Han CK, Ssewamala FM, Wang JS. Family economic empowerment and mental health among AIDS-affected children living in AIDS-impacted communities: evidence from a randomised evaluation in southwestern Uganda. J Epidemiol Community Health. 2013 Mar;67(3):225-30.
To determine whether a family economic empowerment intervention could improve mental health in children affected by HIV/AIDS.
Ten semi-urban public primary schools in two districts of Uganda with high HIV prevalence.
Children aged 12-14, one or more of whose parents had died of AIDS.
Feelings of hopelessness (Beck Hopelessness Scale(1)); depression (Child Depression Inventory(2)).
Ten academically-comparable public primary schools in the Masaka and Rakai districts of Uganda were selected. Five schools were randomly assigned to the intervention condition and five to usual care. All children at each school were assigned to the same condition (even if their parents had not died). The Suubi-Maka ("Hope for Families") intervention's goal was to create economic opportunities for poor families caring for AIDS-orphans. Key components were to promote monetary savings for educational opportunities, conduct financial management workshops and organize family-level income generating projects, and provide adult mentors for children. In addition to usual care, children in the intervention schools received matched child savings accounts, career planning and financial management training sessions, and regular meetings with a mentor. Usual care was comprised of counseling and mentorship, provision of school lunches and provision of school uniforms and other school supplies. Hopelessness was measured with the 20-item Beck Hopelessness Scale, which has true/false responses to questions designed to ascertain feelings of hopelessness. Depression was measured with the 27-item Child Depression Inventory, which has three response categories corresponding to "occasionally," "often" and "always." In both instruments, items with positive wording are reverse-coded to create a summary score. Higher scores indicate higher levels of hopelessness. Covariates in the analysis included child's age and gender, guardian's age and gender, number of years child had lived with current guardian, household size, whether one or both parents had died, quality of family relations and child's physical health.
The five intervention schools included 179 children. Schools receiving usual care included 118 children. The mean age of all children at baseline was 13.4 years. The mean age of primary guardians was 46.3 years. Sixty-five percent of children were female, as were 79% of guardians. The mean duration of time that children had lived with current guardians was 9.7 years. The mean household size was 6.4. Seventy-three percent of children had lost one parent, and 27% of children had lost both parents. Seventy percent of children reported being in good or excellent health. The quality of family relations overall was reported to be good.
There were no significant differences between the groups in regard to child's age, gender, physical health, guardian's gender, duration of time with current guardian, household size, or quality of family relations. Children in usual care tended to have slightly older guardians (mean age of 50 vs. mean age of 44) and to have lost both parents (34% vs. 23%). There were no significant differences between the groups in regard to baseline scores on hopelessness and depression.
After 12 months of the intervention, children in the intervention schools had significantly lower hopelessness scores, decreasing from a mean of 5.59 (standard deviation [SD] 3.10) at baseline to 3.28 (SD 2.57). Children in the schools receiving usual care also had lower hopelessness scores, decreasing from a mean 5.31 (SD 2.96) to a mean 4.27 (SD 2.89), but there was a significant difference between changes in the two groups (p=0.001). Similarly, depression scores decreased in both study arms, though the reduction was proportionately smaller in children attending schools that received usual care. Children in intervention schools scored 13.06 (SD 5.30) at baseline, and at 12 months scored 8.42 (SD 4.96), while children in usual care schools scored 13.24 (SD 6.01) at baseline, and at 12 months scored 10.58 (SD 5.60). In both groups, girls tended to report higher levels of hopelessness than boys (beta coefficient [β]=0.75, standard error [SE] 0.34, p<0.05). The child's gender was not significantly associated with depression, but children with female guardians tended to report higher levels of depression (β=1.27, SE 0.76, p<0.10).
The authors conclude that family economic empowerment interventions may be efficacious in reducing hopelessness and depression in AIDS-affected children living in resource-poor communities.
The overall risk of bias in this trial is moderate to high. The process used in selecting and randomizing the schools is not described. The trial was not blinded and allocation was not concealed. All outcomes were by self-report, and there is a risk of social desirability bias. There may also be a risk of selective outcome reporting. Although the paper reports that mental health outcomes were the primary outcomes, the trial's registration documents(3) report that economic, educational and behavioral outcomes were primary, while mental health outcomes were secondary. No economic, educational or behavioral outcomes are reported in this paper. Further, the registration documents specify that 20 schools would be randomized, while results from only 10 schools are reported in this paper. Subsequent papers may clarify these aspects of the trial.
Children who have lost parents to HIV-associated illnesses are more likely to report symptoms of depression, anxiety and post-traumatic stress disorder than non-orphans and children orphaned by other causes.(4, 5) Feelings of hopelessness and depression are a factor in children and adolescents engaging in sexual risk behavior and substance abuse, as well as feeling suicidal.(6, 7, 8, 9, 10, 11) A previous trial conducted by these investigators found evidence that an economic empowerment intervention significantly improved self-reported physical and mental health in Ugandan adolescents orphaned by AIDS.(12) An important limitation of the current trial is that it was conducted in AIDS-affected orphans attending school and living with an adult care-giver. This may limit the trial's generalizability to children not in school, or living in child-headed households.
Results from this study are promising, but additional research is still needed, especially in children out of school or living in households headed by children. Researchers may wish to emulate this intervention or develop new economic interventions. Policy makers may wish to consider funding proposals of such interventions.
- Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol. 1974 Dec;42(6):861-5.
- Helsel WJ, Matson JL. The assessment of depression in children: the internal structure of the Child Depression Inventory (CDI). Behav Res Ther. 1984;22(3):289-98.
- ClinicalTrials.gov. "Economic Empowerment Program Suubi-Maka." Registration number NCT01180114. [accessed 22 February 2013]
- Cluver L, Gardner F. The mental health of children orphaned by AIDS: a review of international and southern African research. J Child Adolesc Ment Health 2007;19:1e17
- Cluver LD, Orkin M, Gardner F, Boyes ME. Persisting mental health problems among AIDS-orphaned children in South Africa. J Child Psychol Psychiatry. 2012 Apr;53(4):363-70.
- Bolland JM. Hopelessness and risk behaviour among adolescents living in high-poverty inner-city neighborhoods. J Adolesc 2003;26:145e58.
- Beck AT, Steer RA, Beck JS, et al. Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. Suicide Life Threat Behav 1993;23:139e45.
- Becker-Weidman EG, Reinecke MA, Jacobs RH, et al. Predictors of hopelessness among clinically depressed youth. Behav Cogn Psychother 2009;37:267e91.
- Dori GA, Overholser JC. Depression, hopelessness, and self-esteem: accounting for suicidality in adolescent psychiatric inpatients. Suicide Life Threat Behav 1999;29:309e18.
- Perez-Smith A, Spirito A, Boergers J. Neighborhood predictors of hopelessness among adolescent suicide attempters: preliminary investigation. Suicide Life Threat Behav 2002;32:139e45.
- Thompson EA, Mazza JJ, Herting JR, et al. The mediating roles of anxiety, depression, and hopelessness on adolescent suicidal behaviors. Suicide Life Threat Behav 2005;35:14e34.
- Ssewamala FM, Han CK, Neilands TB. Asset ownership and health and mental health functioning among AIDS-orphaned adolescents: findings from a randomized clinical trial in rural Uganda. Soc Sci Med 2009;69:191e8.