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In sub-Saharan Africa, one-quarter of all pregnancies occur in adolescents. Children born to adolescent mothers have poorer physical and socio-cognitive development. One reason may be inadequate knowledge on childcare and psychosocial support during pregnancy and post partum, since adolescent mothers have less antenatal care attendance and overall interaction with the health care system. Mobile health technology has been used to relay health information to special groups; however, psychosocial support commonly requires physical interaction.
We aimed to assess the efficacy of an interactive mobile text messaging platform and support groups in improving adolescent mothers’ knowledge and practices as well as infant growth and development.
This was a quasi-experimental study, conducted among adolescent mothers with infants younger than 3 months, in Homa Bay County, Kenya. Five of the 8 subcounties in Homa Bay County were purposively selected as study clusters. Four subcounties were assigned as intervention clusters and 1 as a control cluster. Adolescent mothers from 2 intervention subcounties received interactive text messaging only (limited package), whereas those from the other 2 subcounties received text messaging and weekly support groups, moderated by a community health extension worker and a counselor (full package); the control cluster only received the end-line evaluation (posttest-only control). The follow-up period was 9 months. Key outcomes were maternal knowledge on childcare and infant development milestones assessed using the Developmental Milestones Checklist (DMC III). Knowledge and DMC III scores were compared between the intervention and control groups, as well as between the 2 intervention groups.
We recruited 791 mother-infant pairs into the intervention groups (full package: n=375; limited package: n=416) at baseline and 220 controls at end line. Attrition from the intervention groups was 15.8% (125/791). Compared with the control group, adolescent mothers receiving the full package had a higher knowledge score on infant care and development (9.02 vs 8.01;
An interactive text messaging platform improved adolescent mothers’ knowledge on nurturing infant care and the development of their children, even without physical support groups. Such platforms offer a convenient avenue for providing reproductive health information to adolescents.
Pan African Clinical Trials Registry PACTR201806003369302; https://tinyurl.com/kkxvzjse
The World Health Organization (WHO) estimates that 23 million girls younger than 20 years of age become pregnant in low- and middle-income countries (LMICs) every year [
Adolescent pregnancies are associated with poorer physical and socio-cognitive development during infancy and early childhood, partly due to inadequate knowledge on infant care [
Adolescent mothers show less sensitive and more intrusive, hostile interactive behaviors and less frequently engage in direct interactions with their children [
Adolescent mothers have less knowledge on infant care and development compared with their older counterparts [
The WHO Nurturing Care Framework identifies the formation of parent groups, counseling, and support as a model for achieving responsive care giving [
This was a quasi-experimental study to assess the efficacy of a nurturing care package delivered through mHealth and psychosocial support on the development of children born to adolescent mothers. The study was conducted in 5 subcounties purposively selected from the 8 subcounties in Homa Bay County, Kenya. Homa Bay County has the second highest prevalence of adolescent pregnancies in Kenya, at 33.3% in 2019 [
The study population was adolescent mothers and their infants. The minimum sample size required per cluster was 200, based on a 22% expected difference in exclusive breastfeeding rates between adolescent and mature mothers [
We adopted a cluster-sampling method, with the subcounty representing a cluster. Four subcounties were randomly selected from the 8 in Homa Bay County and assigned to 1 of the 2 study arms: full package intervention or limited package intervention (2 subcounties each). Eligible adolescent mothers were recruited by community health extension workers working in each of the subcounties. A baseline survey was conducted, collecting key variables including age, education, occupation, telephone number, and knowledge and practices on infant care and development. A total of 791 adolescent mothers were recruited into the study at baseline. We did not recruit a no-intervention control group at baseline due to 2 reasons. First, the community health extension workers in the study locations felt that recruiting a control group and then following up with them until the final evaluation with no intervention may be difficult to explain to the adolescents and their guardians. On the contrary, a control group at end line would be packaged as a health promotion activity in the community. Second, since the study team would still need to do community tracking of the adolescents in the control group, it would be difficult to avoid providing information similar to our interventions if specifically asked by the participants; this would result in contamination risk. Therefore, we adopted a pretest-posttest design with a posttest-only control [
Study CONSORT (Consolidated Standards of Reporting Trials) flow diagram.
