How to enhance adolescents’ autonomy and self-esteem. Cash and schooling help

Editor’s notes: Recent randomized trials of interventions including cash transfers to adolescent girls to encourage school attendance in South Africa have failed to show an effect on the incidence of HIV or pregnancy and had mixed effects on the incidence of HSV2.  However, these large trials both found that school attendance was rather high in the study populations possibly limiting the opportunities for making an impact on HIV.  McPhail et al. now report an interesting study that explores what the young women chose to spend their cash on; who controlled the cash and whether there were adverse consequences of giving cash to dependents rather than to the household or its head.  This is important because some studies elsewhere have suggested that such payments might upset the family dynamic and introduce tensions.  In this relatively poor South African setting (which is still considerably less poor than many other communities in neighbouring countries), the authors found minimal harms and many benefits.  Women used the money to express their autonomy and to build their status among their peers and community.  Money was not wasted on drugs and alcohol that might increase risks of HIV, although it was also not spent on condoms or family planning services (which are anyway provided to some extent at no cost in this community).  Although the HPTN 068 randomised trial in which the study was embedded did not show any impact on the primary and secondary biological endpoints (incidence of HIV, HSV2 and pregnancy), the benefits described in terms of adolescent development are important in their own right.  Cash transfers for people near the poverty line and keeping girls in school probably have many complex and important benefits beyond HIV prevention.

Improving school attendance and integrating reproductive health or HIV prevention into the curriculum feels as though it should be an essential part of HIV programming.  Yet, several large well-designed studies have failed to demonstrate significant effects on HIV incidence, pregnancy or other biological markers.  Hallfors et al. have examined one such negative trial in more detail.  They show that in the trial in Kenya where orphaned children were supported with uniforms, school fees and regular nurse visits, it appeared that the intervention did lead to a higher attendance at school.  However, this did not translate into differences in the biological markers chosen for the endpoints of the trial. The authors comment that “the association between school support and HIV/HSV-2 prevention appears to be weak or under-specified”.  However, as with the cash transfers, the benefits may be much broader than changes in the biological endpoints specified.  Furthermore, it is plausible that a stronger educational input may eventually translate into HIV-relevant outcomes beyond the timeframe of the study.  Trials in these areas are hard to design.  We do need to build a stronger case for the real impact on HIV of different aspects of schooling both in terms of quantity and of quality.  But that should not detract from the obvious benefits of investing in better education for all. 

 

Cash transfers for HIV prevention: what do young women spend it on? Mixed methods findings from HPTN 068.

MacPhail C, Khoza N, Selin A, Julien A, Twine R, Wagner RG, Goméz-Olivé X, Kahn K, Wang J, Pettifor A. BMC Public Health. 2017 Jul 11;18(1):10. doi: 10.1186/s12889-017-4513-3.

Background: Social grants have been found to have an impact on health and wellbeing in multiple settings. Who receives the grant, however, has been the subject of discussion with regards to how the money is spent and who benefits from the grant.

Methods: Using survey data from 1214 young women who were in the intervention arm and completed at least one annual visit in the HPTN 068 trial, and qualitative interview data from a subset of 38 participants, we examined spending of a cash transfer provided to young women conditioned on school attendance.

Results: We found that spending was largely determined and controlled by young women themselves and that the cash transfer was predominately spent on toiletries, clothing and school supplies. In interview data, young women discussed the significant role of cash transfers for adolescent identity, specifically with regard to independence from family and status within the peer network. There were almost no negative consequences from receiving the cash transfer.

Conclusions: We established that providing adolescents access to cash was not reported to be associated with social harms or negative consequences. Rather, spending of the cash facilitated appropriate adolescent developmental behaviours. The findings are encouraging at a time in which there is global interest in addressing the structural drivers of HIV risk, such as poverty, for young women.

Abstract [1]  Full-text [free] access  [2]

 

Process evaluation of a clinical trial to test school support as HIV prevention among orphaned adolescents in western Kenya.

Hallfors DD, Cho H, Hartman S, Mbai I, Ouma CA, Halpern CT. Prev Sci. 2017 Jul 21. doi: 10.1007/s11121-017-0827-8. [Epub ahead of print]

Orphaned adolescents are a large and vulnerable population in sub-Saharan Africa, at higher risk for HIV than non-orphans. Yet prevention of new infection is critical for adolescents since they are less likely than adults to enter and remain in treatment and are the only age group with rising AIDS death rates. We report process evaluation for a randomized controlled trial (RCT) testing support to stay in school (tuition, uniform, nurse visits) as an HIV prevention strategy for orphaned Kenyan adolescentsThe RCT found no intervention effect on HIV/HSV-2 biomarker outcomes. With process evaluation, we examined the extent to which intervention elements were implemented as intended among the intervention group (N = 412) over the 3-year study period (2012-2014), the implementation effects on school enrollment (0-9 terms), and whether more time in school impacted HIV/HSV-2. All analyses examined differences as a whole, and by gender. Findings indicate that school fees and uniforms were fully implemented in 94 and 96% of cases, respectively. On average, participants received 79% of the required nurse visits. Although better implementation of nurse visits predicted more terms in school, a number of terms did not predict the likelihood of HIV/HSV-2 infection. Attending boarding school also increased number of school terms, but reduced the odds of infection for boys only. Four previous RCTs have been conducted in sub-Saharan Africa, and only one found limited evidence of school impact on adolescent HIV/HSV-2 infection. Our findings add further indication that the association between school support and HIV/HSV-2 prevention appears to be weak or under-specified.

Abstract access [3] 

Africa [8]
Kenya [9], South Africa [10]
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