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

Abstract

BackgroundChildren 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.MethodsIntent-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).FindingsAmong 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.ConclusionsMost 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.

The impact of cash transfers on mental health in children and young people in low-income and middle-income countries: a systematic review and meta-analysis

“…Where the same intervention and outcomes were reported multiple times, only one paper was included in the analysis. There were six papers generated from the Bridges to Future Intervention in Uganda, [34][35][36][37][38][39] including one paper by Tozan et al, 39 which summarised all results from the previous papers, and thus was the only one included in the analysis. Two papers reported on Kenya's Cash Transfer Programme for Orphans and Vulnerable Children 40 41 and both reported the same outcomes in adolescents.…”

“…45 The key details of each study are listed in table 1. Overall, the included studies involved 43 861 participants from Latin American or African regions: two in Mexico, 42 43 Malawi 45 46 and Kenya, 40 47 and one in Uganda, 39 Liberia, 48 Ecuador, 49 Nicaragua, 50 South Africa 51 and Cambodia. 52 All studies were published in 2007 or later.…”

Cash Transfers and Health

“…Findings indicate that the CDAs helped parents of children in the treatment group maintain high expectations for their children's education (66), reduced the intensity of maternal depressive symptoms (57), reduced punitive parenting practices (55), and improved children's early social-emotional development (56). Other studies conducted in sub-Saharan Africa have found that a CDA intervention improved mental health functioning for children and caregivers (e.g., 47,63,118,122) and reduced intentions to engage in sexual risk-taking behavior (78,111). Overall, findings suggest that CDAs enable disadvantaged families to build long-term savings and achieve positive health outcomes.…”

“…Despite efforts to test the cost-effectiveness of cash-transfer programs (35,96,99,112,118) and policies (81,82), a lack of benchmarks and comparisons limits our understanding of whether cash transfers are cost-effective (and how they might become so). Future research should (a) collect cost data, (b) establish cost-effectiveness benchmarks for different health outcomes, and (c) accumulate and compare cost-effectiveness evidence in multiple settings.…”

“…Future research should (a) collect cost data, (b) establish cost-effectiveness benchmarks for different health outcomes, and (c) accumulate and compare cost-effectiveness evidence in multiple settings. These contributions can inform policy making to achieve the same effect at a low cost and, thereby, to achieve sustainability (50,118).…”