The intervention consisted of (1) the delivery of targeted messages on childcare and nurturing through an interactive text messaging platform and (2) psychosocial support groups for the adolescent mothers, moderated by trained personnel. This was based on the WHO Nurturing Care Framework, which emphasizes health, nutrition, early learning, and responsive care giving through parent groups, counseling, and support [
A baseline questionnaire was administered, documenting the demographic and contact information of the eligible participants. Key information at baseline included the ages of the mother and infant, residence, and mobile telephone number. Data were collected by community health extension workers. Development assessment used the Developmental Milestones Checklist (DMC III) [
The primary outcomes were (1) maternal knowledge and practices (exclusive breastfeeding, immunization, feeding, and stimulation) on childcare and development and (2) infant developmental milestones at end line as assessed by the DMC III. The secondary outcomes were (1) the incidence of diarrhea and respiratory illnesses and (2) anthropometric measurements. The secondary outcomes are not reported in this paper.
We first explored the descriptive analysis using independent sample 2-tailed
Eligible study participants were given the rationale and aims of the intervention study. Written informed consent was then obtained from all enrolled adolescent mothers. The protocol was approved by the African Medical Research Foundation Ethics and Scientific Review Committee (protocol ESRC P589/2019). We also obtained approval of local authorities, at the county and subcounty levels, and community strategy coordination before the implementation of the study. The study protocol was registered at the Pan African Clinical Trials Registry (PACTR201806003369302).
A total of 1011 adolescent mothers were recruited: 416 in the limited package arm, 375 in the full package arm, and 220 in the control group. The majority of the participants (873/1011, 86.4%) were between the ages 16 and 19 years, and 61.6% (623/1011) were students. Only 10% (101/1011) had completed secondary school. One-quarter (265/1011, 26.2%) were married, and only 16.4% (166/1011) were involved in any form of income-generating activity (business, employment, casual labor, or farming). Antenatal clinic attendance for at least 1 visit was high for all the groups (370/375, 98.7% for the full package group; 396/416, 95.2% for the limited package group; and 215/220, 97.7% for the control group). The comparison of the various parameters across the 3 groups is shown in
At end line, 666 adolescent mothers in the intervention groups were still active in the study, translating to an overall attrition rate of 15.8% (125/791; 70/416, 16.8% in the limited package intervention group vs 55/375, 14.7% in the full package intervention group). The mean age of the children at the end-line evaluation was 11.8 (SD 2.5) months for the full intervention group, 12.4 (S.D 2.8) months for the limited intervention group, and 11.0 (S.D 4.2) months for the control group. Exclusive breastfeeding rates were higher in the full package intervention group compared with the control group (238/375, 63.5% vs 112/220, 50.9%;
Sociodemographic characteristics of study populationa.
