Suubi4Her: a study protocol to examine the impact and cost associated with a combination intervention to prevent HIV risk behavior and improve mental health functioning among adolescent girls in Uganda.
ABSTRACT: BACKGROUND:Asset-based economic empowerment interventions, which take an integrated approach to building human, social, and economic capital, have shown promise in their ability to reduce HIV risk for young people, including adolescent girls, in sub-Saharan Africa. Similarly, community and family strengthening interventions have proven beneficial in addressing mental health and behavioral challenges of adolescents transitioning to adulthood. Yet, few programs aimed at addressing sexual risk have applied combination interventions to address economic stability and mental health within the traditional framework of health education and HIV counseling/testing. This paper describes a study protocol for a 5-year, NIMH-funded, cluster randomized-controlled trial to evaluate a combination intervention aimed at reducing HIV risk among adolescent girls in Uganda. The intervention, titled Suubi4Her, combines savings-led economic empowerment through youth development accounts (YDA) with an innovative family strengthening component delivered via Multiple Family Groups (MFG). METHODS:Suubi4Her will be evaluated via a three-arm cluster randomized-controlled trial design (YDA only, YDA?+?MFG, Usual Care) in 42 secondary schools in the Central region of Uganda, targeting a total of 1260 girls (ages 15-17 at enrollment). Assessments will occur at baseline, 12, 24, and 36 months. This study addresses two primary outcomes: 1) change in HIV risk behavior and 2) change in mental health functioning. Secondary exploratory outcomes include HIV and STI incidence, pregnancy, educational attainment, financial savings behavior, gender attitudes, and self-esteem. For potential scale-up, cost effectiveness analysis will be employed to compare the relative costs and outcomes associated with each study arm. CONCLUSIONS:Suubi4Her will be one of the first prospective studies to examine the impact and cost of a combination intervention integrating economic and social components to reduce known HIV risk factors and improve mental health functioning among adolescent girls, while concurrently exploring mental health as a mediator in HIV risk reduction. The findings will illuminate the pathways that connect economic needs, mental health, family support, and HIV risk. If successful, the results will promote holistic HIV prevention strategies to reduce risk among adolescent girls in Uganda and potentially the broader sub-Saharan Africa region. TRIAL REGISTRATION:Clinical Trials NCT03307226 (Registered: 10/11/17).
Project description:<h4>Introduction</h4>Adolescent girls are at high risk of HIV infection in sub-Saharan Africa. Mental health distress, driven by adverse childhood experiences (ACEs) such as abuse, poverty and family HIV, may be an important driver of HIV risk behaviour among adolescent girls, while education may mitigate these risks. This study aimed to develop an empirically based theoretical model between ACEs, mental health distress and HIV risk behaviour among adolescent girls in South Africa and to investigate the potential moderating effects of free schooling provision.<h4>Methods</h4>Self-report questionnaires using validated scales were completed by adolescent girls aged 12 to 17 at baseline in two provinces in South Africa in 2011, with a 99% one-year follow-up in 2012 (n = 1498). Sampling included every household in randomly selected census enumeration areas of four deprived health districts. Confirmatory factor analysis was employed to identify measurement models and a structural equation model was developed to test pathways of risk and protection.<h4>Results</h4>Internalizing and externalizing mental health distress fully mediated the positive relationship between ACEs at baseline and HIV risk behaviour at follow-up among adolescent girls. Internalizing mental health distress was associated with increased sexual risk at follow-up via higher externalizing problems. Free schooling provision at baseline and follow-up eliminated the pathway from internalizing to externalizing mental health distress by moderating the pathway between ACEs and internalizing mental health distress. It also weakened the pathway from externalizing mental health distress to HIV risk behaviour at follow-up through a direct negative effect on externalizing mental health distress.<h4>Conclusions</h4>Reducing ACEs and adolescent mental health distress is essential for reducing HIV risk behaviour among girls in South Africa. Free schooling provision may be an important tool for reducing these problems and mitigating negative pathways to HIV risk among vulnerable adolescent girls.
