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Do Savings Mediate Changes in Adolescents' Future Orientation and Health-Related Outcomes? Findings From Randomized Experiment in Uganda
Abstract and Figures
This present study tests the proposition that an economic strengthening intervention for families caring for AIDS-orphaned adolescents would positively affect adolescent future orientation and psychosocial outcomes through increased asset accumulation (in this case, by increasing family savings).
Using longitudinal data from the cluster-randomized experiment, we ran generalized estimating equation models with robust standard errors clustering on individual observations. To examine whether family savings mediate the effect of the intervention on adolescents' future orientation and psychosocial outcomes, analyses were conducted in three steps: (1) testing the effect of intervention on mediator; (2) testing the effect of mediator on outcomes, controlling for the intervention; and (3) testing the significance of mediating effect using Sobel-Goodman method. Asymmetric confidence intervals for mediated effect were obtained through bootstrapping-to address the assumption of normal distribution.
Results indicate that participation in a matched Child Savings Account (CSA) program improved adolescents' future orientation and psychosocial outcomes by reducing hopelessness, enhancing self-concept, and improving adolescents' confidence about their educational plans. However, the positive intervention effect on adolescent future orientation and psychosocial outcomes was not transmitted through saving. In other words, participation in the matched CSA program improved adolescent future orientation and psychosocial outcomes regardless of its impact on reported savings.
Further research is necessary to understand exactly how participation in economic strengthening interventions, for example, those that employ matched CSAs, shape adolescent future orientation and psychosocial outcomes: what, if not savings, transmits the treatment effect and how?
Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
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... Savings-led economic empowerment interventions (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25) have demonstrated to be efficacious in addressing the myriad of needs presented by children living in poverty-and AIDS-impacted communities in SSA, including improvement in mental health functioning (15,17,19,26). Economic empowerment interventions directly target family financial stability and investment in the protection of children via: (1) incentivized matched Child Development Accounts (CDAs), (2) financial literacy training (FLT) and income-generating activities (IGAs) for families, and (3) mentorship. ...
... For the proposed study, a CDA will be used, where savings are housed at a local bank and deposits made by the family are matched by the intervention to encourage savings. CDAs yield positive effects, including a greater sense of security, selfconfidence, and future orientation (15,16,19,74,76,77,80,140). CDAs also provide children and families with basic financial education, introduce them to formal financial institutions, and incentivize them to save small amounts by matching their deposits. ...
... The in-country project coordinator will monitor the matching operations. This protocol has been successfully used in Uganda in our prior work (15,16,73,76,77,80,145). ...
Background
Children in Sub-Saharan Africa are burdened by significant unmet mental health needs. Across the region, high rates of poverty, HIV/AIDS, food insecurity, stigma, and an inadequate health safety net system exacerbate serious child behavioral health needs and impede an effective response. Disruptive behavioral disorders are particularly concerning as they persist through adolescence and adulthood. Hence, addressing the context-specific social influences on child behavioral health is critical given that children in the region comprise more than half of the total regional population. Against this backdrop, this study protocol describes a randomized clinical trial that will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial, and context-specific drivers affect the mental health of children in Uganda.
Methods
The study uses an experimental, longitudinal design across 30 cluster-randomized primary schools to compare single and combination intervention options; influences of economic empowerment and family strengthening on economic, perceptual, and functioning mediators; and context-specific moderators. The study will be conducted with 900 Ugandan children in mid-upper primary school (10–14 years). The three study conditions ( n = 300 each) are: (1) economic empowerment only (EE only), (2) multiple family group-based family strengthening only (MFG-based FS only), and (3) combined EE + MFG-based FS. The interventions will be provided for 12 months; and assessments will occur at baseline, 12, 24, and 36 months.
Conclusion
Children in Sub-Saharan Africa are burdened by significant unmet mental health needs, including disruptive behavior disorders that persist through adolescence and adulthood if left untreated. The proposed study will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial and context-specific drivers affect the mental health of children in mid-upper primary schools in Uganda. Findings from this study can inform group, community, and population approaches that are needed for scalable solutions to address the social drivers negatively impacting child behavioral health in low-resource settings, including in Sub-Saharan Africa.
