Economic Empowerment Intervention Research Articles

Improving Quality of Life Among Latina Intimate Partner Violence Survivors Through Economic Empowerment.

This study examined the relationship between (1) quality of life and forms of intimate partner violence (IPV) (i.e., psychological abuse, physical violence, sexual violence, and types of economic abuse), and (2) quality of life and economic empowerment among Latina IPV survivors. The authors used data from the Moving Ahead financial literacy program evaluation (n = 200). Nested random-effects models were conducted. Findings indicated that psychological abuse and economic control were significantly and negatively associated with quality of life. Economic empowerment (i.e., financial knowledge, economic self-efficacy, and economic self-sufficiency) was significantly and positively related to Latinas' quality of life. Financial strain was inversely associated with Latina's quality of life. These findings highlight the importance of identifying strategies for increasing the overall well-being of Latina IPV survivors. Economic empowerment interventions can be an effective mechanism for improving their quality of life. As such, domestic violence organizations should include economic empowerment as part of the services offered to survivors.

Women’s financial well‐being: A systematic literature review and directions for future research

AbstractThe study of financial well‐being has gained attention in recent years and a number of scholarly articles have pointed to gender‐related differences and their antecedents and consequents. The continuous growth of scholarly literature on women’s financial well‐being and its dispersion impose difficulties for researchers to comprehensively assess the state of knowledge on the topic. In this context, the objectives of this research are to conduct a systematic literature review of women’s financial well‐being and to propose directions for future research. This study comprises a review of 130 articles published in peer‐reviewed journals over the period 1990–2020. Bibliometric analysis was used to identify the year of publication and the countries surveyed, journal of publication, methodologies, concepts, measures and theoretical frameworks utilized; subsequent content analysis allowed us to summarize the main findings. We organized the identified antecedents of women’s financial well‐being into three categories: individual, household and community and societal level elements. The elements that constitute these categories are discussed and our findings point to important gender‐related differences. Based on the identified literature gaps, directions for future research are proposed. The theoretical contribution of this study lies in delivering a comprehensive overview of available evidence on women’s financial well‐being. Its practical and societal implications include the provision of knowledge that may allow better targeting of financial education programmes, economic empowerment interventions and public policies, which may help reduce the financial well‐being gender gap.

A Latent Class Analysis of Gender Attitudes and Their Associations with Intimate Partner Violence and Mental Health in the Democratic Republic of Congo.

Gender role attitudes, views held by individuals regarding the roles men and women should play in society, are a powerful social determinant of health. However, work remains in elucidating the associations between gender attitudes and intimate partner violence (IPV) perpetration or victimization and mental health problems. We used latent class analysis to classify patterns of responses on survey items on gender attitudes by male and female adults in households that participated in an economic empowerment intervention and evaluation in rural villages in the Democratic Republic of Congo. Attitudes about IPV and gender equality were two subdomains to emerge from analysis and a 3-class model solution was found to best fit response patterns. Results indicated that, as compared to the least gender equitable class, individuals in the moderately gender equitable and fully gender equitable classes had lower odds of having experienced or perpetrated psychological abuse. Individuals within the moderately gender equitable class were at lower odds of having experienced or perpetrated physical or sexual violence. Further, individuals in the moderately gender equitable and fully gender equitable classes had significantly lower mean scores on symptoms associated with PTSD than individuals in the least gender equitable class. Future research should explore the relationships between gender attitudes, partner violence and mental health to build resilient families.

Family Economic Empowerment, Family Social Support, and Sexual Risk-Taking Behaviors Among Adolescents Living With HIV in Uganda: The Suubi+Adherence Study

