Economic Strengthening Interventions Research Articles

A Cluster-Randomized Controlled Trial of an Economic Strengthening Intervention to Enhance Antiretroviral Therapy Adherence among Adolescents Living with HIV.

We examined the impact of an economic empowerment intervention on ART adherence among ALHIV. We used data from 455 ALHIV, randomized into intervention, n = 111, and control n = 344. ALHIV were aged 12-16 and recruited from 39 clinics in Uganda between January 2013 and December 2015. The intervention comprised a long-term child development account (CDA), micro-enterprise workshops, and educational sessions. Adherence was measured using unannounced pill counts. We used mixed-effects logistic regression analysis to examine the effect of the intervention on ART adherence. The mean age was 12.6 years. Despite observing non-significant group main effects, we found significant group-by-time interaction effects χ2(5) = 45.41, p < 0.001. Pairwise comparisons showed that compared to the control group, participants who received the intervention had significantly higher adherence at visit four, OR = 1.52 (95% CI: 1.07-2.18), p = 0.020; visit five, OR = 1.59 (95% CI: 1.06-2.38), p = 0.026; and visit six, OR = 1.94 (95% CI: 1.24-3.04), p = 0.004. Efforts to support ALHIV to live longer and healthier lives should incorporate components addressing poverty. However, declining adherence raises concerns over ALHIV's long-term well-being. The trial was registered at ClinicalTrials.gov, registration number NCT01790373, with a primary outcome of adherence to HIV treatment.

Examining the Implementation of Conditional Financial Incentives Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework to Improve HIV Outcomes among Persons Living with HIV (PLWH) in Louisiana.

Economic strengthening interventions are needed to support HIV outcomes among persons living with HIV (PLWH). The Baton Rouge Positive Pathway Study (BRPPS), a mixed method implementation science study, was conducted to assess key RE-AIM components tied to the provision of conditional financial incentives among PLWH in Baton Rouge, Louisiana. Seven hundred and eighty-one (781) PLWH enrolled at four HIV clinic sites were included in the final analyses. Participants completed an initial baseline survey, viral load test, and were contacted at 6 and 12 months (±1 month) post-enrollment for follow-up labs to monitor viral load levels. Participants received up to USD140 in conditional financial incentives. The primary analyses assessed whether participation in the BRPPS was associated with an increase in the proportion of participants who were: (a) engaged in care, (b) retained in care and (c) virally suppressed at baseline to 6 and 12 months post-baseline. We constructed a longitudinal regression model where participant-level outcomes at times t0 (baseline) and t1 (6- or 12-month follow-up) were modeled as a function of time. A secondary analysis was conducted using single-level regression to examine which baseline characteristics were associated with the outcomes of interest at 12-month follow-up. Cost analyses were also conducted with three of the participating clinics. Most participants identified as Black/African American (89%). Fewer than half of participants reported that they were unemployed or made less than USD5000 annually (43%). Over time, the proportion of participants engaged in care and retained in care significantly increased (70% to 93% and 32% to 64%, p < 0.00). However, the proportion of virally suppressed participants decreased over time (59% to 34%, p < 0.00). Implementation costs across the three sites ranged from USD17,198.05 to USD396,910.00 and were associated with between 0.37 and 1.34 HIV transmissions averted at each site. Study findings provide promising evidence to suggest that conditional financial incentives could help support engagement and retention in HIV care for a high need and at risk for falling out of HIV care population.

Women’s Economic Contribution, Relationship Status and Risky Sexual Behaviours: A Cross-Sectional Analysis from a Microfinance-Plus Programme in Rural South Africa

In sub-Saharan Africa, women bear a disproportionate burden of HIV/AIDS while also facing economic and gender inequalities. To explore the association of women’s economic contribution and relationship status with risky sexual behaviour, this study analysed cross-sectional data from 626 women aged 22 to 84 in rural South Africa. All women were enrolled in a microfinance plus gender training programme (Intervention with Microfinance for AIDS and Gender Equity (IMAGE)). We used univariable and multivariable logistic regression to explore the associations of relationship status and women’s household income contribution with inconsistent condom use, multiple sexual partners and transactional sex, respectively. We found that married, older women had the highest odds of inconsistent condom use, while those contributing all the household income had higher odds of multiple sexual partnerships, but lower odds of transactional sex compared to those with no contribution. Income contribution and relationship status have a nuanced relationship with sexual risk behaviours. Thus, economic strengthening interventions should target relevant vulnerable women while also addressing the broader social and economic drivers of risky sexual behaviour.