Clinical trial registration
[ https://clinicaltrials.gov/ ], identifier [NCT053 68714].
... M-Suubi comprises of three study conditions: (1) Bolstered usual care consisting of literature on ART adherence promotion and stigma reduction, (2) MFG for HIV stigma reduction plus FEE (MFG-HIVSR plus FEE), and (3) group-based HIV stigma reduction for educators (GED-HIVSR). The study is guided by the HIV stigma framework [64], asset theory [117,118], and family system theory [119,120] and has the following goals: ...
... This proposal is guided by the HIV stigma framework [64], asset theory [117,118], and family systems theory [119,120]. The HIV stigma framework [64] suggests that HIV stigma affects people living with HIV via three distinct mechanisms: stereotyping (cognitive), prejudice (affective), and discrimination (behavioral). ...
BACKGROUND
HIV stigma remains a formidable barrier to HIV treatment adherence among adolescents living with HIV (ALHIV), contributing to low rates of medication adherence, viral suppression, and high attrition from HIV care. ALHIV in schools have lower levels of HIV treatment adherence due to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support, and food insecurity. Thus, this paper presents a protocol for an evidence-informed multilevel intervention that will simultaneously address multiple family- and school-related barriers to HIV treatment adherence and care engagement among ALHIV attending boarding schools in Uganda.
OBJECTIVE
Aim 1: Examine the impact of M-Suubi on HIV viral suppression (primary outcome) and adherence to HIV treatment including keeping appointments, pharmacy refills, pill counts and retention in care Aim 2: Examine the effect of M-Suubi on HIV stigma (internalized, anticipated, and enacted), with secondary analyses to explore hypothesized mechanisms of change (e.g. depression) and intervention mediation; Aim 3: Assess the cost and cost-effectiveness of each intervention condition, and; Aim 4: Qualitatively examine: a) participants’ experiences with HIV stigma, HIV treatment adherence, and the intervention; and 2) educators’ attitudes towards ALHIV and experiences with GED-HIVSR, and program/policy implementation post-training.
METHODS
Study targets ALHIV aged 10 – 17 years and enrolled in a primary or secondary school with a boarding section. This longitudinal study will utilize a three-arm cluster randomized design across 42 HIV clinics in Southwestern Uganda. Participants will be randomized at clinic level to one of the 3 study conditions (n= 14 schools, n=280 students per study arm): 1) Bolstered usual care (BSOC) consisting of literature on ART adherence promotion and stigma reduction; 2) Group-based HIV stigma reduction for educators (GED-HIVSR); and 3) Multiple family groups for HIV stigma reduction plus family economic empowerment (MFG-HIVSR plus FEE) for ALHIV. For ALHIV randomized to treatment Arm 2 (i.e. MFG-HIVSR plus FEE and GED-HIVSR), we will include all the schools in the GED-HIVSR component, irrespective of the number of participants attending the school. M-Suubi will be provided for 20 months, with assessments at baseline, 12, 24, and 36 months.
RESULTS
The study is currently enrolling study participants.
CONCLUSIONS
Study findings will have important implications for HIV treatment adherence and engagement in care among ALHIV SSA. By targeting ALHIV, their caregivers, and educators, this multi-level study will generate evidence on effective intervention strategies for reducing stigma among HIV-infected and non-infected populations in Uganda and enable an ecological assessment of the cascading effects of multi-level HIV stigma reduction strategies. The study, currently recruiting study participants, would provide crucial evidence on effective and scalable strategies for addressing HIV stigma and improving HIV treatment outcomes among in-school ALHIV in resource-poor settings.
CLINICALTRIAL
NCT05307250
... Prior studies have examined the impact of economic empowerment on the psychosocial wellbeing of adolescents living with HIV in low resource communities heavily impacted by HIV/AIDS (Han et al., 2013;Kivumbi et al., 2019;Ssewamala et al., 2009). Yet, few studies have examined the potential mediators which help to explain the causal pathway between economic empowerment interventions and mental health improvements among adolescents (Karimli and Ssewamala, 2015;Karimli et al., 2019). Specifically, economic empowerment reduced child poverty, which in turn led to improved mental health outcomes. ...
