Protocol for intervention development to improve adolescent perinatal mental health in Kenya and Mozambique: The INSPIRE project

Introduction: Mental health interventions have traditionally been developed by clinicians and researchers without the meaningful engagement and partnership with those who would receive, deliver, and fund them. Recent progress has highlighted the importance of the co-design of interventions, through stakeholder participation, as a means of increasing the integration of mental health interventions into existing health, education, and social care systems. This protocol describes the pre-implementation phase of the INSPIRE (Innovative approaches to adolescent perinatal wellbeing) project which aims to identify challenges, and design and test interventions to promote mental wellbeing and good mental health of adolescent girls during pregnancy and the year after birth with local stakeholders in Kenya and Mozambique. Methods: A participatory approach that blends human-centred design, systems thinking, and implementation science methods will be used to engage adolescents (aged 15–19 years), their families, and other stakeholders who can influence implementation efforts, in planning and preparing interventions. First, an understanding of context, barriers, and opportunities related to adolescent perinatal mental health will be elicited through individual interviews, focus group discussions, and observations. This will be complemented by a scoping review of relevant interventions. The research team will identify contextual insights relating to adolescent and system characteristics, strengths, and challenges. These will be shared with and refined by stakeholders. Thematic analysis will be conducted to describe the experiences of adolescent girls, and barriers and enablers to maintaining good mental health. The former will be triangulated with the Context and Implementation of Complex Intervention (CICI) framework. Causal loop diagrams will be developed to illustrate the individual and system-level variables which influence adolescent perinatal mental health. Stakeholder workshops will be used to identify priorities, brainstorm potential interventions, develop a program theory, and prototype an intervention and implementation strategies. Intervention acceptability, appropriateness, and feasibility will be assessed, and a theory of change map finalized. Results: To date the study has recruited 169 participants to complete individual interviews, focus group discussions and observation activities. Conclusions: It is anticipated that the use of a participatory and systematic approach to the development of an intervention to improve mental health, will improve its perceived appropriateness, acceptability, and feasibility among key stakeholders. This may, in turn, significantly improve its availability, uptake, and sustainability

Which Structural Interventions for Adolescent Contraceptive Use Have Been Evaluated in Low- and Middle-Income Countries?

Reducing adolescent childbearing is a global priority, and enabling contraceptive use is one means of achieving this. Upstream factors, e.g., gender inequalities, fertility norms, poverty, empowerment and schooling, can be major factors affecting contraceptive use. We conducted a systematic map to understand which structural adolescent contraception interventions targeting these upstream factors have been evaluated in LMICs. We searched eight academic databases plus relevant websites and a 2016 evidence gap map and screened references based on set inclusion criteria. We screened 6993 references and included 40 unique intervention evaluations, reported in 138 papers. Seventeen evaluations were reported only in grey literature. Poverty reduction/economic empowerment interventions were the most common structural intervention, followed by interventions to increase schooling (e.g., through legislation or cash transfers) and those aiming to change social norms. Half of the evaluations were RCTs. There was variation in the timing of endline outcome data collection and the outcome measures used. A range of structural interventions have been evaluated for their effect on adolescent contraceptive use/pregnancy. These interventions, and their evaluations, are heterogenous in numerous ways. Improved understandings of how structural interventions work, as well as addressing evaluation challenges, are needed to facilitate progress in enabling adolescent contraceptive use in LMICs

The Role of Gender Norms in Shaping Adolescent Girls’ and Young Women’s Experiences of Pregnancy and Abortion in Mozambique