PurposeThis study examined the effect of a family economic empowerment (EE) intervention and family support on sexual risk-taking behaviors among adolescents living with HIV in rural Uganda. MethodsWe used data from the Suubi + Adherence study, a longitudinal cluster randomized clinical trial of 702 adolescents living with HIV aged 10–16 years. Participants were randomly assigned to either the control arm (n = 358) receiving bolstered standard of care or a treatment arm (n = 344) receiving bolstered standard of care plus the family EE intervention. We used mixed-effects models to examine the effect of the EE intervention and family support on sexual risk-taking behaviors at the baseline, 12 months, and 24 months after intervention initiation. ResultsAdolescents in both the intervention and control groups did not differ significantly in their sexual risk-taking attitudes at the baseline and over the 24-month follow-up period. Higher levels of caregiver social support were significantly associated with a decrease in attitudes toward sexual risk-taking (ß = −.40, 95%CI = −.51, −.29). More frequent parent-child communication was significantly associated with increased negative sexual risk-taking attitudes (ß = .21, 95%CI = .16, .26). ConclusionsAlthough we find no direct relationship between family EE and attitudes related to sexual risk-taking behaviors, we find that a supportive family environment can promote positive attitudes related to sexual risk-taking behaviors. The effectiveness of sexual risk reduction interventions would be enhanced by engaging families and strengthening supportive relationships between adolescents and their caregivers.

Relative Risk of Intimate Partner Violence According to Access to Instrumental Social Support Among Pregnant Women in Eswatini Whose Partners Do and Do Not Drink Alcohol.

Intimate partner violence (IPV) affects one in three women around the world and is the tenth leading cause of death for women in Africa aged 15 to 29 years. Partner alcohol use, access to social support, and poverty all affect women's likelihood of experiencing violence. We sought to understand how partner alcohol use differentially affected the hypothesized association between a protective role of instrumental social support (in the form of food or financial loans) against IPV for a clinic-based sample of women in the Kingdom of Eswatini (formerly known as Swaziland). We use cross-sectional data from a parent study of women recruited from urban and rural antenatal clinics in Eswatini (n = 393) to calculate the association between experiencing IPV and perception of one's ability access to large cash loans, small cash loans, and food loans-both for the full sample and stratified by partner alcohol use. In fully adjusted models, the perception that one could access loans of food or money was associated with decreased relative risk of IPV for all women. These associations were modified by partner alcohol use. Access to instrumental support (loans of food or money) is associated with decreased risk of IPV, but this association varies according to the type of loan and whether or not a woman's partner drinks alcohol. Economic empowerment interventions to reduce IPV must be carefully tailored to ensure they are appropriate for a woman's specific individual, relationship, and community context.

Suubi+Adherence-Round 2: A study protocol to examine the longitudinal HIV treatment adherence among youth living with HIV transitioning into young adulthood in Southern Uganda

BackgroundYouth living with HIV (YLHIV) in Sub-Saharan African (SSA) are less likely to adhere to antiretroviral therapy (ART) and other health-related regimens. As a consequence, YLHIV are not only at risk for health problems and mental health comorbidities, but are also at risk for cognitive deficits, including in areas of memory and executive functioning. The Suubi+Adherence study followed 702 adolescents (10-16 years of age) receiving bolstered standard of care and a family economic empowerment intervention comprising an incentivized youth financial savings account (YSA) augmented with financial literacy training (FLT) and peer mentorship. The study findings pointed to superior short-term viral suppression and positive adolescent health and mental health functioning among participants receiving the intervention. The original group of adolescents who received Suubi+Adherence are now transitioning into young adulthood. This paper presents a protocol for the follow-up phase titled Suubi+Adherence Round 2.MethodsThe original cohort in Suubi+Adherence will be tracked for an additional five years (2020-2025). Specifically, the long term follow-up will allow to: 1) ascertain the extent to which the short term outcomes identified in the first 6 years of the intervention are maintained as the same group transitions through young adulthood; and 2) address new scientific questions regarding ART adherence; HIV care engagement; protective health behaviors; and the potential of FEE to mitigate the development of HIV-associated neurocognitive disorders in YLHIV. Additionally, the team examines the potential mechanisms through which the observed long-term outcomes happen. Moreover, the Suubi+Adherence-Round 2 adds a qualitative component and extends the cost effectiveness component.DiscussionGuided by asset and human development theories, Suubi+Adherence-R2 will build on the recently concluded Suubi+Adherence study to conduct one of the largest and longest running studies of YLHIV in SSA as they transition into young adulthood. The study will address new scientific questions regarding long-term ART adherence, HIV care engagement, protective health behaviors, and the potential of FEE to mitigate the development of HIV-associated neurocognitive disorders in YLHIV. The findings may inform efforts to improve HIV care among Uganda’s YLHIV, with potential replicability in other low-resource countries.Trial registrationClinicalTrials.gov, ID: NCT01790373