... Participants in the control arm reviewed content related to HIV and ART as well as ART resistance and adherence. Moreover, an adapted version of the VUKA cartoon curriculum used in South Africa (Bhana et al., 2014) was incorporated into the Suubi + Maka curriculum used in Uganda (Nabunya et al., 2015;Karimli and Ssewamala, 2015) to further strengthen the Suubi + Adherence cartoon curriculum that was provided to all participants and their caregiving families. Both VUKA and Suubi + Maka curriculums are community collaborative developments of timed intervention that focuses on preventing HIV infection in adolescents through resiliency in HIV negative pre-adolescence youth (prior to first sexual debut) and their families. ...
Introduction
Many adolescents living with HIV in sub-Saharan Africa (SSA) experience poverty and have access to limited resources, which can impact HIV and mental health outcomes. Few studies have analyzed the impact of economic empowerment interventions on the psychosocial wellbeing of adolescents living with HIV in low resource communities, and this study aims to examine the mediating mechanism(s) that may explain the relationship between a family economic empowerment intervention (Suubi+Adherence) and mental health outcomes for adolescents (ages 10-16 at enrollment) living with HIV in Uganda.
Method
We utilized data from Suubi+Adherence, a large-scale six-year (2012-2018) longitudinal randomized controlled trial (N=702). Generalized structural equation models (GSEMs) were conducted to examine 6 potential mediators (HIV viral suppression, food security, family assets, and employment, HIV stigma, HIV status disclosure comfort level, and family cohesion) to determine those that may have driven the effects of the Suubi+Adherence intervention on adolescents’ mental health.
Results
Family assets and employment were the only statistically significant mediators during follow-up (β from -0.03 to -0.06), indicating that the intervention improved family assets and employment which, in turn, was associated with improved mental health. The proportion of the total effect mediated by family assets and employment was from 42.26% to 71.94%.
Conclusions
Given that mental health services provision is inadequate in SSA, effective interventions incorporating components related to family assets, employment, and financial stability are crucial to supporting the mental health needs of adolescents living with HIV in under-resourced countries like Uganda. Future research should work to develop the sustainability of such interventions to improve long-term mental health outcomes among this at-risk group.
... Therefore, if participants scored ≥19 on the CDI, and/or ≥9 on the BHS at the 48-month follow-up assessment, they were categorized as having the outcome, 'internalising symptoms' in the current analysis. Both the CDI and the BHS has been pre-tested and adapted for cultural appropriateness and used in past research among children and adolescents affected by HIV in Uganda as well as other sub-Saharan African countries (Han et al., 2013;Karimli, et al., 2015;Kivumbi et al., 2019;Ssewamala et al., 2012;Traube et al., 2010;Cavazos-Rehg et al., 2020). ...
To develop and externally validate a model to predict individualized risk of internalizing symptoms among AIDS-affected youths in low-resource settings in sub-Saharan Africa.
Longitudinal data from 558 Ugandan adolescents orphaned by AIDS was used to develop our predictive model. Least Absolute Shrinkage and Selection Operator logistic regression was used to select the best subset of predictors using 10-fold cross-validation. External validation of the final model was conducted in a sample of 372 adolescents living with HIV in Uganda.
Best predictors for internalizing symptoms were gender, family cohesion, social support, asset ownership, recent sexually transmitted infection (STI) diagnosis, physical health self-rating, and previous poor mental health; area under the curve (AUC) =72.2; 95% CI =67.9-76.5. For adolescents without history of internalizing symptoms, the AUC=69.0, 95% CI=63.4-74.6, and was best predicted by gender, drug use, social support, asset ownership, recent STI diagnosis, and physical health self-rating. Both models were well calibrated. External validation in adolescents living with HIV sample was similar, AUC=69.7; 95% CI=64.1-75.2.
