Well-care visit attendance among children of adolescent mothers in South Africa: a theory-informed mixed-methods study

Background
WHO recommend that children and adolescents attend scheduled well-care visits for health promotion, prevention, early detection, identification and management of disability and disease. Children born to adolescent mothers experience a disproportionate burden of poor health outcomes, but their well-care attendance is under-researched.
Methods
Cross-sectional data were used from a cohort of adolescent and young mothers (10-24 years; n = 1040) and their children (n = 1145) recruited through purposive, convenience-based sampling across healthcare facilities and community-based settings in Eastern Cape, South Africa (2017-2019). Quantitative data on visit attendance up to 18 months were analysed using descriptive statistics for children of adolescent mothers (10-19 years) aged >= 19 months at data collection, to allow complete observation of visits. In 2022, semi-structured interviews (n = 16) were conducted until saturation, to explore factors influencing attendance. Themes were developed and matched to the capability, opportunity and motivation model of behaviour (COM-B) and Theoretical Domains Framework using a realist thematic template analysis approach.
Results
Records were available for 415/482 eligible children. Attendance declined from 85.1% (95%CI: 81.3-88.4) at 6 weeks to 49.7% (95%CI: 46.6-56.5%) at 18 months, with higher attendance during visits coinciding with the childhood immunisation schedule. Attendance and qualitative findings were similar by maternal HIV status. Themes were matched to the COM-B. Capability: mothers' organisational and financial acumen facilitated their child's attendance; mothers persisted in attending despite harsh attitudes from healthcare workers. Opportunity: financial and kinship support and information in the child health booklet facilitated visit attendance; lack of childcare support, poor weather, cost and distance to clinic interfered with attendance. Motivation: mothers were motivated to attend visits to gain knowledge and fulfil their parental role.
Conclusion
This study identified missed opportunities for promoting life-course health and well-being among children and their adolescent mothers, and theory-informed opportunities to support well-care visit attendance. Findings challenge deficit-based narratives highlighting mothers' motivations and strategies for ensuring attendance. Enhancing the quality of nurse-adolescent mother interactions may increase the perceived and actual value of visits and support attendance. Further research is needed on interventions to promote consistent attendance, address barriers to access and identify opportunities to strengthen integration of well-care and HIV-related services.