Project description:BACKGROUND:The roll-out of antiretroviral therapy (ART) has changed contexts of HIV risk, but the influence on HIV incidence among young women is not clear. We aimed to summarise direct estimates of HIV incidence among adolescent girls and young women since ART and before large investments in targeted prevention for those in sub-Saharan Africa. METHODS:We did a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, Global Health, and CINAHL for studies reporting HIV incidence data from serological samples collected among females aged 15-24 years in ten countries (Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe) that were selected for DREAMS investment in 2015. We only included articles published in English. Our main outcome was to summarise recent levels and trends in HIV incidence estimates collected between 2005 and 2015, published or received from study authors, by age and sex, and pooled by region. FINDINGS:51 studies were identified from nine of the ten DREAMS countries; no eligible studies from Lesotho were identified. Directly observed HIV incidence rates were lowest among females aged 13-19 years in Kumi, Uganda (0·38 cases per 100 person-years); and directly observed HIV incidence rates were highest in KwaZulu-Natal, South Africa (7·79 per 100 person-years among females aged 15-19 years, and 8·63 in those aged 20-24 years), among fishing communities in Uganda (12·40 per 100 person-years in females aged 15-19 years and 4·70 in those aged 20-24 years), and among female sex workers aged 18-24 years in South Africa (13·20 per 100 person-years) and Zimbabwe (10·80). In pooled rates from the general population studies, the greatest sex differentials were in the youngest age groups-ie, females aged 15-19 years compared with male peers in both southern African (pooled relative risk 5·94, 95% CI 3·39-10·44) and eastern African countries (3·22, 1·51-6·87), and not significantly different among those aged 25-29 years in either region. Incidence often peaked earlier (during teenage years) among high-risk groups compared with general populations. Since 2005, HIV incidence among adolescent girls and young women declined in Rakai (Uganda) and Manicaland (Zimbabwe), and also declined among female sex workers in Kenya, but not in the highest-risk communities in South Africa and Uganda. INTERPRETATION:Few sources of direct estimates of HIV incidence exist in high-burden countries and trend analyses with disaggregated data for age and sex are rare but indicate recent declines among adolescent girls and young women. In some of the highest-risk settings, however, little evidence exists to suggest ART availability and other efforts slowed transmission by 2016. Despite wide geographical diversity in absolute levels of incidence in adolescent girls and young women, risk relative to males persisted in all settings, with the greatest sex differentials in the youngest age groups. To end new infections among the growing population of adolescents in sub-Saharan Africa, prevention programmes must address gender inequalities driving excessive risk among adolescent girls. FUNDING:This work was conducted as part of a planning grant funded by the Bill & Melinda Gates Foundation.
Project description:BACKGROUND:Adolescent girls in Zambia face risks and vulnerabilities that challenge their healthy development into young women: early marriage and childbearing, sexual and gender-based violence, unintended pregnancy and HIV. The Adolescent Girls Empowerment Program (AGEP) was designed to address these challenges by building girls' social, health and economic assets in the short term and improving sexual behavior, early marriage, pregnancy and education in the longer term. The two-year intervention included weekly, mentor-led, girls group meetings on health, life skills and financial education. Additional intervention components included a health voucher redeemable for general wellness and reproductive health services and an adolescent-friendly savings account. METHODS:A cluster-randomized-controlled trial with longitudinal observations evaluated the impact of AGEP on key indicators immediately and two years after program end. Baseline data were collected from never-married adolescent girls in 120 intervention clusters (3515 girls) and 40 control clusters (1146 girls) and again two and four years later. An intent-to-treat analysis assessed the impact of AGEP on girls' social, health and economic assets, sexual behaviors, education and fertility outcomes. A treatment-on-the-treated analysis using two-stage, instrumental variables regression was also conducted to assess program impact for those who participated. RESULTS:The intervention had modest, positive impacts on sexual and reproductive health knowledge after two and four years, financial literacy after two years, savings behavior after two and four years, self-efficacy after four years and transactional sex after two and four years. There was no effect of AGEP on the primary education or fertility outcomes, nor on norms regarding gender equity, acceptability of intimate partner violence and HIV knowledge. CONCLUSIONS:Although the intervention led to sustained change in a small number of individual outcomes, overall, the intervention did not lead to girls acquiring a comprehensive set of social, health and economic assets, or change their educational and fertility outcomes. It is important to explore additional interventions that may be needed for the most vulnerable girls, particularly those that address household economic conditions. Additional attention should be given to the social and economic environment in which girls are living. TRIAL REGISTRATION:ISRCTN29322231. Trial Registration Date: March 04, 2016; retrospectively registered.
