cancer, and the effect of technology and chemicals on the body were important for future research.

CONCLUSION

The ROLO YPAG offers promising scope for continued collaboration. The themes identified from the meetings contribute to a gap in the literature which will guide future research activities, particularly with children, in view of study design, relevance, and by communication strategies. Trial Details: ISRCTN54392969 registered at www.isrctn.com .

Improving educational and reproductive outcomes for adolescent mothers in South Africa: A cross-sectional analysis towards realising policy goals

Adolescent mothers face numerous challenges. This study aimed to address the operationalisation of the new South African national policy for young mothers by testing the associations of potential protective provisions with three policy goals: School return, grade promotion, and pregnancy/HIV prevention. Adolescent mothers aged 12-24 from rural and urban communities of South Africa's Eastern Cape completed study questionnaires between 2017-2019. Using multivariate multi-level analysis, we simultaneously estimated associations between hypothesized provisions and protective variables and all policy-aligned goals. School return was associated with using formal childcare services, higher confidence and self-efficacy scores, and remaining in school throughout pregnancy. Grade promotion was associated with greater exposure to friendly and respectful health staff, using formal childcare services, higher confidence and self-efficacy scores, and remaining in school throughout pregnancy. Pregnancy/HIV prevention (condom use) was moderately associated with greater exposure to friendly and respectful health staff. There was evidence of synergies of provisions whereby a combination of protective characteristics showed larger positive effects than receipt of any single factor alone. This study provides essential evidence for operationalising South Africa's new policy on the Prevention and Management of Learner Pregnancy in Schools, and points to implementation strategies that provide low-cost opportunities to promote educational and health outcomes for adolescent mothers.

Between Rhetoric and Reality: Learnings From Youth Participation in the Adolescent and Youth Health Policy in South Africa

BACKGROUND

Youth participation makes an essential contribution to the design of policies and with the appropriate structures, and processes, meaningful engagement leads to healthier, more just, and equal societies. There is a substantial gap between rhetoric and reality in terms of youth participation and there is scant research about this gap, both globally and in South Africa. In this paper we examine youth participation in the Adolescent and Youth Health Policy (AYHP) formulation process to further understand how youth can be included in health policy-making.

METHODS

A conceptual framework adapted from the literature encompassing Place, Purpose, People, Process and Partnerships guided the case study analysis of the AYHP. Qualitative data was collected via 30 in-depth, semi-structured interviews with policy actors from 2019-2021.

RESULTS

Youth participation in the AYHP was a 'first' and unique component for health policy in South Africa. It took place in a fragmented policy landscape with multiple actors, where past and present social and structural determinants, as well as contemporary bureaucratic and donor politics, still shape both the health and participation of young people. Youth participation was enabled by leadership from certain government actors and involvement of key academics with a foundation in long standing youth research participatory programmes. However, challenges related to when, how and which youth were involved remained. Youth participation was not consistent throughout the health policy formulation process. This is related to broader contextual challenges including the lack of a representative and active youth citizenry, siloed health programmes and policy processes, segmented donor priorities, and the lack of institutional capability for multi-sectoral engagement required for youth health.

CONCLUSION

Youth participation in the AYHP was a step toward including youth in the development of health policy but more needs to be done to bridge the gap between rhetoric and reality.

From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV

Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.

Art-based reflections from 12 years of adolescent health and development-related research in South Africa

This paper presents empirical and methodological findings from an art-based, participatory process with a group (n = 16) of adolescent and young advisors in the Western Cape Province of South Africa. In a weekend workshop, participants reflected on their participation in 12 years of health and development-related research through theatre, song, visual methodologies and semi-structured interviews. Empirical findings suggest that participants interpreted the group research encounter as a site of empowerment, social support and as a socio-political endeavour. Through song, theatre and a mural illustration, they demonstrated that they value 'unity' in research, with the aim of ameliorating the conditions of adolescents and young people in other parts of South Africa and the continent. Methodological findings document how participants deployed art-based approaches from South Africa's powerful history of activism, including the struggle against apartheid, the fight for anti-retroviral therapy and more recent social movements towards decolonization.

Accelerating ontological security for South African adolescents living in high HIV-prevalence areas: a longitudinal study

