Cash, care, prevention
and adherence
for adolescents:
Latest evidence
from southern africa
L Cluver, M Orkin, M Boyes, L Sherr, F Meinck
Arusha, December 2014
Collaborative research: science to assist policy
Childfocused
research
Universities: Oxford,
UCT, Wits, Curtin,
UKZN
National longitudinal study of adolescents
6850 adolescents, 2500 adult caregivers, 2008-2012
Longitudinal national survey
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•
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•
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Main study: N=6000 (age: 10-18)
3 provinces South Africa; 6 sites >30% prevalence
Stratified random sampling of census EAs
Every household with a child aged 10-17
Urban/rural, 1 year follow-up in 2 provinces
n=3401, 97% follow-up
Measures
•
Standardised scales, national surveys
Ethics
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Approved by Universities of Cape Town,
Oxford, KwaZulu-Natal,
6 Provincial Health & Education Departments
Social & health service referrals
Controlling for prior HIV risk
TEEN TA LK
IKHASI ELIYIMFIHLO LENGXOXO YABASHA
Siyabonga ngok usisiza ng alokh
u.lLemi buzo
i yi m fih o ngokuphe l el e - iyof ak
wa
emvil aph i n i ev al iwe t haqa. Si c
ela un gal i bhal i
i gam lak h o k ul eli ph eph a.
Uhlelo lombuzo no: ....................
Sonke siyazi ukuthi ukwenza ucansi kungasho izinto eziningi. Amantombazana angalala nabafana, amantombazana
namantombazane, noma abafana nabafana. Abanye babo benze ucansi ngesitho sanagasese sangemuva. Uma sithi
wenze ucansi sisho okunye kwalokhu!
Wake waya ocansini?
1
Wanuneminyaka emingakhi ngenkathi uqala
ukuya ocansini? Bhala phansi iminyaka: .........
2
Bangaki abantu oye nabo ocansini kulonyaka
odlulile? Bhala phansi leyonombolo: ..........
Uma uke waya ocansini kulonyaka odlulile,
kukangakanani usebenzisa ikhondomu?
...... njalonje
...... ngaphezulu kwesigamu sesikhathi
...... isigamu sesikhathi
...... isikhathi esingaphansi kakhulu
kwesigamu/hafu
...... angikaze
Kulababantu kulonyaka odlulile, bhala phansi ukuthi bangaki ababe:
........ isoka lakho/intombi yakho, noma umyeni/inkosikazi?
........ umuntu ongasiye umaqondana wakho, kodwa uya naye ocansini
izikhashana eziningana?
........ umuntu ohlangana naye ngalesosi khathi njengowo busuku
obubodwa?
........ umuntu omkhokhele ukuze uye naye ocansini?
4
3
Sicela ubhale igama lakho lapha:
5
........................................
Manje, ngicela ucabange igama
elihlukile esingalisebenzisa masibhala
ngalolucwaningo. Ungakhetha noma
iliphi igama olifunayo!
....................................
6
a
EMIS #: ...........................
. ...
Umbuzi wemibuzo: ............................. Usuku: ...............
Inombolo yendawo yocwaningo: .......................................
º
.
‘
GPS longitude (E): E
º
.
‘
..... Cha
Abantu baya ocansini ngenxa yezizathu
eziningi futhi befuna ukuthola izinuzo ezinXX
ingi. Ezahlukene kwezinye izikhathi, abantu
banikeza lowo abaya naye ocansini izipho.
Uke wanikwa lezizipho ezilandelayo ngoba
uye ocansini nomunye umuntu? K ekelezela
ukuthi yikuphi:
Imali
Inombolo kamazisi: .......................................................
GPS lattitude (S): S
Uke waya ocansini udakiwe? ..... Yebo
7
Indawo obuzelwa kuyo: .................................................
.