Project description:BACKGROUND:Children in Sub-Saharan Africa (SSA) comprise half of the total regional population, yet existing mental health services are severely under-equipped to meet their needs. Although effective interventions for the treatment of disruptive behavioral disorders (DBDs) in youth have been tested in high-poverty and high-stress communities in developed countries, and are relevant for widespread dissemination in low- and middle-income countries (LMICs), most of these evidence-based practices (EBPs) have not been utilized in SSA, a region heavily impacted by poverty, diseases including HIV/AIDS, and violence. Thus, this paper presents a protocol for a scale-up longitudinal experimental study that uses a mixed-methods, hybrid type II, effectiveness implementation design to test the effectiveness of an EBP, called Multiple Family Group (MFG) aimed at improving child behavioral challenges in Uganda while concurrently examining the multi-level factors that influence uptake, implementation, sustainment, and youth outcomes. METHODS:The MFG intervention will be implemented and tested via a longitudinal experimental study conducted across 30 public primary schools located in both semi-urban and rural communities. The schools will be randomly assigned to three study conditions (n?=?10 per study condition): (1) MFG delivered by trained family peers; (2) MFG delivered by community health workers; or; (3) comparison: usual care comprising mental health care support materials, bolstered with school support materials. A total of 3000 children (ages 8 to 13 years; grades 2 to 7) and their caregivers (N?=?3000 dyads); 60 parent peers, and 60 community health workers will be recruited. Each study condition will comprise of 1000 child-caregiver dyads. Data will be collected at baseline, 8 and 16 weeks, and 6-month follow-up. DISCUSSION:This project is the first to test the effectiveness of the MFG intervention while concurrently examining multi-level factors that influence overall implementation of a family-based intervention provided in schools and aimed at reaching the large child population with mental health service needs in Uganda. Moreover, the study draws upon an EBP that has already been tested for delivery by parent peers and community facilitators, and hence will take advantage of the advancing science behind task-shifting. If successful, the project has great potential to address global child mental health needs. TRIAL REGISTRATION:ClinicalTrials.gov, ID: NCT03081195 . Registered on 16 March 2017.
Project description:African American adolescent females continue to be at disproportionate high risk for HIV infection. A repeated measures quasi-experimental comparison group design compared an HIV risk-reduction intervention delivered by mothers with an HIV risk-reduction intervention delivered by health professionals and with a health promotion intervention delivered by mothers. The three interventions were randomly assigned to one of three geographical distinct sites. A convenience sample of 553 low-income African American adolescent girls with a baseline age of 11 to 14 years participated in the study. The results revealed that over a 6-month period, compared to girls in the health promotion intervention, the girls in the HIV risk-reduction interventions had significant higher scores on HIV transmission knowledge, condom attitudes, and self-efficacy to use condoms. The implication is mothers who receive appropriate training may be able to deliver HIV risk reduction to their daughters as well as health professionals.