Ontological security is the personal need to build fundamental certainty about the continuity of life events. It is central to long-term human development, particularly among adolescents in highly vulnerable communities in South Africa. We examined the cumulative effects of eight hypothesised provisions (development accelerators) in reducing the risks of ontological insecurity outcomes aligned with Sustainable Development Goals (SDGs) targets. Three waves of survey data from adolescents living in high HIV prevalence areas in South Africa were analysed. We used standardised tools to measure twelve outcomes linked to two dimensions of ontological security: mental health and violence. Sustained receipt (at baseline and follow-ups) of eight hypothesised accelerators were examined: emotional and social support, parental/caregiver monitoring, food sufficiency, accessible health care, government cash transfers to households, basic economic security, positive parenting/caregiving, and participation in extramural activities. Associations of all accelerators with outcomes were evaluated using multivariable regressions controlling for age, sex, orphanhood and HIV status, rural/urban location, and informal housing. Cumulative effects were tested using marginal effects modelling. Of 1,519 adolescents interviewed at baseline, 1,353 (89%) completed the interviews at two follow-ups. Mean age was 13.8 at baseline; 56.6% were female. Four provisions were associated with reductions in twelve outcomes. Combinations of accelerators resulted in a percentage reduction risk in individual indicators up to 18.3%. Emotional and social support, parental/caregiver monitoring, food sufficiency and accessible health care by themselves and in combination showed cumulative reductions across twelve outcomes. These results deepen an essential understanding of the long-term effects of consistent exposure to accelerators on multi-dimensional human development. They could be directly implemented by existing evidence-based interventions such as peer-based psychosocial support, parenting programmes, adolescent-responsive healthcare and food support, providing safer and healthier environments for South African adolescents to thrive.

Engagement with young people as partners in health research: Four case studies from Sub-Saharan Africa

OBJECTIVES

Existing health services for young people (YP)(10-24 years), which are predominantly designed for but not with young people, often do not meet YP's needs. The 2018 Global Consensus Statement on meaningful adolescent and youth engagement affirms that YP have a fundamental right to actively and meaningfully engage in all matters that affect their lives. We present four case studies from three countries in sub-Saharan Africa as practical examples of the engagement of young people as partners in health research. We critically reflect on best practices to inform and guide the increasing adoption of collaborative approaches.

METHODS

We developed a narrative summary of each case study through review of study documentation and discussions with research staff and young people. A youth engagement framework was used to describe partnership activities according to the following dimensions: purpose, process, positioning, perspective, power relations, place and protection. We reflected on innovative practices used, overall level of participation achieved and strategies to address ethical, logistical and/or financial barriers.

RESULTS

In all case studies, we found evidence of engagement activities that aligned with the Global Consensus Statement on Meaningful Youth Engagement. However, access to participation was often uneven and despite efforts, marginalised young people continue to have insufficient opportunities to engage. Furthermore, although young people had some opportunity to influence the research methods, many of the key design decisions had been determined prior to their involvement. In our case studies, researchers had built in insufficient opportunities to evaluate the level and impact of youth engagement.

CONCLUSIONS

We therefore recommend early involvement of young people in the research process so that they can contribute to setting the research agenda, the design of planned studies and thus increase the scope of their engagement from the beginning. Youth engagement activities need to be evaluated from the perspective of all stakeholders including young people themselves with a focus on opportunities to engage, the level of engagement achieved and impact of engagement. From the beginning, researchers should provide space for learning, and involve young people in encouraging critical reflection of what does not yet work, as well as what does, to enable improvements.

Accelerating Sustainable Development Goals for South African adolescents from high HIV prevalence areas: a longitudinal path analysis

BACKGROUND

Adolescents experience a multitude of vulnerabilities which need to be addressed in order to achieve the Sustainable Development Goals (SDGs). In sub-Saharan Africa, adolescents experience high burden of HIV, violence exposure, poverty, and poor mental and physical health. This study aimed to identify interventions and circumstances associated with three or more targets ("accelerators") within multiple SDGs relating to HIV-affected adolescents and examine cumulative effects on outcomes.

METHODS

Prospective longitudinal data from 3401 adolescents from randomly selected census enumeration areas in two provinces with > 30% HIV prevalence carried out in 2010/11 and 2011/12 were used to examine six hypothesized accelerators (positive parenting, parental monitoring, free schooling, teacher support, food sufficiency and HIV-negative/asymptomatic caregiver) targeting twelve outcomes across four SDGs, using a multivariate (multiple outcome) path model with correlated outcomes controlling for outcome at baseline and socio-demographics. The study corrected for multiple-hypothesis testing and tested measurement invariance across sex. Percentage predicted probabilities of occurrence of the outcome in the presence of the significant accelerators were also calculated.

RESULTS

Sample mean age was 13.7 years at baseline, 56.6% were female. Positive parenting, parental monitoring, food sufficiency and AIDS-free caregiver were variously associated with reductions on ten outcomes. The model was gender invariant. AIDS-free caregiver was associated with the largest reductions. Combinations of accelerators resulted in a percentage reduction of risk of up to 40%.

CONCLUSION

Positive parenting, parental monitoring, food sufficiency and AIDS-free caregivers by themselves and in combination improve adolescent outcomes across ten SDG targets. These could translate to the corresponding real-world interventions parenting programmes, cash transfers and universal access to antiretroviral treatment, which when provided together, may help governments in sub-Saharan Africa more economically to reach their SDG targets.