Developing a framework for cash transfer programs that foster sustained economic empowerment to reduce sexual risk among adolescent girls and young women: a qualitative study

BackgroundTransactional sexual relationships contribute to a high incidence of HIV infection among adolescent girls and young women (AGYW) living in low-resource settings. Cash transfers (CT) are a structural approach to reduce sexual risk behaviors, but their positive economic effects frequently fade after the program ends. We aimed to understand AGYW’s decision-making processes related to sexual, relationship, and financial decisions, in order to design a framework for a CT program that could lead to long-term financial independence and reduced transactional sex among AGYW.MethodsWe conducted qualitative research with AGYW participating in a CT program in Tanzania. Phase one was formative research to understand the context and experiences of AGYW regarding sexual behavior, relationships, and finances. Participants included 36 AGYW (15–23 years old), 15 influencers of AGYW (mothers and male partners) and 10 financially empowered women (FEW – women aged 20–30 with a sustained, reliable source of income independent of their partner). Decisions and decision-making contexts of AGYW that we identified in phase one informed the content of phase two. In phase two we simulated scenarios for decision-making and economic goals with 80 AGYW and 40 FEW, in order to identify key principles or intervention opportunities to guide development of a CT program framework.ResultsThrough phases one and two of our research we identified three key themes in AGYW’s vision of their desired future economic state: 1) positive social image, 2) power balance and respect, and 3) emotional and economic security. An important theme distinguishing AGYW from FEW was that AGYW lacked a vision to build self-agency.ConclusionsOur findings suggest that providing economic resources to AGYW through CT without ensuring self-agency is unlikely to be an effective long-term intervention for economic empowerment. Using these findings we developed a framework for CT programs with three key pillars for developing self-agency: 1) emotional efficacy, to increase AGYW’s perception of rewards associated with developing self-agency; 2) social efficacy, to build constructive relationships and exit negative relationships that inhibit self-agency, and 3) economic efficacy, to help AGYW build a resilient stream of financial resources.

Prep Acceptability and Initiation Among Women Engaged in Sex Work in Uganda: Implications for HIV Prevention

Background and Purpose: Women engaged in sex work (WESW) are disproportionately affected by HIV. In Uganda, HIV prevalence among WESW is estimated at 37%, accounting for 18% of all new infections in the country. WESW experience poverty, gender-based violence, and other issues that reduce their power and limit their ability to negotiate condom use. Female-controlled strategies, including pre-exposure prophylaxis (PrEP), may afford women more transmission protection, but barriers to access and use persist. This study examined baseline PrEP acceptability and initiation among WESW recently enrolled in a randomized clinical trial in Uganda to test the impact of a combination HIV risk reduction and economic empowerment intervention on sexual risk outcomes (clinicaltrials.gov, NCT03583541). Methods: A total of 542 WESW from 19 high HIV-prevalent geographical areas were enrolled in the Kyaterekera study between June 2019 and March 2020. Women were eligible for the study if they: 1) were age 18 or over; 2) reported engagement in transactional sex (a sex act in exchange for pay) in the past 30 days; and 3) reported engagement in one or more episodes of unprotected sex in the past 30 days. Women completed a baseline assessment, were tested for HIV and other sexually transmitted infections (STIs) at enrollment, and were connected with antiretroviral therapy (ART), STI treatment, or PrEP, based on need and interest. Descriptive statistics examined baseline data on PrEP acceptability and initiation. Independent variables (i.e. years in sex work, recent sexual coercion, perceived HIV and sex work stigmas, harmful alcohol use, barriers to medical care, and social support) were derived from the empirical literature and women’s self-report. Bivariate analysis was performed to test associations between main effects of these variables. Using binomial logistic regression, predictive models were evaluated for two distinct outcomes—PrEP acceptability and PrEP initiation/uptake. Findings: At baseline, 59% of women (n=322) tested HIV negative. Among WESW testing negative, 11% (n=36) were already PrEP enrolled. Most women reported willingness to use PrEP (n=317; 91%). Only slightly over half of WESW not already on PrEP agreed to initiate PrEP (n=158; 55%). Logistic regression models demonstrate that acceptability of or willingness to use PrEP was significantly associated with fewer years engaged in sex work (r= .147, n=273, P<.05) and greater perceived social support from family (r=.146, n=273, p<.05). PrEP initiation was negatively associated with perceived social support from friends (r=-1.62, n=273, p<.05) and positively associated with lower perceived family stigma (r=.320, n=273, p<.05). Interpretation: Despite endorsing PrEP use, many WESW remain reluctant to use it. This gap in prevention practice highlights the heart of a failing PrEP prevention cascade. Findings point to the important role family and friend support may play in destigmatizing sex work and PrEP use for women. Social and structural-level efforts are needed to improve educational messaging and to integrate positive messaging into health promotion campaigns for women and their families, while also working toward decriminalizing sex work. Trial Registration: This study was registered with number (clinicaltrials.gov, NCT03583541). Funding: US National Institute of Mental Health Declaration of Interest: None to declare. Ethical Approval: All study procedures were approved by Institutional Review Boards (IRBs) at Washington University in St. Louis, Columbia University, the Uganda Virus Research Institute, and the Uganda National Council of Science and Technology.