Isikole/inhlangano: .................................... Ibnga:
Ingabe ukhona omunye umuntu oke waya naye
ocansini obeneminyaka engaphezulu kwemihlanu
ubudala kunawe
..... Yebo ..... Cha
Uke waya ocansini ngoba udakwe izidakamizwa
ezinjenge Tik, insangu noma yini enye?
..... Yebo
..... Cha
Inombolo w
Yohlelo Le mi buzo: . ........... U
m
f n a/I nt ombaz ane
Privacy code: ...................
ECT
Uke wezwa nge Sandulela Ngculaza ne
Ngculaza uqobo?
..... Yebo
..... Cha
Bhala phansi noma yini ocabanga ukuthi
umuntu angayenza ukugwema ukuthola
igciwane lesandulela ngculaza, igciwane
elibanga ingculaza.
9
.....................................................
.....................................................
.....................................................
.....................................................
Indawo yokuhlala
.....................................................
Ukugitsheliswa emotweni/etekisini
A
AFRIC
a lok hu. Azikh o iz Ak uk hon a uk uh lolw
ing eyi zo!
Ikheli: ........................................
impen dul o ezi yizo nez
za abantu
usi
uk
e
ond
luq
.................................................
ngo
Lol ucw ani
o a
abong
Siy
.
ika
Afr
u
..................................................
abasha eNingizim
o.
kh
lwa
z
izo
Inombolo yocingo: ........................... f
ngesi kh ath i nan gos
8
Cellphone airtime
s
r
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a
C
g
oun
PROJ
Ungaba nenkinga yini uma singaphinde sikuthinte futhi? Sicela
ubhale ikheli nezinombolo zocingo ukuze siphinde sikuthinte futhi:
Uke waya ocansini nomuntu ube
ungathandi, bekuzwisa ubuhlungu, noma
ngoba ubusaba ukuthi bazokulimaza uma
ungavumanga?
..... Yebo
..... Cha
.....................................................
Ukuthengela okokuphuza
Izingubo
SOUTH
...... Cha
Uma uphendule wathi ‘Cha’ ungaligcwalisi lelipheshana lonke. Yiya ekhasini elilandelayo!
TEEN TALK
O
SUTH AFRICA
Nomayini ooyi sho izba yimih lo. aLokhu
kusho ukuthi ngeke sibike ngegama lakho
langempela.
..... Yebo
Amamaki aphezulu esikoleni
Imali yesikole
Ukudla
Nomayini enye
10
Uke wakhulelwa noma wakhulelisa?
..... Yebo
..... Cha
12
22
Igciwane lesandulela ngculaza liyathelelana
uma abantu beya ocansini. Ucabanga ukuthi
amathuba akho okuthola I HIV/AIDS angakanani?
..... anginalo ithuba nhlobonhlobo
..... ithuba elincane
..... ithuba elingahle libe phakathi nendawo
50/50
..... ithuba elikhulu kakhulu
..... ngike ngahlolwa kulezizinyanga ezintathu
ezindlulile, futhi ngiyasazi isimo sami
..... angazi ukuthi yini I HIV/AIDS
11
Unazo yini izingane? Sicela ubhale iminyaka yazo:
13
............................................................
Predicting adolescent ART adherence & SRH use
• N=700 adolescents, 3-year
tracking
• All 32 ART clinics (>5 adolescents)
Buffalo City/Amathole Districts,
Eastern Cape
• Enrolled and lost-to-follow-up
• Viral load, CD4, pharmacy refills,
self-reported adherence
• Clinic assessments for facility-level
effects
• + 2-year qualitative ethnography
Effects of abuse, poverty & parental AIDS on
female adolescent risk of transactional sex
57%
Cluver, Orkin, Boyes, Meinck, Makhasi (2011). JAIDS
13%
7%
1%
Healthy family
AIDS-sick parent
Abused & hungry
AIDS-sick parent,
abused, hungry
Pathways to HIV-risk
mean
χ2(679)
640.06
AIDSorphan
BollenStine
p=.001
mean
χ2/df
1.57
RMSEA
SRMR
CFI
TLI
.032
.044
.939
.930
Stigma
.13
Education
risks
.12
.43
.18
.32
.08
Abuse
.15
.72
Psych.
distress
.14
.15
.15
.24
AIDSsick
parent
.22
.10
HIV Risk
Behaviour
Poverty
Cluver, Orkin, Boyes, Sherr, Nikelo, Makhasi (2013). Soc. Sci & Medicine. Analyses funded by RIATT.
