A brief overview of the project
Poverty increases the likelihood that adolescents will develop common mental health problems such as depression and anxiety. Most of the world’s adolescents live in low and middle-income countries (LMIC), where poverty levels are high, and there are few effective interventions to prevent depression and anxiety.
There is evidence that poverty increases the risk of adolescent depression and anxiety both directly, and through its effect on self-regulation (i.e. the ability to set goals, to maintain goal-directed behaviour in the face of distractors, and to flexibly adapt behaviour based on new information).
We propose to conduct a 4-armed pilot randomised controlled trial to evaluate an intervention that includes a poverty reduction element and also strengthens self-regulation among adolescents living in urban poverty in Bogotá (Colombia), Kathmandu (Nepal) and Cape Town (South Africa).
We have designed the evaluation to allow us to eventually test whether the poverty-reduction or the self-regulation component, or both combined are most effective in preventing adolescent depression and anxiety in the three LMIC sites. We also propose to adapt and validate key measurement instruments, to assess how the intervention is delivered, how much it costs, the way in which it works and its effect. Our pilot evaluation will allow us to test all the procedures required for a future fully powered randomised controlled trial.
Work packages:
The ALIVE project is divided into six work packages based on the project objectives. The aim of each Work Package is to ensure that each of the four objectives of the Project are met, with strong adolescent engagement throughout the research process.
Study leadership and coordination
Work package 1 will be responsible for developing project policies, reporting to the Wellcome Trust, as well as coordinating and managing the project activities across all three sites (Bogotá, Kathmandu and Cape Town).
Theoretical model
Work package 2 will be responsible for developing the theoretical model which will identify the causal mechanisms linking poverty, self-regulation, depression and anxiety among adolescents. This will be done through a realist synthesis of the literature, as well as through qualitative research with adolescents, using a narrative approach, to identify common self-regulation strategies that adolescents use to cope with the social and economic challenges of living in poverty. The qualitative research will be conducted in all three sites (Bogotá, Kathmandu and Cape Town).
Intervention development
Work package 3 will be responsible for developing the intervention that will comprise anti-poverty and self-regulation modules, as well as for designing and testing implementation and delivery strategies through nimble evaluations (rapid, low-cost mini randomised controlled trials). The purpose of the intervention will be to prevent depression and anxiety among adolescents living in urban poverty in Bogotá, Kathmandu and Cape Town.
Instrument development and validation
Work package 4 will be responsible for selecting or developing, as well as validating key measures to be used in the pilot randomised controlled trial. These measures will cover eligibility instruments (e.g., poverty-related measure, risk for depression/anxiety), primary and secondary outcomes (e.g., depressive and anxiety symptoms, functioning), mediators (e.g., self-regulation skills), process indicators (e.g., feasibility, costs), and contextual factors (e.g., socio-economic measures, trauma, neighbourhood characteristics, life events). This will ensure that all tools or measures used are adapted for the local context in all three sites.
Pilot study
Work package 5 will be responsible for conducting the pilot randomised controlled trial, which will take place in Bogotá, Kathmandu and Cape Town. This will be a four-arm trial to test the feasibility, acceptability and cost of the intervention, as well as to test the trial procedures and measures to inform a future fully powered multi-site trial.
Adolescent and stakeholder engagement
Work package 6 will be responsible for ensuring that we engage with adolescents and other key stakeholders throughout the project. In part, this will entail setting up adolescent advisory groups in all three sites – their main purpose will be to explore adolescents’ reflections, suggestions and expressions on the study design, intervention design and instrument design, and ensure that the study remains relevant and informed by young people.
Country sites:
The ALIVE project is taking place in three low- and middle-income country sites: Bogotá (Colombia), Kathmandu (Nepal) and Cape Town (South Africa).
Colombia
Colombia ranks among the world’s most unequal countries, where 34% of children and adolescents live in poverty and 20% of 15-19 year old adolescents are not in employment, education or training. There remain high rates of violence and displacement linked to the armed conflict, with 22.6% of adolescents suffering from common mental health problems.
Nepal
Nepal is one of the poorest countries in south Asia and has been affected by a 10-year civil war and two major earthquakes. Based on gross national income per capita, Nepal ranks 193 out of 226 countries globally. More than one-fifth (22%) of Nepal’s population are adolescents (age 10-19 years). Only 54% enroll in secondary school and, among girls, early marriage is a common reason for leaving school.
South Africa
South Africa has one of the highest youth unemployment rates in the world, with 58% of 15-24 year old youth not engaged in employment, education or training. It is one of the most unequal countries in the world, with persistent child and adolescent poverty; 60% of children still lived below the poverty line in 2019.