Evaluation of a community-based intervention for health and economic empowerment of marginalized women in India

BackgroundEmpowered women have improved decision-making capacity and can demand equal access to health services. Community-based interventions based on building women’s groups for awareness generation on maternal and child health (MCH) are the best and cost-effective approaches in improving their access to health services. The present study evaluated a community-based intervention aimed at improving marginalized women’s awareness and utilization of MCH services, and access to livelihood and savings using the peer-led approach from two districts of India.MethodsWe used peer educators as mediators of knowledge transfer among women and for creating a supportive environment at the household and community levels. The intervention was implemented in two marginalized districts of Uttar Pradesh, namely Banda and Kaushambi. Two development blocks in each of the two districts were selected randomly, and 24 villages in each of the four blocks were selected based on the high percentage of a marginalized population. The evaluation of the intervention involved a non-experimental, ‘post-test analysis of the project group’ research design, in a mixed-method approach. Data were collected at two points in time, including qualitative interviews at the end line and tracking data of the intervention population (n = 37,324) through an online management information system.ResultsMost of the women in Banda (90%) and Kaushambi (85%) attended at least 60% of the education sessions. Around 39% of women in Banda and 35% of women in Kaushambi registered for the livelihood scheme, and 94 and 80% of them had worked under the scheme in these two places, respectively. Women’s awareness about MCH seemed to have increased post-intervention. The money earned after getting work under the livelihood scheme or from daily savings was deposited in the bank account by the women. These savings helped the women investing money at times of need, such as starting their work, in emergencies for the medical treatment of their family members, education of their children, etc.ConclusionPeer-led model of intervention can be explored to improve the combined health and economic outcomes of marginalized women.

Gender, HIV knowledge and prevention attitudes among adolescents living with HIV participating in an economic empowerment intervention in Uganda

ABSTRACT HIV disproportionately affect adolescent girls and young women in sub-Saharan Africa. In Uganda, the HIV prevalence is four times higher in adolescent girls compared to boys. This study examined gender, HIV general and clinical knowledge, and prevention attitudes among adolescents living with HIV in Uganda. Data from a cluster randomized clinical trial were analyzed. A total of 702 adolescents (average age of 12.4) were randomized to either a control arm receiving bolstered standard of care or the treatment arm receiving bolstered standard of care plus a family economic empowerment intervention to support medication adherence. Ordinary Least Squares models that adjust for clustering of adolescents within health clinics were conducted. No gender differences were observed in HIV knowledge and prevention attitudes at baseline. However, at 12-months follow-up, boys were more likely than girls to report correct HIV general knowledge (d = 0.21), clinical knowledge (d = 0.48), and favorable prevention attitudes (d = 0.27). The intervention was not associated with any of the outcomes. Given the high HIV prevalence among adolescents, specifically girls, there is need to develop and/or tailor existing programs and interventions that equip adolescent girls with comprehensive knowledge and prevention attitudes, that are culturally appropriate, to reduce HIV transmission and reinfection within this population.