The model predicted internalizing symptoms among African AIDS-affected youth reasonably well and showed good generalizability. The model offers opportunities for the design of public health interventions addressing poor mental health among youth affected by HIV/AIDS.
... Where the same intervention and outcomes were reported multiple times, only one paper was included in the analysis. There were six papers generated from the Bridges to Future Intervention in Uganda, [34][35][36][37][38][39] including one paper by Tozan et al, 39 which summarised all results from the previous papers, and thus was the only one included in the analysis. Two papers reported on Kenya's Cash Transfer Programme for Orphans and Vulnerable Children 40 41 and both reported the same outcomes in adolescents. ...
Introduction
Although cash transfer programmes are not explicitly designed to improve mental health, by reducing poverty and improving the life chances of children and young people, they may also improve their mental health. This systematic review and meta-analysis assessed the evidence on the effectiveness of cash transfers to improve the mental health of children and young people in low-income and middle-income countries.
Methods
We searched Pubmed, EBSCOhost, Scientific Electronic Library Online, ISI Web of Science and Social Sciences Citation Index and grey literature (from January 2000 to July 2020) for studies which quantitatively assessed the impact of cash transfers on mental health in young people (aged 0–24 years), using a design that incorporated a control group. We extracted Cohen’s d effects size and used a random-effects model for the meta-analysis on studies that measured depressive symptoms, I ² statistic and assessment of study quality.
Results
We identified 12 116 articles for screening, of which 12 were included in the systematic review (covering 13 interventions) and seven in the meta-analysis assessing impact on depressive symptoms specifically. There was high heterogeneity (I ² =95.2) and a high risk of bias (0.38, 95% CIs: −5.08 to 5.85; p=0.86) across studies. Eleven interventions (85%) showed a significant positive impact of cash transfers on at least one mental health outcome in children and young people. However, no study found a positive effect on all mental health outcomes examined, and the meta-analysis showed no impact of cash transfers on depressive symptoms (0.02, 95% CIs: −0.19 to 0.23; p=0.85).
Conclusion
Cash transfers may have positive effects on some mental health outcomes for young people, with no negative effects identified. However, there is high heterogeneity across studies, with some interventions showing no effects. Our review highlights how the effect of cash transfers may vary by social and economic context, culture, design, conditionality and mental health outcome.
... We utilized three indicators of mental health functioning (hopelessness, depression, and self-concept), as the main independent variables, to better understand how they affect ALWHIV's HIV knowledge and HIV prevention attitudes at 12-month follow-up. These measures have been tested, validated, and adapted for cultural appropriateness among children and adolescents in Uganda [23][24][25][26]. ...
We assessed the effect of depression, hopelessness, and self-concept on HIV prevention attitudes and knowledge about infection, transmission and sexual risk behavior among adolescents living with HIV in Uganda. Utilizing longitudinal data from 635 adolescents living with HIV, multiple ordinary least square regression was used to evaluate associations between the three indicators of mental health functioning at baseline and HIV knowledge and prevention attitudes at 12-months follow-up. We found that depression (β = − 0.17; 95% CI − 0.31, − 0.04) and hopelessness (β = − 0.16; 95% CI − 0.28, − 0.04) scores at baseline were associated with a 0.17 and 0.16 average reduction in HIV prevention attitudes and HIV knowledge scores, respectively at 12-months follow-up. However, self-concept was not significantly associated with HIV knowledge or prevention attitudes. Adolescents living with HIV with greater levels of hopelessness are at increased risk of having limited HIV knowledge while those with greater symptoms of depression had less favorable HIV prevention attitudes.
... Adolescents affected by AIDS experience even more severe mental health problems than other at-risk groups (24)(25)(26). Studies of AIDS-affected Ugandan adolescents living in poverty show high rates of depression (26)(27)(28), anxiety, learning problems (29,30), and risky sexual behaviors (31,32). Compounded by poverty, the lack of self-esteem and hope for the future can influence sexual risk taking and increase HIV risk. ...