The financial lives of female sex workers in Addis Ababa, Ethiopia: Implications for economic strengthening interventions for HIV prevention

ABSTRACT Understanding the financial context of the lives of female sex workers (FSWs) is essential to address structural drivers of HIV risk. We used a financial diary methodology to record daily financial transactions over six weeks from a stratified purposive sample (n = 34) of FSWs in Addis Ababa, Ethiopia. FSWs also provided information on their experience with gender-based violence and condom use. FSWs generated 90.1% of total cash from sex work, with a median weekly income of USD 60.53. They engaged mostly in protected vaginal sex, earning approximately USD 4.57 per act. Food, housing, and clothing represented the largest areas of expenditure. Around 17% of expenses were recorded as costs of sex work (e.g., alcohol). Median weekly expenditures accounted for 62% of median weekly income. Nearly all participants reported depositing money into savings at least once over six weeks, while 71% reported a loan transaction during the six-week period, most as borrowers. Findings suggest that financial literacy and formalized savings activities, with life skills and empowerment training, have potential to build FSW’s economic resilience, mitigating a structural driver of sex work and HIV risk.

“The sky is the limit; I am going there”: experiences of hope among young women receiving a conditional cash transfer in rural South Africa

Young women in South Africa face elevated risk of HIV infection compared to male peers. Cash transfers may mitigate their risk for HIV; however, there is limited understanding of mechanisms of impact. We explored hope as one potential mechanism. Longitudinal qualitative analysis was used to explore how cash transfer recipients in the HPTN 068 study conceptualised hope and how the intervention influenced their hope over time. We found the intervention increased confidence, alleviated financial stressors and instilled in young women the belief that a better life, defined as being educated, independent and supportive to family, was attainable. Findings support hope as a critical outcome of cash transfer and other economic strengthening interventions.

Women’s economic status, male authority patterns and intimate partner violence: a qualitative study in rural North West Province, South Africa

There are conflicting views on the impact of microfinance-only interventions on women’s economic empowerment and intimate partner violence in low and middle-income countries. Evidence suggests however that when microfinance is combined with complementary programmes (microfinance plus) it may be effective for empowering women and addressing intimate partner violence. We conducted in-depth interviews with adult women in rural South Africa who had received microfinance loans for more than a year and had recently completed gender training. We explored women’s perceptions on income generation; the effects on their relationships, including intimate partner violence; their notions of power; and perspectives on men’s reactions to their empowerment. Findings reveal that the notion of ‘power within the self’ is supported by women’s income generation, alongside a sense of financial independence and improved social support. Women reported increased happiness and reduced financial stress, although social norms and gender expectations about women subservience and male headship remain salient, particularly among older women. Furthermore, younger women appeared to tolerate abuse due to financial and caring responsibilities. These findings underpin the importance of complementary gender training programmes and of including men as participants for enhancing the effectiveness of economic strengthening interventions.

The ASHA (Hope) Project: Testing an Integrated Depression Treatment and Economic Strengthening Intervention in Rural Bangladesh: A Pilot Randomized Controlled Trial.

Depression, a debilitating disorder, is highly prevalent among low-income women in low- and middle-income countries. Standard psychotherapeutic approaches may be helpful, but low treatment uptake, low retention, and transient treatment effects reduce the benefit of therapy. This pilot randomized controlled trial examined the effectiveness and feasibility of an integrated depression treatment/economic strengthening intervention. The study took place in two villages in the Sirajganj district in rural Bangladesh. Forty-eight low-income women with depressive symptoms (Patient Health Questionnaire (PHQ-9) score ≥ 10) were recruited and randomized to intervention or control arms. The intervention included a six-month group-based, fortnightly depression management and financial literacy intervention, which was followed by a cash-transfer of $186 (equivalent to the cost of two goats) at 12 months’ follow-up. The cash transfer could be used to purchase a productive asset (e.g., agricultural animals). The control arm received no intervention. Findings showed significant reduction in depression scores in the intervention group. The mean PHQ-9 score decreased from 14.5 to 5.5 (B ± SE, −9.2 ± 0.8 95% CI −10.9, −7.5, p < 0.01) compared to no change in the control group. Most other psycho-social outcomes, including tension, self-esteem, hope, social-support, and participation in household economic decision-making, also improved with intervention. An integrated depression treatment and financial empowerment intervention was found to be highly effective among rural low-income women with depression. Next steps involve formal testing of the model in a larger trial.