More assets, more decision-making power? Mediation model in a cluster-randomized controlled trial evaluating the effect of the graduation program on women's empowerment in Burkina Faso

Abstract To promote women’s empowerment, numerous programs provide economic services meant to increase women’s access to economic resources in the household. However, women’s access to economic resources does not always translate into improved bargaining power, and effects of economic strengthening interventions may vary across different decision-making domains. There is little robust evidence, particularly in sub-Saharan Africa, showing the effect of improved access to economic resources on specific domains of decision-making within a family and very little is known about variation in this effect between monogamous and polygynous families. Furthermore, very few assessments explicitly examine specific pathways from participation in economic strengthening interventions to improved decision-making power in the household for women. Our study aims to address these gaps by examining—in the context of a randomized controlled trial administered in rural Burkina Faso—the effect of an economic strengthening intervention on specific domains of women’s decision-making power and how it relates to monogamous/polygynous family structures and challenges to intra-household gender roles and responsibilities. Furthermore, we examine a specific pathway to better understand whether increased access to economic resources from this intervention translates into improved decision-making power for women. We use repeated-measures data collected from 360 adult female caregivers in the 3-arm cluster-randomized controlled trial conducted among households living in abject poverty in Burkina Faso. We ran multilevel mixed-effects logistic regression models to examine the effect of the intervention on different domains of women’s involvement into household-level decision-making and variation of this effect by family structure (i.e. polygamous vs. monogamous families). We fit a structural equation model to examine whether access to assets mediates the effect of the intervention on different domains of women’s involvement into household-level decision-making. We found that economic empowerment intervention increased women’s involvement in making decisions about their children’s well-being, but had no effect on women’s say in making decisions about general household economy. We found most effects to be stronger in the treatment arm that received economic strengthening combined with family coaching offered to the whole household and directly targeting normative beliefs related to child wellbeing and gender norms. We also found no evidence that increased access to assets mediates the effect of intervention on improving women’s decision-making power in different domains. Our findings suggest that to improve decision-making power for women in their household it is important to address structural gender inequalities and gender norms rooted in patriarchy, alongside the efforts to economically empower women.

The role of family factors in antiretroviral therapy (ART) adherence self-efficacy among HIV-infected adolescents in southern Uganda

BackgroundAdolescents living with HIV in sub-Saharan Africa are a vulnerable group at the intersection of poverty and health disparities. The family is a vital microsystem that provides financial and emotional support to achieve optimal antiretroviral therapy (ART) adherence. In this study, we explore the association between family factors and ART adherence self-efficacy, a significant psychological concept playing a critical role in ART adherence.MethodsData from an NIH-funded study called Suubi + Adherence, an economic empowerment intervention for HIV positive adolescents (average age = 12.4 years) in southern Uganda was analyzed. We conducted multilevel regression analyses to explore the protective family factors, measured by family cohesion, child-caregiver communication and perceived child-caregiver support, associated with ART adherence self-efficacy.ResultsThe average age was 12.4 years and 56.4% of participants were female. The average household size was 5.7 people, with 2.3 children> 18 years. Controlling for sociodemographic and household characteristics, family cohesion (β = 0.397, p = 0.000) and child-caregiver communication (β = 0.118, p = 0.026) were significantly associated with adherence self-efficacy to ART.ConclusionFindings point to the need to strengthen family cohesion and communication within families if we are to enhance adherence self-efficacy among adolescents living with HIV.Trial registrationThis trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.

The long-term effects of a family based economic empowerment intervention (Suubi+Adherence) on suppression of HIV viral loads among adolescents living with HIV in southern Uganda: Findings from 5-year cluster randomized trial.

