Ssewamala FM, Alicea S, Bannon WM Jr, Ismayilova L. A novel economic intervention to reduce HIV risks among school-going AIDS orphans in rural Uganda. J Adolesc Health 2008 Jan;42(1):102-4.
To test whether an intervention providing in-school, AIDS-orphaned adolescents with funds in a personal bank account and with counseling improves their attitudes about HIV prevention.
Cluster randomized trial.
Seven comparable primary schools in the Rakai district of southern Uganda.
96 AIDS-orphaned, school-going adolescents were randomly assigned, by school, to experimental (n=50) and comparison (n=46) conditions. Adolescents in the sample were primarily girls (70%) of an average age of 13.8 years.
All adolescents in the study received the usual care for AIDS orphans in Uganda, including peer counseling, health education, and scholastic materials. In the intervention arm, adolescents received a Child/Youth Development Account (CDA) and six 2-hour classes on career planning, career goals, microfinance, and financial well-being. The CDA was held under the adolescent's name in a bank and was funded by contributions from the adolescent's family members and friends, with 2:1 matching funds contributed by the intervention. The adolescent could use the CDA only to pay for educational expenses or to invest in family income-generating activities.
The primary outcome was change in HIV prevention attitudes and educational planning between baseline and 12 months post-intervention. Prior to delivery of the intervention and at 12 months post-intervention, a research assistant blind to study assignment obtained outcome data through 1-hour assessment interviews with each person. Questions in a six-item attitude scale on HIV prevention asked youths to rate opinions regarding HIV prevention behaviors on a four-point continuum, from strongly disagree to strongly agree. In addition, educational planning was measured via a single item in which adolescents were asked what their educational plans were after high school. Responses were dichotomized into no educational plan versus all other options.
Changes in mean scores from baseline to 12-month follow-up between experimental and control arms were compared using multivariate analysis of variance on each outcome variable, controlling for gender and age. Effect size was measured via partial eta-squared (a measure of the portion of variance attributable to a factor), in which small, medium, and large effects were operationalized as .01, .06, and .14, respectively.
Adolescents did not significantly differ in their baseline scores on attitudes about HIV prevention or educational plans. At 12-month follow-up, adolescents in the experimental arm had improved their HIV prevention attitude scores (from 17.2 to 18.5), whereas youth within the comparison group revealed decreased scores (from 18.5 to 17.6) (F (3, 79) = 3.9, p <.05, partial eta-squared = 0.1, 95% confidence interval (CI) of the difference = -.27 to -.01). The improvement in HIV prevention attitudes among experimental-arm adolescents with 0.1 partial eta-squared indicates an effect size between medium and large.
Experimental-arm adolescents reported a significant increase in educational plans (88% to 96%), whereas youth in the comparison condition evidenced a decrease (93% to 83%) (F (3, 78) = 4.4. p < .05, partial eta-squared = .07, 95% CI of the difference = -.02 to 2.5). The 0.07 partial eta-squared indicates a medium effect size.
Data on savings outcomes indicated that adolescents in the experimental arm saved an equivalent of U.S. $8.85 monthly. With a matching contribution rate of 2:1, the average participant accumulated U.S. $26.55 monthly or U.S. $318.60 per year. This was sufficient to cover a student's post-primary education for 2 years.
The authors conclude that AIDS-orphaned adolescents can benefit from a simple and feasible family economic intervention, as seen by the increased aspirations for the future shown by experimental-arm compared with control-group adolescents.
According to the Newcastle-Ottawa scale for assessing the quality of observational studies, this study was of poor quality. The study was limited by the small sample size, self-reported measures, a focus on school-going orphaned adolescents, and short follow-up. Adolescents were given money instead of earning money, which cannot be considered microfinance. More information on who gave adolescents money, how the money was used (school fees vs. family income-generating activities), and how much was saved versus spent over the 1 year period would strengthen the findings of the intervention. The use of attitudes toward HIV prevention and educational plans rather than actual sexual behavior and educational achievement greatly weakens the authors' conclusion that the adolescents benefited from the intervention.
Rather than targeting individual behavioral change, economic interventions such as this one may reduce the spread of HIV infection through improving lives and increasing level of education among adolescents. Using asset theory, the researchers hypothesized that economic incentives may lead adolescents to think and behave differently. Prior studies have illustrated the relationship between asset-ownership and adolescents' health and educational outcomes.(1,2,3)
Greater resources improve adolescents' expectations for the future and their well-being, leading to continued education and positive health behaviors. Economic interventions warrant further investigation in terms of cost/benefit, but with better behavioral outcome measures.
- Sherer RD Jr, Bronson JD, Teter CJ, et al. Microeconomic loans and health education to families in impoverished communities: implications for the HIV pandemic. J Int Assoc Physicians AIDSC Care 2004;3(4):110-4.
- Zhan M, Sherraden M. Assets, expectations, and children's educational achievement in female-headed households. Soc Serv Rev 2003June:191-211.
- Booysen F, Van Der Berg S. The role of social grants in mitigating the socio-economic impact of HIV/AIDS in two free state communities. S Afr J Econ 2005;73:545- 63.