Project description:Low caste adolescent girls living in rural northern Karnataka are at increased risk of school drop-out, child marriage, and entry into sex-work, which enhances their vulnerability to HIV, early pregnancy and adverse maternal and child health outcomes. This protocol describes the evaluation of Samata, a comprehensive, multi-level intervention designed to address these structural drivers of HIV risk and vulnerability.The Samata study is a cluster randomised controlled trial that will be conducted in eighty village clusters (40 intervention; 40 control) in Bijapur and Bagalkot districts in northern Karnataka. The intervention seeks to reach low caste girls and their families; adolescent boys; village communities; high school teachers and school governing committees; and local government officials. All low caste (scheduled caste/tribe) adolescent girls attending 7th standard (final year of primary school) will be recruited into the study in two consecutive waves, one year apart. Girls (n = 2100), their families (n = 2100) and school teachers (n = 650) will be interviewed at baseline and at endline. The study is designed to assess the impact of the intervention on four primary outcomes: the proportion of low caste girls who (i) enter into secondary school; (ii) complete secondary school; (iii) marry before age 15; and (iv) engage in sex before age 15. Observers assessing the outcomes will be blinded to group assignment. The primary outcome will be an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at follow-up. We will also conduct survival analyses for the following secondary outcomes: marriage, sexual debut, pregnancy and entry into sex work. Complementary monitoring and evaluation, qualitative and economic research will be used to explore and describe intervention implementation, the pathways through which change occurs, and the cost-effectiveness of the intervention.This is an innovative trial of a comprehensive intervention to improve the quality of life and reduce HIV vulnerability among marginalised girls in northern Karnataka. The findings will be of interest to programme implementers, policy makers and evaluation researchers working in the development, education, and sexual and reproductive health fields.ClinicalTrials.Gov NCT01996241 . 16th November 2013.
Project description:<h4>Background</h4>Adolescents and young people (10-24 years old) in the Latin America and the Caribbean (LAC) region represent approximately 25% of the region's population. Since the 2008 global economic crisis, the pace of reduction in poverty and income inequality in the LAC region has stalled. The region is characterised by high levels of inequities and is also vulnerable to many natural disasters. Food systems are changing with increased availability and marketing of packaged and fast foods and sugar-sweetened drinks. Adolescence is a formative phase of the life course with multiple physical, emotional and social changes which can make them vulnerable to health problems. We assess the potential impact of macro-determinants, human and economic development as well as income inequality, on 2 top-ranking regional priorities for adolescent nutrition and mental health, using measures of overweight and suicidal ideation and planning which some have shown to be associated.<h4>Methods and findings</h4>The Global School-based Health Survey (GSHS) is a nationally representative self-administered, school-based survey. We examined overweight/obesity and suicidal ideation with planning by gross domestic product (GDP) per capita or human development index (HDI) in 10-19-year-old adolescents from 21 LAC countries between 2009 and 2013. Sample sizes varied from 943 in Anguilla to 27,988 in Argentina. A total of 55,295 adolescents had a measure of overweight/obesity status, and 59,061 adolescents reported about suicidal ideation with planning. There was equal representation by sex in the surveys (52% girls and 48% boys). A total of 28.8% of boys and 28.1% of girls had overweight/obesity, and 7.5% of boys and 17.5% of girls reported suicidal ideation with planning over the last 12 months. Adjusted for individual socioeconomic and risk behaviours, and relative to the highest GDP per capita tertile, the middle tertile was associated with 42% (95% confidence interval (CI) 59% to 17%, p = 0.003) and 32% (95% CI 60% to 5%, p = 0.023), and the lowest tertile with 40% (95% CI 55% to 19%, p = 0.001) and 46% (95% CI 59% to 29%, p < 0.001) lower chances of overweight/obesity for girls and boys, respectively. A similar positive effect was seen with HDI, with lowest chances of overweight in the lowest tertile compared with the highest tertile for both sexes. Overweight/obesity was positively related with suicidal ideation with planning for girls (odds ratio (OR) 1.12, 95% CI 1.02 to 1.22, p = 0.009) and weakly related for boys (OR 1.09, 95% CI 0.96 to 1.24, p = 0.182). In contrast to overweight/obesity status, suicidal ideation with planning was not related to macro-level indices despite both outcomes sharing common individual socioeconomic and risk behaviour correlates. Limitations include the dominance of Argentinians in the sample (40%), the exclusion of vulnerable adolescents who dropped out of school, and reporting bias due to stigma of mental health-related issues.<h4>Conclusions</h4>This study shows that economic and human development were positively associated with adolescent overweight/obesity but not with suicidal ideation with planning. We also observed an interconnectedness between overweight/obesity and suicide ideation with planning among girls. These findings highlight the importance of strategies that engage with both upstream and downstream determinants to improve adolescent nutrition and mental health.