BackgroundThe rapid scale-up of HIV therapy across Africa has failed to adequately engage adolescents living with HIV (ALWHIV). Retention and viral suppression for this group (ALWHIV) is 50% lower than for adults. Indeed, on the African continent, HIV remains the single leading cause of mortality among adolescents. Strategies tailored to the unqiue developmental and social vulnerabilities of this group are urgently needed to enhance successful treatment.MethodsWe carried out a five-year longitudinal cluster randomized trial (ClinicalTrials.gov ID: NCT01790373) with adolescents living with HIV (ALWHIV) ages 10 to 16 years clustered at health care clinics to test the effect of a family economic empowerment (EE) intervention on viral suppression in five districuts in Uganda. In total, 39 accredited health care clinics from study districts with existing procedures tailored to adolescent adherence were eligible to participate in the trial. We used data from 288 youth with detectable HIV viral loads (VL) at baseline (158 –intervention group from 20 clinics, 130 –non-intervention group from 19 clinics). The primary end point was undetectable plasma HIV RNA levels, defined as < 40 copies/ml. We used Kaplan-Meier (KM) analysis and Cox proportional hazard models to estimate intervention effects.FindingsThe Kaplan-Meier (KM) analysis indicated that an incidence of undetectable VL (0.254) was significantly higher in the intervention condition compared to 0.173 (in non-intervention arm) translated into incidence rate ratio of 1.468 (CI: 1.064–2.038), p = 0.008. Cox regression results showed that along with the family-based EE intervention (adj. HR = 1.446, CI: 1.073–1.949, p = 0.015), higher number of medications per day had significant positive effects on the viral suppression (adj.HR = 1.852, CI: 1.275–2.690, p = 0.001).InterpretationA family economic empowerment intervention improved treatment success for ALWHIV in Uganda. Analyses of cost effectiveness and scalability are needed to advance incorporation of this intervention into routine practice in low and middle-income countries.

Evaluation of a savings-led family-based economic empowerment intervention for AIDS-affected adolescents in Uganda: A four-year follow-up on efficacy and cost-effectiveness.

Children who have lost a parent to HIV/AIDS, known as AIDS orphans, face multiple stressors affecting their health and development. Family economic empowerment (FEE) interventions have the potential to improve these outcomes and mitigate the risks they face. We present efficacy and cost-effectiveness analyses of the Bridges study, a savings-led FEE intervention among AIDS-orphaned adolescents in Uganda at four-year follow-up. Intent-to-treat analyses using multilevel models compared the effects of two savings-led treatment arms: Bridges (1:1 matched incentive) and BridgesPLUS (2:1 matched incentive) to a usual care control group on the following outcomes: self-rated health, sexual health, and mental health functioning. Total per-participant costs for each arm were calculated using the treatment-on-the-treated sample. Intervention effects and per-participant costs were used to calculate incremental cost-effectiveness ratios (ICERs). Among 1,383 participants, 55% were female, 20% were double orphans. Mean age was 12 years at baseline. At 48-months, BridgesPLUS significantly improved self-rated health, (0.25, 95% CI 0.06, 0.43), HIV knowledge (0.21, 95% CI 0.01, 0.41), self-concept (0.26, 95% CI 0.09, 0.44), and self-efficacy (0.26, 95% CI 0.09, 0.43) and lowered hopelessness (-0.28, 95% CI -0.43, -0.12); whereas Bridges improved self-rated health (0.26, 95% CI 0.08, 0.43) and HIV knowledge (0.22, 95% CI 0.05, 0.39). ICERs ranged from $224 for hopelessness to $298 for HIV knowledge per 0.2 standard deviation change. Most intervention effects were sustained in both treatment arms at two years post-intervention. Higher matching incentives yielded a significant and lasting effect on a greater number of outcomes among adolescents compared to lower matching incentives at a similar incremental cost per unit effect. These findings contribute to the evidence supporting the incorporation of FEE interventions within national social protection frameworks.

Economic Empowerment of Rural Women through Micro-credit Intervention: The Case of Kedida Gamela District, Southern Region, Ethiopia

