The inspiring work that the Institute for Life Course Health Research (ILCHR) do in communities resonates with the vision of the of Stellenbosch University's Faculty of Medicine and Health Sciences (FMHS) to enhance health and health equity with and for the communities we serve.
With this message, Mr Eben Mouton, FMHS Senior Director: Business Manager welcomed the ILCHR to its new home in the Department of Global Health at the institute's official launch in the FMHS.
The ILCHR, led by Prof Mark Tomlinson and Dr Sarah Skeen, is a transdisciplinary entity that conducts research into infant, child, adolescent, maternal and family wellbeing, health and development in low resource communities.
“We are interested in testing solutions and doing three things," Tomlinson said at the launch. “We want to develop cutting edge research evidence that prioritises the wellbeing of children, families and people across the life course; work with communities to develop interventions; and to share the knowledge that we generate."
“Underlying all of this is a commitment to being part of the solution to the deep and profound inequality that exists," Tomlinson said.
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. Said 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 explained. “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," said 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," said 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 a 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", said 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," said 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 explained.
Banner photo caption: Prof Mark Tomlinson and Dr Sarah Skeen.
Insert caption: Prof Mark Tomlinson, Marguerite Marlow, Vuyolwethu Notholi, Dr Sarah Skeen, Zena Jacobs, Zanele Siqabatiso and Jackie Stewart.
Photo credit: Stefan Els and Wilma Stassen