Exploring pathways to adherence and retention for HIV-positive savings group members in Ethiopia

ABSTRACT Savings groups are an economic strengthening intervention used to enhance the well-being of vulnerable groups. However, it is unclear how savings groups influence treatment outcomes for people living with HIV. This article reports on a study that conducted 48 in-depth interviews with HIV-positive savings group members in Ethiopia and used their narratives to qualitatively assess pathways linking savings group participation to adherence, retention, and general well-being. No single pathway was described, but almost the entire sample described improved adherence or retention through a combination of increased food security, economic and social well-being. The complexity of pathways supports the necessity for multisectoral approaches that address structural barriers to care.

Interventions for reducing violence against children in low- and middle-income countries: An evidence and gap map.

More than half of the children in the world experience some form of interpersonal violence every year. As compared with high-income countries, policy responses in low- and middle-income countries (LMICs) are limited due to resource constraints and paucity of evidence for effective interventions to reduce violence against children in their own contexts, amongst other factors. The aim of this evidence and gap map (EGM) is to provide an overview of the existing evidence available and to identify gaps in the evidence base on the effectiveness of interventions to reduce violence against children in LMICs. This report covers evidence published in English; a follow-up study is under preparation focusing on evidence in five additional languages-Arabic, Chinese, French, Portuguese and Spanish. The intervention-outcome framework for this EGM is based on INSPIRE-Seven Strategies for Ending Violence against Children, published by WHO and other partners in 2016. The seven strategies includeimplementation and enforcement of laws; norms and values, safe environment; parent-child and caregiver support; income and economic strengthening; response and support services; education and life skills. The search included both academic and grey literature available online. We included impact evaluations and systematic reviews that assessed the effectiveness of interventions to reduce interpersonal violence against children (0-18 years) in LMICs (World Bank, 2018b). Interventions targeting subpopulation of parents, teachers and caregivers of 0-18 years' age group were also included. A critical appraisal of all included studies was carried out using standardised tools. The map includes 152 studies published in English of which 55 are systematic reviews and 97 are impact evaluations. Most studies in the map are from Sub-Saharan Africa. Education and life skills are the most widely populated intervention area of the map followed by income and economic strengthening interventions. Very few studies measure impact on economic and social outcomes, and few conduct cost-analysis. More studies focusing on low-income and fragile and conflict-affected settings (FCS) and studying and reporting on cost-analysis are required to address gaps in the evidence. Most interventions covered in the literature focused on addressing a wide range of forms of violence and harm, which limited understanding of how and for whom the interventions work in a given context, for specific forms of violence. More impact evaluation studies are required that assess specific forms of violence, gendered effects of interventions and on diverse social groups in a given context, utilising mixed methods.

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.

Microenterprise Intervention to Reduce Sexual Risk Behaviors and Increase Employment and HIV Preventive Practices Among Economically-Vulnerable African-American Young Adults (EMERGE): A Feasibility Randomized Clinical Trial

Economic vulnerability, such as homelessness and unemployment, contributes to HIV risk among U.S. racial minorities. Yet, few economic-strengthening interventions have been adapted for HIV prevention in this population. This study assessed the feasibility of conducting a randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Primary feasibility objectives assessed recruitment, randomization, participation, and retention. Secondary objectives examined employment, sexual risk behaviors, and HIV preventive behaviors. Outcome assessments used an in-person pre- and post-intervention interview and a weekly text message survey. Several progression criteria for a definitive trial were met. Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19) of which 95% were retained. The comparison intervention enhanced willingness to be randomized and reduced non-participation. Mean age of participants was 21.0 years; 35% were male; 81% were unemployed. Fifty-eight percent (58%) of experimental participants completed ≥ 70% of intervention activities, and 74% completed ≥ 50% of intervention activities. Participation in intervention activities and outcome assessments was highest in the first half (~ 10 weeks) of the study. Seventy-one percent (71%) of weekly text message surveys received a response through week 14, but responsiveness declined to 37% of participants responding to ≥ 70% of weekly text message surveys at the end of the study. The experimental group reported higher employment (from 32% at baseline to 83% at week 26) and lower unprotected sex (79% to 58%) over time compared to reported changes in employment (37% to 47%) and unprotected sex (63% to 53%) over time in the comparison group. Conducting this feasibility trial was a critical step in the process of designing and testing a behavioral intervention. Development of a fully-powered effectiveness trial should take into account lessons learned regarding intervention duration, screening, and measurement.Trial Registration ClinicalTrials.gov. NCT03766165. Registered 04 December 2018. https://clinicaltrials.gov/ct2/show/NCT03766165