A study was set out to investigate the extent of rural women's economic empowerment through credit services in Kedida Gamela, District Southern region of Ethiopia. A cross-sectional survey design was used for this specific study. Household surveys, Key Informant Interviews, and Focus Group discussions were used to gather data. The data were analyzed using SPSS version 25 by using multiple linear regression models and descriptive statistics. The economic empowerment of women was significantly affected by demographic, socio-economic, cultural and institutional reasons in the study area. Specifically, multiple linear regressions analysis revealed experience in income-generating activities, the age difference between wife and husband, participation in extension and amount of cumulated loan received as the significant factors determining the economic empowerment of women. The results obtained from focused group discussants and key informants interview also confirmed that women who are credit users are better empowered than non-credit users. Inadequate finance was the prime constraint that limits women’s economic empowerment. The study concludes that the problem associated with women's economic empowerment is pertaining to the issue in the study area. To overcome such problems, effective initiatives should be undertaken by the concerned agencies in improving women`s education, skill acquisition training and access to adequate finance. also, concerted efforts like extension work, the introduction of labor and time-saving technologies along with adequate loan supervision could enhance women's economic empowerment in order to achieve gender equality and development at all levels in the study area. Keywords : Empowerment, Women empowerment, women economic empowerment and microcredit intervention DOI : 10.7176/JESD/11-1-06 Publication date: January 31 st 2020

Suubi+Adherence Study Protocol: A family economic empowerment intervention addressing HIV treatment adherence for perinatally infected adolescents

BackgroundGlobally, 1.8 million children<15 years are living with HIV. Sub-Saharan Africa (SSA), as a region, is heavily burdened by HIV, with 90% of new infections among children happening there. Within SSA, Uganda has an HIV prevalence of 7.2% among 15-49-year-olds, with high prevalence in Masaka region (12%). Uganda also reports unprecedented numbers of perinatally HIV-infected children, with close to 150,000 children (ages 0-14) living with HIV (CLHA). However adherence to antiretroviral therapy (ART) among children and youth is poor, and has been attributed to economic insecurity, including lack of finances for transportation to clinic appointments, inadequate meals to support medication consumption, and resource prioritization towards school expenses. Yet, few programs aimed at addressing ART adherence have applied combination interventions to address economic stability and ART Adherence within the traditional framework of health education and HIV care. This paper describes a study protocol for a 5-year, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) funded, cluster randomized-controlled trial to evaluate a combination intervention, titled Suubi+Adherence, aimed at improving ART adherence among HIV perinatally infected adolescents (ages 10-16 at study enrollment) in Uganda. MethodsSuubi+Adherence was evaluated via a two-arm cluster randomized-controlled trial design in 39 health clinics, with a total enrollment of 702 HIV+ adolescents (ages 10-16 at enrollment). The study addresses two primary outcomes: 1) adherence to HIV treatment regimen and 2) HIV knowledge and attitudes. Secondary outcomes include family functioning, sexual risk-taking behavior, and financial savings behavior. For potential scale-up, cost effectiveness analysis was employed to compare the relative costs and outcomes associated with each study arm: family economic strengthening comprising matched savings accounts, financial management training and small business development, all intended for family economic security versus bolstered usual care (SOC) comprising enhanced adherence sessions to ensure more standardized and sufficient adherence counseling. DiscussionThis study aims to advance knowledge and inform the development of the next generation of programs aimed at increasing adherence to HIV treatment for HIV+ adolescents in low-resource regions such as SSA. To our knowledge, the proposed study is the first to integrate and test family economic empowerment and stability-focused interventions for HIV+ adolescents in Uganda (and much of SSA)—so families would have the necessary finances to manage HIV/AIDS as a chronic illness. The study would provide crucial evidence about the effects of an economic empowerment program on short and long-term impact, which is essential if such interventions are to be taken to scale. Trial registrationThis trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.

Suubi4Cancer: A Protocol for An Innovative Combination Intervention to Improve Access to Pediatric Cancer Services and Treatment Adherence among Children living with HIV/AIDS in Uganda

Youth Living with HIV (YLWHIV) are at high risk for cancer. Sub-Saharan Africa (SSA) has some of the worst pediatric cancer survival rates due to barriers to accessing cancer services and treatment adherence. This protocol describes a study that aims at: 1) Identifying confirmed and suspected cancer cases in a cohort of >3000 HIV positive youth; 2) Examining the short-term preliminary outcomes of an evidence-based Economic Empowerment (EE) intervention, Suubi (“hope” in a local Ugandan language), on access to pediatric cancer diagnosis and care, and treatment adherence among YLWHIV with suspected cancers in Uganda; and 3) Exploring multi-level factors impacting intervention participation and experiences. The proposed Suubi4Cancer intervention combines savings-led EE through family development accounts (FDA) with financial literacy and management (FLM) and cancer education (CE). The study will review medical charts in 39 clinics in Southwest Uganda to identify confirmed and suspected cancer cases. Subsequently, Suubi4Cancer will be evaluated via a randomized-controlled trial design (FDA+FLM+CE versus Usual Care) targeting a total of 78 youth ages 10-to-24 and their caregivers. Assessments at baseline and 9 months will examine change in cancer treatment access; cancer treatment adherence; and knowledge, attitudes, and beliefs about cancer and cancer treatment. Semi-structured interviews with the intervention group will explore their intervention experiences. To our knowledge, Suubi4Cancer will be the first study to test the preliminary impact and acceptability of a combination intervention to increase access to cancer diagnosis and treatment services for YLWHIV. Trial RegistrationClinical Trials NCT03916783 (Registered: 04/16/19).

