Gender and the Effects of an Economic Empowerment Program on Attitudes Toward Sexual Risk-Taking Among AIDS-Orphaned Adolescent Youth in Uganda

doi:10.1016/j.jadohealth.2009.08.010

Journal of Adolescent Health

Volume 46, Issue 4, April 2010, Pages 372-378

https://doi.org/10.1016/j.jadohealth.2009.08.010 Get rights and content

Abstract

Purpose

This article examines gender differences in attitudes toward sexual risk–taking behaviors of acquired immune deficiency syndrome (AIDS)–orphaned youth participating in a randomized control trial testing an economic empowerment intervention in rural Uganda.

Methods

Adolescents (average age 13.7 years) who had lost one or both parents to AIDS from 15 comparable schools were randomly assigned to either an experimental (n = 135) or a control condition (n = 142). Adolescents in the experimental condition, in addition to usual care, also received support and incentives to save money toward secondary education.

Results

Findings indicate that although adolescent boys and girls within the experimental condition saved comparable amounts, the intervention appears to have benefited girls, in regard to the attitudes toward sexual risk–taking behavior, in a different way and to a lesser extent than boys.

Conclusions

Future research should investigate the possibility that adolescent girls might be able to develop equally large improvements in protective attitudes toward sexual risk taking through additional components that address gendered social norms.

Section snippets

Background and Theory: The SUUBI Research Program

Data examined here were obtained from the SUUBI Research Program (hereafter, SUUBI, which is a Luganda word for “hope”). SUUBI (2005–2008) was funded by the National Institute of Mental Health. The study was carried out in Rakai District of Uganda, which is the site of the first HIV infection detected in East Africa during the 1980s [7]. This study received institutional review board approval by Columbia University and Uganda National Council of Science and Technology. The overall aim of SUUBI

Participant selection and assignment

SUUBI included 286 AIDS-orphaned youth (average age 13.7 years) in primary school—immediately before the transition to secondary school. AIDS orphan status was defined as having lost either one or both parents to AIDS, according to self-report. Due to attrition, the final sample included 277 participants. Participants were selected from 15 primary schools with similar socioeconomic characteristics, including overall performance on the standardized national primary leaving examinations used as a

Sociodemographic characteristics

As indicated in Table 1, with the exception of employment status of caregivers, there were no observable significant gender differences within the control group. Within the experimental group, boys and girls differed significantly only according to the type of female caregiver.

Gender differences in savings outcomes

The AMND for boys was equivalent to $7.26 (standard deviation = $2.56), whereas girls saved $6.72 (standard deviation = $1.92). The median AMND for girls and boys was $5.01 and $5.70, respectively. Three girls (of 83) and

Discussion and Implications

Findings partially support the hypothesis that gender has a moderating effect on SUUBI study outcomes. SUUBI, as a combined intervention, worked better for boys than girls in improving attitudes toward sexual risk–taking behaviors. That said, both boys and girls in the SUUBI intervention group benefited relative to their same-sex counterparts assigned to the control group, although the intervention, overall, seems to have had a moderate or smaller effect for girls.

Conclusion

The findings of this study provide essential knowledge regarding the benefits of an economic empowerment approach in the care and support for orphaned adolescents within a family setting. In this particular case, adolescent girls saved as much as boys and maintained slightly more protective attitudes toward sexual risk taking than their female peers in the control condition. Interestingly, the largest disparity in outcomes was manifest between boys and girls in the experimental condition. In

Acknowledgments

We thank the SUUBI-Uganda Research Staff and volunteers for monitoring the study implementation process, especially Ms. Proscovia Nabunya and Reverend Fr. Kato Bakulu. We thank Professors Jane Waldfogel, Nabila El-Bassel, Michael Sherraden, and Torsten Neilands for helpful comments on the study intervention design, implementation, and/or data collection methods. We also thank all the adolescents and their caregiving families who agreed to participate in the SUUBI study.

References (39)

D. Serwadda et al.
Slim disease: A new disease in Uganda and its association with HTLV-III infection
Lancet
(1985)
F.M. Ssewamala et al.
A novel economic intervention to reduce HIV risks among AIDS orphans in rural Uganda
J Adolesc Health
(2008)
M. Marmot
Social determinants of health inequalities
Lancet
(2005)
R. Horton et al.
Putting prevention at the forefront of HIV/AIDS
Lancet
(2008)
C. MacPhail et al.
“I think condoms are good but, aai, I hate those things”: Condom use among adolescents and young people in a southern African township
Soc Sci Med
(2001)
Chen LC. Engendering international health: The Challenge of Equity. Paper presented to Swedish International...
G. Foster et al.
A review of current literature on the impact of HIV/AIDS on children in sub-Saharan Africa
AIDS
(2000)
S. Gregson et al.
Contrasting gender differentials in HIV-prevalence and associated mortality increase in eastern and southern Africa: Artifact of data or natural course of epidemics
AIDS
(2000)
S. Gregson et al.
HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe
AIDS Care
(2005)
J.R. Glynn et al.
Why do young women have a much higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia
AIDS
(2001)

J. Hargreaves et al.

Girl power: The impact of girls' education on HIV and sexual behaviour

(2006)

Uganda HIV/AIDS Sero-Behavioural Survey 2004–2005

(2008)

T. Thurman et al.

Sexual risk behavior among South African adolescents: Is orphan status a factor?