Project description:BACKGROUND:Teenage pregnancy is a serious public health and social problem, with 95% occurring in developing countries. The aim of the study was to investigate the behavioural, familial and social factors associated with teenage pregnancy among girls aged 13-19 years in Lira District, Uganda. METHODS:Primary data from a case-control study of teenage girls (aged 13-19 years) in Lira District, Uganda was analysed. A Structured questionnaire was administered using face-to-face interviews to collect data on 495 participants, identified through simple random sampling from 32 villages in two counties in Lira District. Data analyses were done using SPSS Statistics 23 for descriptive, bivariate (i.e. Chi-square tests) and multivariable analyses (i.e. logistics regression) used for determining independent associations. RESULTS:A total of 495 teenage girls participated in the study, however, final analyses were undertaken for 480 respondents. At bivariable analysis, all variables except alcohol consumption were significantly associated with teenage pregnancy. Among the behavioural factors assessed, multivariable analyses showed that having multiple sexual partners, frequent sex and irregular contraceptive use increased the likelihood of teenage pregnancy. Among familial factors, being married was found to increase the likelihood of teenage pregnancy. Peer pressure, sexual abuse and lack of control over sex was observed to increase the likelihood of teenage pregnancy. CONCLUSIONS:Demographic, behavioural, familial and social factors are important predictors of teenage pregnancy in Lira District. Interventions focussing on: retaining pregnant and married girls at school, information on sexual and reproductive health of teenage girls, improving access to and information about contraceptive use among teenage girls, improving socio-economic status of households, and law enforcement on sexual abuse among girls may come a long way to improving adolescent sexual and health services in the low-income settings.
Project description:ABSTRACTMental health issues are a predisposing factor for HIV acquisition. We examined the association between depressive symptoms and patterns of sexual experience among girls aged 10–14 years living in Korogocho and Viwandani slums in Nairobi, Kenya. We analysed data collected in 2017 from a random sample of 606 girls. Using Latent Class Analysis, we modelled patterns of sexual experiences and used multivariable regression analysis to determine the association between self-reported depressive symptoms and sexual experiences. Seven in ten girls reported at least one symptom of self-reported depression in the past 12 months. About 13% of girls had had a sexual experience, resulting in two patterns of sexual experience – naïve and experienced. Girls reporting depressive symptoms were more likely to be sexually experienced. Sexual and reproductive health programs targeting adolescent girls should consider including intervention packages that address mental health conditions such as depression.
Project description:Cross-sectional studies demonstrated associations of several sociodemographic and psychosocial factors with generic health-related quality of life (HRQoL) in children and adolescents. However, little is known about factors affecting the change in child and adolescent HRQoL over time. This study investigates potential psychosocial risk and protective factors of child and adolescent HRQoL based on longitudinal data of a German population-based study.Data from the BELLA study gathered at three measurement points (baseline, 1-year and 2-year follow-ups) were investigated in n = 1,554 children and adolescents aged 11 to 17 years at baseline. Self-reported HRQoL was assessed by the KIDSCREEN-10 Index. We examined effects of sociodemographic factors, mental health problems, parental mental health problems, as well as potential personal, familial, and social protective factors on child and adolescent HRQoL at baseline as well as over time using longitudinal growth modeling.At baseline, girls reported lower HRQoL than boys, especially in older participants; low socioeconomic status and migration background were both associated with low HRQoL. Mental health problems as well as parental mental health problems were negatively, self-efficacy, family climate, and social support were positively associated with initial HRQoL. Longitudinal analyses revealed less increase of HRQoL in girls than boys, especially in younger participants. Changes in mental health problems were negatively, changes in self-efficacy and social support were positively associated with the change in HRQoL over time. No effects were found for changes in parental mental health problems or in family climate on changes in HRQoL. Moderating effects for self-efficacy, family climate or social support on the relationships between the investigated risk factors and HRQoL were not found.The risk factor mental health problems negatively and the resource factors self-efficacy and social support positively affect the development of HRQoL in young people, and should be considered in prevention programs.