Adolescents and young women in Mozambique experience high levels of unintended pregnancies, with induced abortion being a common outcome. Stigma and gender norms are likely to negatively impact experiences of pregnancy and abortion, and hamper access to information and services. We assessed knowledge, attitudes, practices, and experiences around pregnancy and abortion in six communities in Nampula and Zambézia provinces. We conducted 19 triad interviews with young women and girls, 19 focus group discussions with male and female adult community members, and 15 in-depth interviews with young women with abortion experience. Participants described how gender values, norms, and practices affect girls’ risk of unintended pregnancy and their experiences of pregnancy and abortion. The drivers of adolescent pregnancy included transactional sex and gender-based violence, including early marriage, and gender roles and expectations that lead parents and others to oppose contraception. Stigma around abortion, early or unintended pregnancy, and adolescent sexuality is fueled by gender norms and contributes to girls seeking unsafe abortions. Pregnancy and abortion decision making often involves male partners and family members. In conclusion, gender norms strongly influence the occurrence and outcome of unintended pregnancies and abortion in Mozambique. While abortion legislation was recently liberalized, gender values, norms, and practices inhibit young women’s and girls’ access to services and need to be addressed in policy and programming

Structural Interventions to Enable Adolescent Contraceptive Use in LMICs: A Mid-Range Theory to Support Intervention Development and Evaluation

Enabling contraceptive use is critical for addressing high adolescent pregnancy rates in low- and middle-income countries (LMICs). Broader or ‘upstream’ determinants, such as poverty, education, and social norms, can affect the knowledge, attitudes, motivation, and ability to access and use contraception. Structural interventions aim to address these broader determinants, e.g., through poverty alleviation from livelihood training or cash transfers, increasing school participation, or changing social norms. We conducted an evidence synthesis using intervention component analysis, a case-based approach, following a systematic mapping of the evidence base. We identified 17 studies with 29 structural intervention arms, which reported adolescent contraceptive use outcomes compared to a control group or baseline. It was not possible to identify with certainty which interventions were ‘likely effective’ or ‘likely ineffective’ due to the high heterogeneity of the methods. We built on an existing framework of family planning use to propose three steps to designing interventions: (1) tailor interventions to adolescents’ life stages; (2) assess the baseline situation; and (3) select appropriate activities to match the gaps. These steps will aid developers and evaluators of structural adolescent contraceptive interventions to develop an evidence base that is of use across a wide range of settings and use scenarios

Protocol for intervention development to improve adolescent perinatal mental health in Kenya and Mozambique: The INSPIRE project

Introduction Mental health interventions have traditionally been developed by clinicians and researchers without the meaningful engagement and partnership with those who would receive, deliver, and fund them. Recent progress has highlighted the importance of the co-design of interventions, through stakeholder participation, as a means of increasing the integration of mental health interventions into existing health, education, and social care systems. This protocol describes the pre-implementation phase of the INSPIRE (Innovative approaches to adolescent perinatal wellbeing) project which aims to identify challenges, and design and test interventions to promote mental wellbeing and good mental health of adolescent girls during pregnancy and the year after birth with local stakeholders in Kenya and Mozambique. Methods A participatory approach that blends human-centred design, systems thinking, and implementation science methods will be used to engage adolescents (aged 15–19 years), their families, and other stakeholders who can influence implementation efforts, in planning and preparing interventions. First, an understanding of context, barriers, and opportunities related to adolescent perinatal mental health will be elicited through individual interviews, focus group discussions, and observations. This will be complemented by a scoping review of relevant interventions. The research team will identify contextual insights relating to adolescent and system characteristics, strengths, and challenges. These will be shared with and refined by stakeholders. Thematic analysis will be conducted to describe the experiences of adolescent girls, and barriers and enablers to maintaining good mental health. The former will be triangulated with the Context and Implementation of Complex Intervention (CICI) framework. Causal loop diagrams will be developed to illustrate the individual and system-level variables which influence adolescent perinatal mental health. Stakeholder workshops will be used to identify priorities, brainstorm potential interventions, develop a program theory, and prototype an intervention and implementation strategies. Intervention acceptability, appropriateness, and feasibility will be assessed, and a theory of change map finalized. Results To date the study has recruited 169 participants to complete individual interviews, focus group discussions and observation activities. Conclusions It is anticipated that the use of a participatory and systematic approach to the development of an intervention to improve mental health, will improve its perceived appropriateness, acceptability, and feasibility among key stakeholders. This may, in turn, significantly improve its availability, uptake, and sustainability