AIDS Behav

(2006)

G. Evans

The environment of childhood poverty

Am Psychol

(2004)

J. Kim et al.

Understanding the impact of a microfinance-based intervention on women's empowerment and the reduction of intimate partner violence in South Africa

Am J Public Health

(2007)

M. Sherraden

Stake-holding: Notes in a theory of welfare based on assets

Social Service Review

(1990)

M. Sherraden

Assets and the Poor: A new American welfare policy

(1991)

M. Schreiner et al.

Can the Poor Save? Saving and Asset Building in Individual Development Accounts

(2007)

M. Sherraden

School Dropouts in Perspective

Educational Forum

(1986)

Cited by (83)

Peer Pressure and Risk-Taking Behaviors Among Adolescent Girls in a Region Impacted by HIV/AIDS in Southwestern Uganda
2024, Journal of Adolescent Health
This paper uses data from a 3-arm Cluster Randomized Control Trial, Suubi4Her (N = 1260; 14–17-year-old school-going girls) to (1) assess the relationship between peer pressure and adolescent risk-taking behaviors; and (2) test the mediating effect of peer pressure on an intervention on adolescent risk-taking behaviors.
Students in the southwestern region of Uganda were assigned to three study arms: control (n = 16 schools, n = 408 students) receiving usual care comprising of sexual and reproductive health curriculum; and two active treatment arms: Treatment 1 (n = 16 schools, n = 471 students) received everything the control arm received plus a savings led intervention. Treatment 2 (n = 15 schools, n = 381 students) received everything the control and treatment arms received plus a family strengthening intervention. We used multilevel models to assess the relationship between peer pressure and risk-taking behaviors. We ran structural equation models for mediation analysis.
Using baseline data, we found that direct peer pressure was significantly associated with substance use risk behaviors, (β = 0.044, 95% CI = 0.008, 0.079). We also found a statistically significant effect of the intervention on acquiring STIs through the mediating effect of sexual risk-taking significant (β = −0.025, 95% CI: −0.049, −0.001, p = .045) and total indirect (β = −0.042, 95% CI: −0.081, −0.002, p = .037) effects. Also, there was a significant mediation effect of the intervention on substance use through peer pressure (β = −0.030, 95% CI: −0.057, −0.002, p = .033).
Overall, the study points to the role of peer pressure on adolescent girls' risk-taking behaviors; and a need to address peer pressure at an early stage.
Using Hierarchical Regression to Examine the Predictors of Sexual Risk-Taking Attitudes among Adolescents Living with Human Immunodeficiency Virus in Uganda
2023, Journal of Adolescent Health
We explored the factors influencing sexual risk-taking attitudes—defined as beliefs and values regarding sexual activity—among adolescents living with human immunodeficiency virus (ALHIV) in Uganda.
The study used baseline data from a five-year cluster-randomized control trial (2012–2018) among 702 ALHIV in Uganda. Participants were aged 10–16 years, HIV-positive, taking antiretroviral therapy, and living within a family. We fitted hierarchical regression models to assess the demographic, economic, psychological, and social predictors of sexual risk-taking attitudes. Using R², the final model explained 11.4% of the total variance.
Under economic factors, caregiver being formally employed (β = −0.08, 95% confidence interval [CI]: −0.10–0.06, p < .001), and the ALHIV working for pay (β = 1.78, 95% CI: 0.28–3.29, p = .022), were associated with sexual risk-taking attitudes. Among the psychological factors, more depressive symptoms (β = 0.22, 95% CI: 0.11–0.32, p < .001) were associated with more approving attitudes toward sexual risk-taking. Family and social factors including communicating with the caregiver about HIV (β = 1.32, 95% CI: 0.56–2.08, p = .001), sex (β = 1.09, 95% CI: 0.20–1.97, p = .017), and experiencing peer pressure (β = 3.37, 95% CI: 1.85–4.89, p < .001) were also associated with more approving attitudes toward sexual risk-taking. The final model explained 11.54% of the total variance.
Economic, psychological, and social factors influence sexual risk-taking attitudes among ALHIV. There is a need for more research to understand why discussing sex with caregivers improves adolescents' positive attitudes toward sexual risk-taking. These findings have significant ramifications in preventing sexual transmission of HIV among adolescents in low-income settings.
Family Economic Empowerment, Family Social Support, and Sexual Risk-Taking Behaviors Among Adolescents Living With HIV in Uganda: The Suubi+Adherence Study
2021, Journal of Adolescent Health
Citation Excerpt :
This study is guided by two theories—asset theory and social support theory. Several researchers have drawn on asset theory to explain how assets influence adolescents' health behaviors, attitudes, and future orientation [9,19–22]. Suubi + Adherence is guided by asset theory, which posits that an individual's access to assets such as education, savings accounts, or productive assets (e.g., economic resources) changes not only their economic wellbeing, but also their health behaviors, attitudes, and hope for the future [9,22].
This study examined the effect of a family economic empowerment (EE) intervention and family support on sexual risk-taking behaviors among adolescents living with HIV in rural Uganda.
We used data from the Suubi + Adherence study, a longitudinal cluster randomized clinical trial of 702 adolescents living with HIV aged 10–16 years. Participants were randomly assigned to either the control arm (n = 358) receiving bolstered standard of care or a treatment arm (n = 344) receiving bolstered standard of care plus the family EE intervention. We used mixed-effects models to examine the effect of the EE intervention and family support on sexual risk-taking behaviors at the baseline, 12 months, and 24 months after intervention initiation.
Adolescents in both the intervention and control groups did not differ significantly in their sexual risk-taking attitudes at the baseline and over the 24-month follow-up period. Higher levels of caregiver social support were significantly associated with a decrease in attitudes toward sexual risk-taking (ß = −.40, 95%CI = −.51, −.29). More frequent parent-child communication was significantly associated with increased negative sexual risk-taking attitudes (ß = .21, 95%CI = .16, .26).
Although we find no direct relationship between family EE and attitudes related to sexual risk-taking behaviors, we find that a supportive family environment can promote positive attitudes related to sexual risk-taking behaviors. The effectiveness of sexual risk reduction interventions would be enhanced by engaging families and strengthening supportive relationships between adolescents and their caregivers.
Access and utilization of financial services among poor HIV-impacted children and families in Uganda
2020, Children and Youth Services Review
With high prevalence of both poverty and HIV, Sub-Saharan Africa (SSA) has one of the highest numbers of unbanked individuals and families. Although the use of savings products to promote financial inclusion among poor individuals and families has increasingly become more important to policy makers in SSA, limited research exists about the mechanisms and relative importance of institutional and individual-level factors associated with access and utilization of financial services. Using survey data and administrative bank records from a randomized controlled trial in southwestern Uganda, we find that given an opportunity, poor HIV-impacted families and individuals can engage with financial institutions and accumulate savings. Additionally, individual-level factors (e.g., household wealth, child poverty, child work, and attitudes towards savings) were significantly associated with three of the eight outcomes (i.e. saved any money, average monthly total savings, and total number of deposits). Furthermore, institutional-level factors (e.g., access and proximity to the bank, matching incentive rate, and financial education) were associated with all the eight outcomes included in the analysis. Our findings indicate that poor HIV-impacted families can engage with financial institutions and save for their children, if opportunities and institutional arrangements are in place. Findings have implications for financial inclusion policy and programming that target vulnerable youth and families to engage with financial institutions and accumulate savings.
Systematic review of cash plus or bundled interventions targeting adolescents in Africa to reduce HIV risk
2024, BMC Public Health
Suubi + Adherence4Youth: a study protocol to optimize the Suubi Intervention for Adherence to HIV treatment for youth living with HIV in Uganda
2023, BMC Public Health