Unconditional cash transfers
South Africa: Child grant reduces incidence & prevalence
of transactional sex and age-disparate sex for girls
8
% Incidence of transactional sex
(OR .49 CI .26-.93*)
7
% Incidence of age-disparate sex
(OR .29 CI .13-.67**)
No cash transfer
6
Child cash transfer
5
4
3
2
1
0
12-14 years
15-17 years
12-14 years
Cluver, Boyes, Orkin, Pantelic, Molwena, Sherr (2013). The Lancet Global Health.
15-17 years
Kenya: Summary Impacts of OVC cash transfer
on adolescents (Odds Ratios)
2,4
2,2
All
Females
2
1,8
1,6
1,4
1,2
1
Delayed Debut Never pregnant No depressive
Hope
Symptoms
Scale<Median
Handa, Halpern, Pettifor, Thirmurthy (2014) PLOS One.
School
Enrollment
Cash plus care?
Can CASH + CARE reduce HIV risk behavior?
Incidence rates:
CASH
Transactional sex
Age-disparate sex
Sex using substances
Multiple partners
CARE
Unprotected sex
Teen pregnancy
Food garden
Child-focused
grant
Positive
parenting
Regular food parcels
Free school meals
School counsellor
Teacher support
% girls with incidence of 1+ HIV risk behavior:
Cash plus care = halved risk
60
50
41%
Cash alone: OR .63
Cash plus care: OR .55
42%
Cash alone: no effect
Cash plus care: OR .50
40
28%
25%
30
15%
20
17%
10
0
no
support
cash
cash plus
care
Cluver, Orkin, Boyes, Sherr (2014). AIDS.
no support cash cash plus care
Controlling for: family HIV/AIDS, informal/formal housing, age of child,
poverty levels, number of moves of home, baseline HIV risk behaviour
HIV+ adolescents: ART adherence, cash and care
• Indicative percentages only, n=250
• Random sampling 32 state clinics, South Africa
Past week ART adherent (%)
Cash plus care: OR 2.42
Past-week self-reported adherence (%)
80
75
70
65
60
55
50
45
40
35
30
no support
cash: transfer/food
care: positive
garden/food parcel parenting/treatment
buddy
cash plus care
Structural drivers and
mechanisms
Poverty & family AIDS predict adolescent HIV-risks: how?
2011
Structural deprivation
2012
HIV-risk behavior
incidence
Hunger
Transactional sex
Age-disparate sex
Community violence
Sex using substances
Parental HIV/AIDS
all p<.001
Multiple partners
Unprotected sex
Informal settlement
Cluver, Orkin, Boyes, Sherr (2014). AIDS.
Pregnancy
controlling for: baseline HIV-risk, age, gender
school dropout
child abuse
conduct problems
psychological distress
drug/alcohol use
Structural
deprivation
Psychosocial problems
Cluver, Orkin, Boyes, Sherr (2014). AIDS.
p<.004
HIV-risk
behavior
incidence
controlling for: baseline HIV-risk, age, gender
Girls: ‘starving sex’ incidence
(longitudinal, 60% of HIV-risk behavior explained)
CARE
CASH
Psychosocial
risks
High
vulnerability
Starving Sex
CLASSROOM
controlling for: age,
baseline HIV-risk
What kinds of cash and care
work best?
