Researchers of the Institute for Life Course Health Research (ILCHR) in the Department of Global Health of the Faculty of Medicine and Health Sciences envisage a society where children thrive rather than simply survive.
To learn how to achieve this, these researchers study low-resource communities from a long-term perspective. “Life-course health research tries to understand and track what happens across the whole lifespan, not just during a ‘snapshot’ of one or two moments,” says Prof Mark Tomlinson, who co-directs the ILCHR with senior researcher Dr Sarah Skeen.
The ILCHR works throughout South Africa, with research teams based in Khayelitsha in the Western Cape and the OR Tambo district in the Eastern Cape. They also run projects across Africa and South Asia, and collaborate with international agencies such as the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF) on programmes on child and adolescent mental health and development.
Early events, later repercussions
It is now well-recognised that events in early childhood and in utero have long-term health impacts: Research has revealed the vulnerability of the first 1 000 days of life (conception to two years), especially regarding neurodevelopment.
Intergenerational factors are also significant. Says Tomlinson: “We’re starting to realise that one predictor of an infant’s growth is the grandmother’s nutritional status. And that a young woman’s health – her nutrition, whether she’s getting regular medical check-ups – is key in the health of the baby she’s not even pregnant with yet.”
This is also true of mental health. “Research 30 years ago was mainly focused on postnatal depression and its impact on the mother and her child. Then we realised antenatal depression is as important, if not more so,” Tomlinson explains.
“Also chronic depression is far worse than a single episode.”
No inoculation against adversity
As a result, there’s been a worldwide push for investment in early-childhood interventions. However, nothing can completely “inoculate” a child against developmental disruption. “We’ve found that sometimes interventions only have very small positive impacts, or sometimes large impacts wash out. Sometimes they fade and then re-emerge later,” says Skeen. “One can’t expect just one short programme in the early years will change the outcomes of people’s lives, especially in conditions of extreme poverty.”
Continued investment is needed – including, and perhaps particularly, in adolescence. “While brain development is incredibly fast, with lots of synapse pruning in those first 1 000 days, we now know that an enormous amount of brain development also happens in adolescence,” says Tomlinson.
Current research suggests that certain adolescent interventions are particularly successful, especially those focusing on interpersonal skills and emotional regulation. However, such findings have come mostly from high-income countries. The challenge is to adapt these interventions for low-income settings. The ILCHR is working with the WHO on guidelines for such programmes, and exploring targeted prevention for at-risk adolescents, encompassing depression and anxiety, substance abuse, aggression and self-harm.
Other important ILCHR work testing interventions for younger children includes the Thula Sana (“Hush Baby”) trial in South Africa, the Philani trial, and the Mphatlalatsane study in Lesotho. All have involved community health workers making home visits to mothers during pregnancy and early childhood.
The Philani study is tracking the impact of a home visiting programme run by a well-known NGO in Khayelitsha. The Mphatlalatsane study, completed in 2018, focused on a group-based intervention on nutrition, HIV testing and language development. During the Thula Sana trial, the ILCHR tracked children for the first eighteen months, again at 13 years, and then later re-enrolled the group into an adolescent intervention. “You’re trying to determine when interventions are most effective – does an intervention at age 17 give a significant reinforcing boost to an intervention built on the first six months?” Tomlinson explains.
Challenges of long-haul research
Life-course studies can be expensive and time-consuming: Thula Sana has run for 18 years; the Philani study has lasted eight. They’re logistically tough as well. Data collectors “disappear into the rural Eastern Cape or Lesotho for a month, going from village to village”, says Tomlinson. And sometimes access requires four-wheel drives or even donkeys.
The work is also conceptually challenging. Mental health is difficult to measure, as are adversity, violence and poverty. “Sometimes it’s hard to see how those factors impact directly on outcomes,” says Skeen. “We try to measure exposure to all kinds of risks within the individual and the immediate environment.”
And there are so many factors: Some children struggle when faced with “the smallest environmental insult … but if that same child were in a really good environment, they’d thrive,” Tomlinson explains.
Caption: Prof Mark Tomlinson and Dr Sarah Skeen
Photo credit: Stefan Els