The effects of the integration of an economic strengthening and HIV prevention education programme on the prevalence of sexually transmitted infections and savings behaviours among adolescents: a full-factorial randomised controlled trial in South Africa

BackgroundMultisectoral approaches are thought necessary to prevent HIV among adolescents. We examined whether an economic strengthening (ES) and an HIV-prevention education intervention improved outcomes when combined versus separately.MethodsWe conducted a...

The Unaddressed Needs of Alcohol-Using Couples on Antiretroviral Therapy in Malawi: Formative Research on Multilevel Interventions.

Alcohol use among HIV-positive individuals in sub-Saharan Africa directly impacts adherence to antiretroviral therapy and HIV outcomes. Few studies have examined approaches to reduce alcohol use among HIV-affected couples, despite evidence that alcohol use is a couple-level concern. We conducted a qualitative study with 23 alcohol-using couples to identify multilevel barriers and facilitators of alcohol use, and potential intervention options with couples. Data were analyzed at individual and dyadic levels using framework analysis. All couples were married and had at least one partner on ART. Men were the primary alcohol drinkers with few women reporting alcohol use. Most women tried to persuade their partners to reduce their alcohol intake and when unsuccessful, enlisted help from relatives and HIV care providers. Effective couple negotiation around men's alcohol use was constrained by negative peer influence and men's desire for friendship to cope with life stressors. Women were primarily concerned about the expense of alcohol and described how alcohol prevented the family from meeting basic needs and investing in the future. Alcohol use was described as a major barrier to ART adherence, but was also viewed as the cause of couple and family violence, extramarital partnerships, food insecurity, and poverty. We conclude that multilevel interventions based on couples' needs and preferences are urgently needed. Couple-based intervention approaches could include provider-led alcohol counseling with couples, alcohol reduction support groups for couples, couples' counseling to bolster couple communication and problem-solving around alcohol, and economic-strengthening interventions for couples.

Microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices in economically-vulnerable African-American young adults (EMERGE): protocol for a feasibility randomized clinical trial

BackgroundEconomic vulnerability, such as homelessness and unemployment, contributes to the HIV risk among racial minorities in the U.S., who are disproportionately infected. Yet, few economic-strengthening interventions have been adapted for HIV prevention in economically-vulnerable African-American young adults. Engaging Microenterprise for Resource Generation and Health Empowerment (EMERGE) is a feasibility randomized clinical trial of an HIV prevention microenterprise intervention with integrated text messages (“nudges”) that are informed by behavioral economic principles. The trial aims to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors.Methods/designIn total, 40 young adults who are African-American, aged 18–24, live in Baltimore City, have experienced at least one episode of homelessness in the last 12 months, are unemployed or underemployed (fewer than 10 h per week), are not enrolled in school, own a cell phone with text messaging, and report at least one episode of unprotected or unsafe sex in the prior 12 months will be recruited from two community-based organizations providing residential supportive services to urban youth. Participants will undergo a 3-week run-in period and thereafter be randomly assigned to one of two groups with active interventions for 20 weeks. The first group (“comparison”) will receive text messages with information on job openings. The second group (“experimental”) will receive text messages with information on job openings plus information on HIV prevention and business educational sessions, a mentored apprenticeship, and a start-up grant, and business and HIV prevention text messages based on principles from behavioral economics. The two primary outcomes relate to the feasibility of conducting a larger trial. Secondary outcomes relate to employment, sexual risk behaviors, and HIV preventive practices. All participants will be assessed using an in-person questionnaire at pre-intervention (prior to randomization) and at 3 weeks post-intervention. To obtain repeated, longitudinal measures, participants will be assessed weekly using text message surveys from pre-intervention up to 3 weeks post-intervention.DiscussionThis study will be one of the first U.S.-based feasibility randomized clinical trials of an HIV prevention microenterprise intervention for economically-vulnerable African-American young adults. The findings will inform whether and how to conduct a larger efficacy trial for HIV risk reduction in this population.Trial registrationClinicalTrials.gov, NCT03766165. Registered on 4 December 2018.