(preliminary analyses)
Combinations for HIV-prevention
Males
Females
Careless Economic Careless Economic
Cash
Child Grants
Medical care
Class- School feeding
room Free school &
books
Care
Monitoring
Teacher
support
Pregnancy
MALES: % Probability of incidence of ’careless sex' HIVrisk behaviors (unprotected sex, sex whilst on
drugs/drunk, multiple partners, casual sex)
20,0
18,0
16,0
14,0
12,0
10,0
8,0
6,0
4,0
2,0
0,0
No intervention Good monitoring Teacher support Both interventions
12,0
FEMALES: % Probability of incidence of 'Economic
Sex' HIV-risks (transactional or age-disparate sex)
10,0
8,0
6,0
4,0
2,0
0,0
No intervention
Child grant
Free school
Both
interventions
Operationalising care
(preliminary analyses)
Parenting for Lifelong Health: Sinovuyo SA
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Aims: Reduce child abuse, improve parenting and supervision
Local NGO staff, no materials needed
Free: Creative Commons
WHO and UNICEF: scale-up to other countries
Thula Sana (pregnancy – 6 months)
Book sharing (toddlers)
Sinovuyo Kids (ages 2-9)
Sinovuyo Teen (ages 10-17)
SUNSHI NE
OF
POSI TI VE
ATTENTI ON
DEALI NG
WI TH DI FFI CULT
BEHAVI OUR
HOUSEHOLD RULES
GI VI NG CLEAR I NSTRUCTI ONS
PRAI SE AND REWARDS
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•
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Group work,
collaborative problem-solving
Home practice, role-playing
Evidence-based core principles
TALKI NG ABOUT FEELI NGS
BUI LDI NG LANGUAGE SKI LLS
SPECI AL TI ME WI TH YOUR CHI LD
HANDOUT # 1
RONDAVEL OF SUPPORT
Building a Rondavel of Support
Physical abuse p<.001
2,5
2
1,5
1
0,5
0
Pre
Post
Emotional Abuse p<.001/.002
3,5
3
2,5
2
1,5
1
0,5
0
Caregiver
Teen
Pre
Neglect p<.001/<.004
Sexual Abuse not
significant
1,2
1
0,2
0,8
0,15
0,6
Post
0,1
0,4
0,05
0,2
0
0
Pre
Post
Pre
Post
Caregiver depression p<.001
Teen depression and Suicidality
p<.001
30
7
6
5
4
3
2
1
0
25
Caregiver
depression
20
15
Caregiver
parenting
stress
10
5
Pre
Teen
depression
Suicidal teen
pre
Post
post
Adolescent Aggressive behavior
p<.002/<.02)
Caregiver negative coping i.e.
alcohol use
10
3
8
2
6
Caregiver
4
1
Teen
2
0
Pre
Post
0
pre
post
Girls: odds reduction in risk incidence
0,57
0,49
cash only
cash +care
0,47
0,32
0,31
0,25
0,17
0,15
0,06
multiple partners
transactional sex
unprotected sex
pregnancy
school dropout
Boys: odds reduction in risk incidence
0,35
0,31
0,28
0,2
0,11
multiple partners
unprotected sex
school dropout
criminal behavior
Controlling for: age,
formal/informal housing,
poverty, urban/rural,
household employment,
child migration, caregiver
gender, non-biological
caregiver & outcome risk
at baseline. Cash alone,
care alone & cash+care
entered simultaneously.
Unconditional, government cash transfers
reduce adolescent HIV risks
Cash plus care gives greater effects
Cash and care mitigate structural risk
Cumulative impacts of 2+ interventions
Effective in real-world sub-Saharan Africa
Funders: thank you.
‘I would like to advice the
government to issue grants to
those countries that are
suffering socially and see the
difference. And see how the
impact it could create in the
life many of youngsters. How it
can better their decision and
destiny.Take it from me I am
the living difference.’
Noxolo, 19 yrs.