Characteristics | Full package (n=375), n (%) | Limited package (n=416), n (%) | Control (n=220), n (%) | ||||
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12-15 | 64 (20) | 63 (15.1) | 11 (5) | |||
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16-19 | 311 (82.9) | 353 (84.9) | 209 (95) | |||
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Primary, incomplete | 134 (38.7) | 163 (39.2) | 83 (37.5) | |||
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Primary, completed | 38 (10.1) | 59 (14.2) | 27 (12.3) | |||
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Secondary, incomplete | 156 (41.6) | 162 (38.9) | 88 (40.2) | |||
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Secondary, completed and above | 47 (12.5) | 32 (7.7) | 22 (10.1) | |||
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Business | 8 (2.1) | 32 (7.7) | 11 (5) | |||
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Casual laborer | 6 (1.6) | 7 (1.7) | 4 (1.6) | |||
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Farming | 24 (6.4) | 50 (12) | 20 (9.3) | |||
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Formal employment | 0 (0) | 2 (0.5) | 0 (0) | |||
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Housewife | 68 (18.1) | 72 (17.3) | 39 (17.9) | |||
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Student | 260 (69.3) | 227 (54.6) | 136 (61.7) | |||
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Other | 9 (2.4) | 26 (6.3) | 10 (4.5) | |||
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Married | 84 (22.4) | 123 (29.6) | 58 (26.4) | |||
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Single | 291 (77.6) | 292 (70.2) | 162 (73.6) | |||
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Otherb (separated, divorced, or widowed) | 0 (0) | 1 (0.2) | 0 (0) | |||
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Agriculture | 128 (34.1) | 286 (68.8) | 115 (52.3) | |||
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Business | 195 (52) | 75 (18) | 75 (34.1) | |||
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Employment | 30 (8) | 14 (3.4) | 12 (5.6) | |||
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Others | 22 (5.9) | 41 (9.9) | 18 (8) | |||
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Christian | 375 (100) | 409 (98.3) | 218 (99.1) | |||
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Muslim | 0 (0) | 7 (1.7) | 2 (0.9) | |||
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Yes | 370 (98.7) | 396 (95.2) | 215 (97.7) | |||
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No | 5 (1.3) | 20 (4.8) | 5 (2.3) |
aThis includes the number of participants as at recruitment—the intervention groups at baseline and the control group at end line.
bOther includes those who are separated, divorced, or widowed; these were combined since the numbers were very small.
cANC: antenatal care.
Compared with the control group, adolescent mothers who received the full package had a higher knowledge score on infant care and development (9.02 vs 8.01;
The infants of mothers in both intervention groups also had higher average scores on the DMC III in developmental milestones (
Comparison of maternal knowledge score between the 2 interventions groups and the control group at end linea.
Package | Intervention | Control | Knowledge score, mean difference | ||||||
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Participant, n | Knowledge score, mean (SD) | Participant, n | Knowledge score, mean (SD) |
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Full package | 307 | 9.02 (2.19) | 199 | 8.01 (2.07) | 1.01 | <.001b | |||
Limited package | 297 | 8.73 (2.22) | 199 | 8.01 (2.07) | 0.73 | <.001b |
aThe n values differ from the numbers analyzed from the CONSORT (Consolidated Standards of Reporting Trials) diagram due to records with missing key variables that were dropped from the model.
bSignificant results at
Comparison between groups in (A) maternal knowledge and (B) infant developmental milestones at end line. (A) Full package vs control:
Compared with the control group, participants who received the full package had significantly higher gross motor (26.55 vs 23.50;
Participants who received limited package also had significantly higher scores in fine motor (12.59 vs 11.41;
Comparison of mean Developmental Milestones Checklist (DMC III) scores between the intervention groups and the control group.
Score | Full package (n=307), mean (SD) | Control (n=199), mean (SD) | Limited package (n=297), mean (SD) | Control (n=199), mean (SD) | ||
Fine motor | 12.97 (4.80) | 11.41 (5.09) | <.001a | 12.59 (4.02) | 11.41 (5.03) | <.001a |
Gross motor | 26.55 (9.52) | 23.50 (10.60) | .56 | 27.95 (9.33) | 23.50 (10.60) | <.001a |
Language | 13.57 (8.20) | 13.68 (9.18) | .01a | 17.75 (7.91) | 13.68 (9.18) | <.001a |
Total DMC III score | 53.09 (20.02) | 48.59 (23.32) | <.001a | 58.29 (19.28) | 48.59 (23.32) | .002a |
aSignificant results at
Overall, there was no statistical difference in developmental milestones between those who received the full package and those that received the limited package (
Comparison of knowledge and mean Developmental Milestones Checklist (DMC III) scores between the full and limited package groups.