Quasi-experimental evaluation using confirmatory procedures: A case study of an economic and social empowerment intervention to reduce girls’ vulnerability to HIV in rural Mozambique

PurposeOur goal was to determine whether an economic and social empowerment intervention implemented in Zambézia Province, Mozambique reduced girls’ vulnerability to HIV. We use this experience to discuss challenges of evaluating real-world interventions. MethodsTwo rounds of data were collected from 885 girls, 13–19 years, for this clustered, non-equivalent (two-stage) cohort trial. We used multi-level exact matching and difference-in-differences estimation to estimate intervention effects on two outcomes: girls’ knowledge of gender-based violence and school attendance. ResultsEstimates of two outcomes analysed indicated no statistically significant intervention effects. Preliminary analysis of data from the intervention group revealed this study was unable to obtain accurate measures for five outcomes related to HIV vulnerability. ConclusionsAlthough our study did not find evidence of impact on the a priori selected outcomes, we report on our experience implementing this robust methodologic design and describe how the challenges encountered in this program setting affected our ability to attain results. We recommend prospective evaluation designs with random allocation be accommodated early during planning. When not possible, quasi-experimental studies should collect data from large samples. To reduce measurement bias, biological endpoints such sexually transmitted infections should serve as primary outcomes for programs intending to reduce sexual behaviors.

The effects of a cash transfer intervention on sexual partnerships and HIV in the HPTN 068 study in South Africa

Evidence on cash transfer interventions for HIV prevention in adolescent girls and young women is unclear and indicates that they may not work uniformly in all settings. Qualitative interviews were conducted with 22 girls and young women post-intervention to determine how a cash transfer study (HPTN 068) in South Africa was perceived to influence sexual behaviours and to explore mechanisms for these changes. Participants described how the intervention motivated them to increase condom use, have fewer partners, end risky relationships and access HIV testing services at local primary health clinics. Changes were attributed to receipt of the cash transfer, in addition to HIV testing and sexual health information. Processes of change included improved communication with partners and increased negotiation power in sexual decision-making. Economic empowerment interventions increase confidence in negotiating behaviours with sexual partners and are complementary to sexual health information and health services that provide young women with a foundation on which to make informed decisions about how to protect themselves.

A longitudinal qualitative evaluation of an economic and social empowerment intervention to reduce girls’ vulnerability to HIV in rural Mozambique

PurposeAn intervention including business training and health education was implemented in Mozambique, where girls are at elevated risk for acquiring HIV. As part of a mixed-methods evaluation, we describe perceived effects of the intervention on girls’ sexual behavior and school attendance. MethodsWe conducted 49 in-depth interviews (IDIs) with girl intervention participants (ages 13–19), 24 IDIs with heads of girls’ households, 36 IDIs with influential males identified by girls, and 12 focus group discussions with community members after the intervention ended and one year later. ResultsInformants said the primary intervention benefit was realized when girls had money to stay in or return to school and/or to buy necessities for themselves and their households—reducing their need for transactional or intergenerational sex. However, some girls did not make a profit and some businesses were not sustainable. Sometimes the intervention appeared to be implemented in a way to reinforce inequitable gender norms resulting in some girls feeling shame when they reengaged in risky sex after their businesses failed. ConclusionsEarning money enabled girls to potentially reduce their vulnerability to HIV. We offer recommendations for future multi-sector interventions, including the need to address potential harms in programs serving vulnerable girls.