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

Autoři: Yesim Tozan aff001;  Sicong Sun aff002;  Ariadna Capasso aff001;  Julia Shu-Huah Wang aff003;  Torsten B. Neilands aff004;  Ozge Sensoy Bahar aff002;  Christopher Damulira aff002;  Fred M. Ssewamala aff002
Působiště autorů: College of Global Public Health, New York University, New York, New York, United States of America aff001;  International Center for Child Health and Development, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, United States of America aff002;  Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China aff003;  Center for AIDS Prevention Studies, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America aff004
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article
doi: 10.1371/journal.pone.0226809



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.

Klíčová slova:

Adolescents – Cost-effectiveness analysis – Finance – HIV prevention – Mental health and psychiatry – Schools – Socioeconomic aspects of health


1. World Health Organization. Health for the world’s adolescents: A second chance in the second decade. 2014 [cited 2019 January 9]. http://apps.who.int/adolescent/second-decade/.

2. Mokdad AH, Forouzanfar MH, Daoud F, Mokdad AA, El Bcheraoui C, Moradi-Lakeh M, et al. Global burden of diseases, injuries, and risk factors for young people's health during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. (1474-547X (Electronic)).

3. Bryant M, Beard J. Orphans and Vulnerable Children Affected by Human Immunodeficiency Virus in Sub-Saharan Africa. Pediatr Clin North Am. 2016;63(1):131–47. Epub 2015/11/29. doi: 10.1016/j.pcl.2015.08.007 26613693.

4. Goldberg RE, Short SE. What do we know about children living with HIV-infected or AIDS-ill adults in Sub-Saharan Africa? A systematic review of the literature. AIDS Care. 2016;28(sup2):130–41. doi: 10.1080/09540121.2016.1176684 27392008

5. United Nations Children’s Fund. Women: At the heart of the HIV response for children. New York, NY: UNICEF, 2018.

6. United Nations Children’s Fund. For Every Child, End AIDS—Seventh Stocktaking Report. New York, NY: UNICEF, 2016.

7. Mkandawire P, Tenkorang E, Luginaah IN. Orphan Status and Time to First Sex Among Adolescents in Northern Malawi. AIDS and Behavior. 2012;17(3):939–50. doi: 10.1007/s10461-011-0120-y 22223299

8. Cluver L, Orkin M, Boyes M, Gardner F, Meinck F. Transactional sex amongst AIDS-orphaned and AIDS-affected adolescents predicted by abuse and extreme poverty. J Acquir Immune Defic Syndr 2011;58(3):336–43. doi: 10.1097/QAI.0b013e31822f0d82 21857361

9. Operario D, Underhill K, Chuong C, Cluver L. HIV infection and sexual risk behaviour among youth who have experienced orphanhood: systematic review and meta-analysis. Journal of the International AIDS Society. 2011;14(25).

10. Raymond JM, Zolnikov TR. AIDS-Affected Orphans in Sub-Saharan Africa: A Scoping Review on Outcome Differences in Rural and Urban Environments. AIDS Behav. 2018;22(10):3429–41. Epub 2018/05/04. doi: 10.1007/s10461-018-2134-1 29721717.

11. Atwine B E C-G, Bajunirwe F. Psychological distress among AIDS orphans in rural Uganda. Social Service Review. 2005;61:555–64.

12. Nabunya P, Ssewamala FM. The Effects of Parental Loss on the Psychosocial Wellbeing of AIDS-Orphaned Children Living in AIDS-Impacted Communities: Does Gender Matter? Child Youth Serv Rev. 2014;43:131–7. Epub 2014/07/30. doi: 10.1016/j.childyouth.2014.05.011 25067869.

13. Ismayilova L, Ssewamala FM, Karimli L. Family Support as a Mediator of Change in Sexual Risk-Taking Attitudes Among Orphaned Adolescents in Rural Uganda. Journal of Adolescent Health. 2012;50(3):228–35. doi: 10.1016/j.jadohealth.2011.06.008 22325127

14. UNICEF-ESARO/Transfer Project. Social Cash Transfer and Children’s Outcomes: A Review of Evidence from Africa. United Nations Children’s Fund, 2015.