Score | Full package (n=307), mean (SD) | Limited package (n=297), mean (SD) | |
Knowledge | 9.02 (2.19) | 8.73 (2.22) | .048a |
Fine motor | 12.97 (4.80) | 12.59 (4.02) | .15 |
Gross motor | 26.55 (9.52) | 27.24 (9.44) | .97 |
Language | 13.57 (8.20) | 17.75 (7.91) | >.99 |
Total DMC III score | 53.09 (20.02) | 58.29 (19.28) | >.99 |
aSignificant results at
In this study, using an interactive text messaging service to provide information and support to adolescent mothers improved their knowledge on nurturing infant care and the developmental milestones of their children at 1 year of age. Adding psychosocial support groups did not have superior impact on maternal knowledge nor infant developmental milestones compared with the interactive text messaging alone.
Other studies have showed mixed findings on the impact of providing information and psychosocial support to mothers; most showed improvement in some but not all of the growth and developmental parameters of the children. A cluster intervention trial in Zambia evaluating home visits and parenting groups found an improvement in some anthropometric measures (stunting) as well as language but no effects on motor skills, cognitive, or socio-emotional development [
The findings of this study should be interpreted in consideration of some limitations. First, the study had a limited number of clusters. To minimize the likely effect on the type 1 error rate, the GEE model with a small-sample correction was performed. Due to reservations of community stakeholders on recruiting vulnerable adolescent mothers with no planned interventions, we were not able to recruit a control group at baseline. The control group was recruited during the end-line survey, in a different subcounty in the study county, among adolescent mothers with infants between the ages of 9-12 months (similar to the intervention groups at the end of follow-up). Therefore, uncontrolled differences between the intervention groups and the control group could have contributed, in part, to the observed differences in developmental outcomes. Studies with posttest-only controls also have a weakness in that they may not adequately measure the change brought about by maturation (threats to validity that happen over time during follow-up) or sensitization (the impact of the intervention groups being exposed to the survey at baseline) [
Our study also has several strengths. Our target population was a vulnerable segment of the female reproductive population, which is a leading contributor to maternal and infant morbidity as well as mortality. Since the lack of information on reproductive health among adolescents is a key causative factor, out study provides evidence on how such information and support can be availed efficiently to this vulnerable demographic. Second, other than the information itself, our implementation approach was to use currently available structures (mobile phones and community health strategy) to make available information and support to adolescent mothers. Only 5.8% (49/840) of eligible participants were excluded due to the lack of a reliable mobile phone. This can make scaling up both feasible and sustainable. The mHealth strategic framework and electronic community health information system by the Kenya Ministry of Health are some of the pathways through which our findings can be adopted into policy, to drive interventions targeted at adolescent mothers and their children.
In this study, an interactive text messaging platform among adolescent mothers in rural Kenya improved both the knowledge of mothers on infant nurturing care and the development milestones of their infants. These findings, if replicated in other studies in different settings, can provide a mechanism of improving the overall reproductive health of adolescents in LMICs. Although the addition of support groups in such interventions has been adopted before, we did not find any additional benefit in improving developmental outcomes. Therefore, an interactive mHealth solution could serve as a minimum intervention package among this vulnerable group to improve health outcomes.
CONSORT-eHEALTH checklist (V 1.6.1).
antenatal care
Developmental Milestones Checklist
generalized estimating equations
low- and middle-income country
mobile health
World Health Organization
We wish to thank the Homa Bay County Department of Health and the Field Epidemiology Society of Kenya team, for their support and facilitation during the conduction of this study.
This study was funded by Grand Challenges Canada, under the Saving Brains Initiative (grant SB-POC-1810-19773).
VM conceived and provided leadership in the execution of the study; IM led the monitoring and evaluation component; VO and VW performed the data processing, analysis, and reporting; and JO coordinated the study fieldwork. All the authors led and approved the final version of the manuscript.
None declared.