Exploring the Potential of Savings-Led Economic Strengthening HIV Interventions Among High-Risk Economically Vulnerable Fishing Communities in Uganda: Associations Between Use of Commitment Savings, Sexual Risk Behavior, and Problematic Alcohol Use.

Fishing communities are a most-at-risk population for HIV in Uganda. Alcohol use and abuse and economic vulnerability fuel risky sexual practices and lead to increased risk of HIV infection in these communities. Economic strengthening is an emerging intervention approach and interventions promoting saving money via mechanisms with a "soft commitment" in the form of restricting or charging small fees for withdrawals, may serve to reduce spending on alcohol and spending that leads to HIV risk behaviors in cash-based economies. However, little research has been conducted to explore the potential for commitment savings-led economic strengthening interventions to address alcohol use and sexual risk behavior among fisherfolk. This cross-sectional study explored the associations between commitment savings, HIV sexual risk behavior, and problematic alcohol among fisherfolk. We also determined whether commitment savings moderated the associations between problematic alcohol use and risky sexual behaviors. 300 (132 male, 168 female) residents of fishing communities on Lake Victoria, Uganda completed a structured interviewer-assisted interview. Over half (55.3%) used commitment savings by saving money in a bank or savings cooperative or via mobile money. Having problematic alcohol use increased the rate of risky unprotected sex with: all partners (adjIRR 6.08, 95% CI 4.30-8.60) and with casual partners and CSWs/clients (adjIRR 4.90, 95% CI 3.09-7.78), and increased the odds of having met a sex partner at an alcohol venue (adjOR 2.84, 95% CI 1.46-5.51) compared to those without problematic alcohol use. Commitment savings was associated with lower odds of: problematic alcohol use (adjOR 0.50, 95% CI 0.26-0.96), meeting a sex partner at an alcohol venue (adjOR 0.43, 95% CI 0.24-0.78), as well as lower rates of risky unprotected sex with all partners (adjIRR 0.68, 95% CI 0.48-0.96), and with causal partners, CSWs/clients (adjIRR 0.38, 95% CI 0.17-0.85). Use of commitment savings moderated the associations between problematic alcohol use and unprotected sex. However, the moderating effects of commitment savings varied by gender. These findings suggest that promoting saving money in savings mechanisms which involve a commitment may be a potentially viable avenue for HIV prevention among fishing communities and may be particularly helpful for those who have problematic alcohol use.

Utilizing a family-based economic strengthening intervention to improve mental health wellbeing among female adolescent orphans in Uganda

BackgroundIt is estimated that almost 20% of the world’s adolescents have experienced or are experiencing a mental health problem. Several factors have been associated with the onset of adolescent mental health disorders, including poverty, child abuse and violence, particularly among adolescent girls. This paper examines the effect of participating in a family-based economic strengthening intervention on the mental health well-being of female adolescent orphans impacted by HIV/AIDS in rural Uganda.MethodsData utilized in this study was from the Bridges to the Future Study (2011–2016), an economic empowerment intervention aimed at improving health outcomes of orphaned children. Adolescents were randomly assigned to either the control condition receiving bolstered standard of care services for orphaned adolescents; or one of two treatment conditions receiving bolstered standard of care as well as an economic empowerment intervention comprising of a child development account, a mentorship program and workshops on financial management and microenterprise development. Data was collected at baseline, 12- and 24-months post intervention initiation. Multilinear regression analyses were conducted to examine the impact of an economic empowerment intervention on mental health functioning of female participants over time. Mental health functioning was measured by: (1) the Child Depression Inventory; (2) Beck Hopelessness Scale; and (3) Tennessee Self Concept Scale.ResultsAnalysis results show an improvement in mental health functioning over time among female participants receiving the intervention compared to their control counterparts. Specifically, compared to participants in the control condition, participants receiving the intervention reported a reduction in depressive symptoms from baseline to 12-months follow-up (b = − 1.262, 95% CI − 2.476, − 0.047), and an additional 0.645-point reduction between baseline and 24-months follow-up (b = − 1.907, 95% CI − 3.192, − 0.622). Participants receiving the intervention reported significant improvement in their reported self-concept from baseline to 24 months follow-up (b = 3.503 (95% CI 1.469, 5.538) compared to participants in the control condition.ConclusionsEmpowerment of young girls, either in the form of peer mentorship and/or economic strengthening seems to significantly improve the overall mental health functioning of adolescent girls impacted by HIV and AIDS in low-income settings.