Background: Uganda has one of the highest HIV/AIDS rates and poor mental health services. Children and adolescents in communities with persistent poverty, disease (including HIV/AIDS), and violence, are more likely to suffer from chronic mental health problems. Combined, these characteristics negatively impact communities' response to HIV and mental health beginning with children, adolescents, and young adults. Yet, there is limited research capacity in child and adolescent mental health (CAMH), especially in the HIV/AIDS context in Uganda. Hence, this NIH-funded research training program aims to: (1) train three cohorts of early-career investigators at universities or research institutions in Uganda; (2) connect fellows with committed mentors; and (3) define key factors for successful mentorship and training of new investigators.
Methods: CHILD-GRF is a multi-component program that engages selected young investigators in year-round activities for 3 years. Paired with mentors from Washington University in St. Louis and academic institutions in Uganda, fellows participate in a 6-week intensive summer training each year. Year 1 focuses on didactic learning and mentorship. In Year 2, fellows design and conduct their pilot study. Year 3 is devoted to presenting pilot study findings, manuscript preparation/ submission and extramural grant writing.
Discussion: CHILD-GRF seeks to provide a solid foundation for the development and implementation of evidence-based HIV prevention and mental health interventions for youth and families impacted by HIV/AIDS. By producing a sustainable network of well-trained individuals in key research institutions, this program contributes to improving CAMH and HIV prevention efforts, both of which have public health implications.
Background
HIV stigma remains a formidable barrier to HIV treatment adherence among school-attending adolescents living with HIV, owing to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support, and food insecurity. Thus, this protocol paper presents an evidence-informed multilevel intervention that will simultaneously address family- and school-related barriers to HIV treatment adherence and care engagement among adolescents living with HIV attending boarding schools in Uganda.
Objective
The proposed intervention—Multilevel Suubi (MSuubi)—has the following objectives: examine the impact of M-Suubi on HIV viral suppression (primary outcome) and adherence to HIV treatment, including keeping appointments, pharmacy refills, pill counts, and retention in care; examine the effect of M-Suubi on HIV stigma (internalized, anticipated, and enacted), with secondary analyses to explore hypothesized mechanisms of change (eg, depression) and intervention mediation; assess the cost and cost-effectiveness of each intervention condition; and qualitatively examine participants’ experiences with HIV stigma, HIV treatment adherence, and intervention and educators’ attitudes toward adolescents living with HIV and experiences with group-based HIV stigma reduction for educators, and program or policy implementation after training.
Methods
MSuubi is a 5-year multilevel mixed methods randomized controlled trial targeting adolescents living with HIV aged 10 to 17 years enrolled in a primary or secondary school with a boarding section. This longitudinal study will use a 3-arm cluster randomized design across 42 HIV clinics in southwestern Uganda. Participants will be randomized at the clinic level to 1 of the 3 study conditions (n=14 schools; n=280 students per study arm). These include the bolstered usual care (consisting of the literature on antiretroviral therapy adherence promotion and stigma reduction), multiple family groups for HIV stigma reduction plus family economic empowerment (MFG-HIVSR plus FEE), and Group-based HIV stigma reduction for educators (GED-HIVSR). Adolescents randomized to the GED-HIVSR treatment arm will also receive the MFG-HIVSR plus FEE treatment. MSuubi will be provided for 20 months, with assessments at baseline and 12, 24, and 36 months.
Results
This study was funded in September 2021. Participant screening and recruitment began in April 2022, with 158 dyads enrolled as of May 2022. Dissemination of the main study findings is anticipated in 2025.
Conclusions
MSuubi will assess the effects of a combined intervention (family-based economic empowerment, financial literacy education, and school-based HIV stigma) on HIV stigma among adolescents living with HIV in Uganda. The results will expand our understanding of effective intervention strategies for reducing stigma among HIV-infected and noninfected populations in Uganda and improving HIV treatment outcomes among adolescents living with HIV in sub-Saharan Africa.