15. Robertson L, Mushati P, Eaton JW, Dumba L, Mavise G, Makoni J, et al. Effects of unconditional and conditional cash transfers on child health and development in Zimbabwe: a cluster-randomised trial. The Lancet. 2013;381(9874):1283–92. doi: 10.1016/s0140-6736(12)62168-0 23453283

16. Ssewamala FM, Karimli L, Torsten N, Wang JS, Han CK, Ilic V, et al. Applying a Family-Level Economic Strengthening Intervention to Improve Education and Health-Related Outcomes of School-Going AIDS-Orphaned Children: Lessons from a Randomized Experiment in Southern Uganda. Prev Sci. 2016;17(1):134–43. Epub 2015/08/01. doi: 10.1007/s11121-015-0580-9 26228480.

17. UNAIDS. Gap report. 2014.

18. Cluver L, Boyes M, Orkin M, Pantelic M, Molwena T, Sherr L. Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study. The Lancet Global Health. 2013;1(6):e362–e70. doi: 10.1016/S2214-109X(13)70115-3 25104601

19. Schreiner M, Sherraden MW. Can the poor save?: Saving and asset building in individual development accounts. New Brunswick, NJ: Transaction Publishers; 2007.

20. Ssewamala FM, Ismayilova L, McKay M, Sperber E, Bannon W Jr., Alicea S. Gender and the effects of an economic empowerment program on attitudes toward sexual risk-taking among AIDS-orphaned adolescent youth in Uganda. J Adolesc Health. 2010;46(4):372–8. Epub 2010/03/24. doi: 10.1016/j.jadohealth.2009.08.010 20307827.

21. Ssewamala FM, Alicea S, Bannon WM Jr., Ismayilova L. A novel economic intervention to reduce HIV risks among school-going AIDS orphans in rural Uganda. J Adolesc Health. 2008;42(1):102–4. Epub 2007/12/25. doi: 10.1016/j.jadohealth.2007.08.011 18155037.

22. Ssewamala FM, Neilands TB, Waldfogel J, Ismayilova L. The Impact of a Comprehensive Microfinance Intervention on Depression Levels of AIDS-Orphaned Children in Uganda. Journal of Adolescent Health. 2012;50(4):346–52. doi: 10.1016/j.jadohealth.2011.08.008 22443837

23. Han C-K, Ssewamala FM, Wang JS-H. Family economic empowerment and mental health among AIDS-affected children living in AIDS-impacted communities: evidence from a randomised evaluation in southwestern Uganda. Journal of Epidemiology and Community Health. 2013;67(3):225–30. doi: 10.1136/jech-2012-201601 23410851

24. Karimli L, Ssewamala FM. Do Savings Mediate Changes in Adolescents’ Future Orientation and Health-Related Outcomes? Findings from Randomized Experiment in Uganda. Journal of Adolescent Health. 2015;57(4):425–32. doi: 10.1016/j.jadohealth.2015.06.011 26271162

25. Jennings L, Ssewamala FM, Nabunya P. Effect of savings-led economic empowerment on HIV preventive practices among orphaned adolescents in rural Uganda: results from the Suubi-Maka randomized experiment. AIDS Care. 2016;28(3):273–82. doi: 10.1080/09540121.2015.1109585 26548549

26. Ssewamala FM, Wang JS, Neilands TB, Bermudez LG, Garfinkel I, Waldfogel J, et al. Cost-Effectiveness of a Savings-Led Economic Empowerment Intervention for AIDS-Affected Adolescents in Uganda: Implications for Scale-up in Low-Resource Communities. J Adolesc Health. 2018;62(1S):S29–S36. Epub 2017/12/24. doi: 10.1016/j.jadohealth.2017.09.026 29273115.

27. Uganda AIDS Commission, Ministry of Health of Uganda. 2014 Uganda HIV and AIDS Country Progress report. Kampala, Uganda: UAC and Ministry of Health, 2015.

28. Frankenberg E, Jones N. Self-rated health and mortality: does the relationship extend to a low-income setting? Journal of Health and Social Behavior. 2004;45(4):441–52. doi: 10.1177/002214650404500406 15869115

29. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology. 1974;42(6):861–5. doi: 10.1037/h0037562 4436473

30. Fitts WH, Warren WL. Tennessee Self-Concept Scale: TSCS-2. Los Angeles, CA: Western Psychological Services; 1996.

31. Earls F, Visher CA. Project on human development in Chicago neighborhoods: A research update. Washington, DC: US Department of Justice, Office of Justice programs, National Institute of Justice, 1997.