Poverty, economic strengthening, and mental health among AIDS orphaned children in Uganda: Mediation model in a randomized clinical trial

Some evidence points to the positive effects of asset accumulation programs on mental health of children living in low-resource contexts. However, no evidence exists as to why and how such impact occurs. Our study aims to understand whether child poverty, child work, and household wealth serve as pathways through which the economic strengthening intervention affects the mental health of AIDS-orphaned children.The study employed a cluster-randomized experimental design with a family-based economic strengthening intervention conducted among 1410 school-going AIDS-orphaned children ages 10 and 16 years old in 48 primary schools in South Western Uganda. To test the hypothesized relationships between the intervention, mediators (household wealth, child poverty, and child's work) and mental health, we ran structural equation models that adjust for clustering of individuals within schools and account for potential correlation among the mediators.We found significant unmediated effect of the intervention on children's mental health at 24 months (B = −0.59; 95% CI: 0.93, −0.25; p < 0.001; β = −0.33). Furthermore, the results suggest that participation in the intervention reduced child poverty at 12 months, which in turn improved latent mental health outcome at 24 months (B = −0.14; 95% CI: −0.29, −0.01; p < 0.06; β = −0.08). In addition, though not statistically significant at the 0.05 level, at 36 and 48 months, mental health of children in the treatment group improved by 0.13 and 0.16 standard deviation points correspondingly with no evidence of mediation. Our findings suggest that anti-poverty programs that aim solely to improve household income may be less advantageous to children's mental health as compared to those that are specifically targeted towards reducing the impact of poverty on children. Further studies using more comprehensive measures of child work and age-appropriate child mental health may shed more light on understanding the link between asset accumulation interventions, child labor and children's mental health.

Examining the nonkin support networks of orphaned adolescents participating in a family-based economic-strengthening intervention in Uganda.

In this study, we examined the nonkin support networks of orphaned adolescents participating in a family-based economic-strengthening intervention in HIV-impacted communities in Uganda. We analyzed data from a cluster randomized experimental study for orphaned adolescents aged 11-17 years. Participants were randomly assigned to either the control condition, which received bolstered standard of care (BSOC) services, or the treatment condition, which received BSOC services plus an economic-strengthening intervention. We conducted binary logistic regression analyses to examine the effect of the intervention on participants' nonkin support networks. Results indicated that the existing social support networks for orphaned adolescents are small, limited, and usually comprised individuals with similar socioeconomic situations and challenges. Because orphaned adolescents are socially isolated and the threshold for nonkin supportive services is very low, the BSOC services provided to the control condition appeared to be instrumental in their survival and well-being. Availability of personal savings was associated with higher odds of identifying at least one supportive nonkin tie. The extended family system is still the primary and major source of social support to orphaned children in HIV-affected communities. In the absence of public safety nets, building social assets, over and above offering economic opportunities to extended families supporting orphaned children, is critical.

Applying Factorial Designs to Disentangle the Effects of Integrated Development

In this article, we discuss the study design and lessons learned from a full-factorial randomised controlled study conducted with beneficiaries of a youth programme in Pretoria, South Africa. The study assesses whether the integration of an economic strengthening intervention with an HIV-prevention education intervention improves economic and health outcomes beyond singular interventions. The selected youth were randomised into four groups: combined economic strengthening and HIV-prevention interventions; economic strengthening intervention only; HIV-prevention education intervention only; or no interventions. We conducted a pre-intervention and two post-intervention assessments with the participants to measure outcomes, including the primary outcome – prevalence of sexually transmitted infections. We discuss our rationale for the study design and the challenges faced when implementing it. We consider how features of the integrated programme, such as how synergy is assessed, and features of context, for example available sample size, determine which methods can be used to test the effectiveness of integrated programming.

Learning About Integrated Development Using Longitudinal Mixed Methods Programme Evaluation

Globally, millions of children are living without parental care. Families experience multiple challenges that lead to family–child separation, with financial hardship a common theme. The integration of interventions to strengthen families socially, emotionally, and economically is therefore a priority, but requires knowing which combination(s) of interventions might work for which households. This article reflects on an ongoing evaluation of two projects in Uganda that implemented integrated family and economic strengthening interventions with families at risk of a child being separated and those where a separated child was reunited. We discuss how the practical realities of integrated programming influence research design options and our attempts to mitigate the potential limitations of a non‑experimental design with the use of a mixed methods approach.