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

在世界各地，患有2型糖尿病和高血压等非传染性疾病的人数正在增加。患糖尿病的风险与儿童时期营养不良有关，然后在以后的生活中变得肥胖，不活跃，饮食质量差，以及遗传和子宫内生长不良。南非等中低收入国家的非传染性疾病患者人数增长尤其迅速，其卫生系统已经在努力应对传染病的负担。我们已经表明，在南非农村，三分之一的女孩在一岁时生长迟缓，三分之一的青少年和年轻女性在20岁时超重或肥胖。7%至15奥尔兹的青少年已经出现糖尿病的早期预警信号，为了应对非传染性疾病日益流行的问题，有人建议改善青少年的营养状况可能是一项成功的战略，并建议制定和评估孕前干预措施，在生育年龄往往较低的贫困社区促进健康行为，可能是解决方案的一部分。撒哈拉以南非洲是全世界青少年人数预计将增长的唯一区域，但它也是青少年健康状况最差的区域。迄今为止，我们仍然不清楚如何最好地干预，以改善低收入或中等收入国家的青少年的营养状况。我们在过去五年的广泛研究，为针对青春期女孩和男孩的干预措施的发展提供了信息。它将雇用受过训练的以青少年为重点的社区卫生工作者，与青少年一起解决体重不足和肥胖问题，办法是：㈠促进健康行为，增加青少年对青少年卫生服务的使用; ㈡鼓励更好的照顾者和朋友支持，增加社区中变得更健康的机会;及（iii）支持怀孕少女在怀孕期间尽早及更频密地接受产前健康服务，以识别及减低青少年患非传染性疾病的风险，通过支持行为改变，增加他们对卫生服务的利用。卫生保健工作者将接受“健康对话技能”的培训，这是一套专门为社会经济处境不利的妇女制定和测试的支持行为改变的技能，以提高她们对实现健康目标的信心。AHW将利用这些技能作为他们在南非农村工作的基础，为期两年，与青少年及其家庭建立关系，鼓励社会支持更健康的青少年生活方式。干预的方法是灵活的，将侧重于每个参与者最相关的困难领域。卫生工作者还将让村里的青少年同龄人参与促进卫生知识普及。卫生知识普及将增加青少年获得卫生信息的机会，并培养他们有效利用这些信息的能力。AHW将动员乡村社区领导人创造更多机会，促进和支持更健康的生活方式。怀孕的青少年将得到AHW的进一步支持，以获得和定期参加产前服务，促进护理人员的参与，并在怀孕期间加强最佳的个人健康（包括体重增加）。通过这些干预措施，我们的目标是减少婴儿出生体重过低或过高的发生率，因为这些与以后生活中的糖尿病风险有关。拟议的发展赠款将使我们能够在两个村庄完成可行性和试点研究，为试验的设计和实施提供关键数据。

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.