Trial Registration
ClinicalTrials.gov NCT05307250; https://clinicaltrials.gov/ct2/show/NCT05307250
International Registered Report Identifier (IRRID)
PRR1-10.2196/40101
Few efforts in sub-Saharan Africa (SSA) have explored interventions capable of targeting the root causes and consequences of persistent poverty, violence, and co-occurring mental health problems, particularly depression and trauma. In addition, few studies aimed at enhancing mental health functioning of communities and families have addressed critical, culturally congruent, and scientifically documented risk factors of persistent family poverty, community violence, and impact of HIV/AIDS. Most investigators in SSA target their intervention studies primarily on personal/individual trait models, emphasizing generic psychosocial counseling. Such interventions often fall short of fielding and testing contextually grounded, multidisciplinary, combined approaches necessary to break the vicious cycle of persistent poverty, community violence, HIV risk, and co-occurring mental health problems that affect children, adolescents, and their families. Moreover, it is critical that mental health and HIV prevention interventions in SSA countries are guided by contextually relevant methods and conceptual models developed and tested in SSA. This chapter discusses the importance of combination interventions and research studies targeted at examining their impact in addressing persistent poverty, co-occurring mental health problems, and HIV infection in the SSA region as an important step in this direction.
Educational success of immigrant youths in young adulthood, e.g. college graduation, signifies them a milestone of upward mobility (Rumbaed, 2005, p.1043). In this study, I employed a representative sample of 3344 immigrant youths from the Children of Immigrants Longitudinal Study (CILS) and investigated how individual and school-level academic aspirations of immigrant youths in early adolescence (Mage=14) contributed to their successful college graduation in young adulthood (Mage=24) through their development of academic aspiration in late adolescence (Mage= 17). Results found that, even accounting for structural factors proposed by the conventional assimilation perspective and segmented assimilation theory and pertinent background covariates at individual and school levels, development of immigrant youths’ individual- and school-level academic aspirations during adolescence significantly predicted their successful college graduation in young adulthood.
Time perspective, as defined by Lewin (Time perspective and morale. In: Watson G (ed) Civilian morale. Houghton Mifflin, Boston, pp 48–70, 1942a, Time perspective and morale. In: Lewin GW (ed) Resolving social conflicts. Houghton Mifflin, Boston, pp 103–124, 1942b) is deeply rooted in the social contexts individuals live in. When facing poverty, social exclusion or socioeconomic insecurity, people are prone to psychologically leave out the future, and to restrain their time perspective to present or past. Drawing from the Lewin’s field theory, this chapter reviews research findings on the influence of socioeconomic status on time perspective, and present original findings showing that time perspective acts as an intervening factor in the relation between socioeconomic status and a wide range of behavioral or psychological consequences. The shrinking of the temporal dimension of the psychological field when facing danger and uncertainty is an avenue for a better understanding of how people deal with crisis situations and the risk society. We claim for a better consideration of psychological time in policy making and collective action against poverty.
A Monte Carlo study compared 14 methods to test the statistical significance of the intervening variable effect. An intervening variable (mediator) transmits the effect of an independent variable to a dependent variable. The commonly used R. M. Baron and D. A. Kenny (1986) approach has low statistical power. Two methods based on the distribution of the product and 2 difference-in-coefficients methods have the most accurate Type I error rates and greatest statistical power except in 1 important case in which Type I error rates are too high. The best balance of Type I error and statistical power across all cases is the test of the joint significance of the two effects comprising the intervening variable effect.
This study examines variations in saving behavior among poor families enrolled in a Child Savings Account program for orphaned and vulnerable school-going children in Uganda. We employ multilevel analyses using longitudinal data from a cluster-randomized experimental design. Our analyses reveal the following significant results: (1) given the average number of months during which the account was open (18 months), families saved on average, USD 54.72, which, after being matched by the program (2:1 match rate) comes to USD 164.16—enough to cover approximately five academic terms of post-primary education; (2) children’s saving behavior was not associated with quality of family relations; it was, however, significantly associated with family financial socialization; (3) family demographics were significantly associated with children’s saving behavior in the matched Child Savings Account program; and (4) children enrolled in some schools saved better compared to children enrolled in other schools within the same treatment group