32. Ssewamala FM, Ismayilova L. Integrating Children's Savings Accounts in the Care and Support of Orphaned Adolescents in Rural Uganda. Soc Serv Rev. 2009;83(3):453–72. Epub 2010/05/07. doi: 10.1086/605941 20445763.

33. Uganda Bureau of Statistics. Consumer Price Index Kampala, Uganda: Uganda Bureau of Statistics,; 2015. www.ubos.org.

34. Drummond MF, O'Brien BJ, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes. 2nd ed. Oxford, U.K.: Oxford Univeristy Press; 1997.

35. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Erlbaum; 1988.

36. Husereau D, Drummond M, Petrou S. Consolidated health economic evaluation reporting standards (CHEERS)—Explanation and elaboration: A report of the ISPOR health economic evaluations publication guidelines good reporting practices task force. Value Health. 2013;16:231–50. doi: 10.1016/j.jval.2013.02.002 23538175

37. Briggs A, Sculpher M, Buxton M. Uncertainty in the economic evaluation of health care technologies: The role of sensitivity analysis Health Economics. 1994;3(2):95–104. doi: 10.1002/hec.4730030206 8044216

38. Glewwe P, Muralidharan K. Improving School Education Outcomes in Developing Countries: Evidence, Knowledge Gaps, and Policy Implications. RISE-WP-15/001, RISE Programme, 2015.

39. Kilburn K, Handa S, Angeles G, Mvula P, Tsoka M. Short-term Impacts of an Unconditional Cash Transfer Program on Child Schooling: Experimental Evidence from Malawi. Econ Educ Rev. 2017;59:63–80. Epub 2017/06/30. doi: 10.1016/j.econedurev.2017.06.002 29531427.

40. Handa S, Halpern CT, Pettifor A, Thirumurthy H. The government of Kenya's cash transfer program reduces the risk of sexual debut among young people age 15–25. PLoS One. 2014;9(1):e85473–e. doi: 10.1371/journal.pone.0085473 24454875.

41. Sarkar S, Corso P, Ebrahim-Zadeh S, Kim P, Charania S, Wall K. Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review. EClinicalMedicine. 2019;10:10–31. doi: 10.1016/j.eclinm.2019.04.006 31193863.

42. Fieno J, Leclerc-Madlala S. The promise and limitations of cash transfer programs for HIV prevention. Afr J AIDS Res. 2014;13(2):153–60. Epub 2014/09/02. doi: 10.2989/16085906.2014.943251 25174632.

43. Remme M, Vassall A, Lutz B, Luna J, Watts C. Financing structural interventions: going beyond HIV-only value for money assessments. AIDS. 2014;28(3):425–34. Epub 2014/03/29. doi: 10.1097/QAD.0000000000000076 24670525.

44. Karlan D, Ratan AL, Zinman J. Savings by and for the Poor: A Research Review and Agenda. Review of Income and Wealth. 2014;60(1):36–78. doi: 10.1111/roiw.12101 25792764

45. Madrian BC. Matching Contributions and Savings Outcomes: A Behavioral Economics Perspective. National Bureau of Economic Research. 2012;NBER Working Paper Series 18220.

46. Wang JS-H, Ssewamala FM, Neilands T, Bermudez LG, Garfinkel I, Waldfogel J, et al. Effects of financial incentives on saving outcomes and material well-being: Evidence from a randomized controlled trial in Uganda. Journal of Policy Analysis and Management. 2018;37(3):602–29. doi: 10.1002/pam.22065 30122799

47. Harris DN. Toward Policy-Relevant Benchmarks for Interpreting Effect Sizes: Combining Effects With Costs. Educational Evaluation and Policy Analysis. 2009;31(1):3–29. doi: 10.3102/0162373708327524

48. McEwan PJ. Cost-effectiveness analysis of education and health interventions in developing countries. Journal of Development Effectiveness. 2012;4(2):189–213. doi: 10.1080/19439342.2011.649044

49. Brener ND, Billy JOG, Grady WR. Assessment of factors affecting the validity of self-reported health-risk behavior among adolescents: evidence from the scientific literature. Journal of Adolescent Health. 2003;33(6):436–57. doi: 10.1016/s1054-139x(03)00052-1 14642706

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