View all citing articles on Scopus

: The SUUBI-project was funded by a grant from the National Institute of Health (R21 MH076475-01).

View full text

Original articleGender and the Effects of an Economic Empowerment Program on Attitudes Toward Sexual Risk-Taking Among AIDS-Orphaned Adolescent Youth in Uganda

Abstract

Purpose

Methods

Results

Conclusions

Section snippets

Background and Theory: The SUUBI Research Program

Participant selection and assignment

Sociodemographic characteristics

Gender differences in savings outcomes

Discussion and Implications

Conclusion

Acknowledgments

Lancet

J Adolesc Health

Lancet

Lancet

Soc Sci Med

A review of current literature on the impact of HIV/AIDS on children in sub-Saharan Africa

AIDS

Contrasting gender differentials in HIV-prevalence and associated mortality increase in eastern and southern Africa: Artifact of data or natural course of epidemics

AIDS

HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe

AIDS Care

Why do young women have a much higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia

AIDS

Girl power: The impact of girls' education on HIV and sexual behaviour

Uganda HIV/AIDS Sero-Behavioural Survey 2004–2005

Sexual risk behavior among South African adolescents: Is orphan status a factor?

AIDS Behav

The environment of childhood poverty

Am Psychol

Understanding the impact of a microfinance-based intervention on women's empowerment and the reduction of intimate partner violence in South Africa

Am J Public Health

Stake-holding: Notes in a theory of welfare based on assets

Social Service Review

Assets and the Poor: A new American welfare policy

Can the Poor Save? Saving and Asset Building in Individual Development Accounts

School Dropouts in Perspective

Educational Forum

Original article
Gender and the Effects of an Economic Empowerment Program on Attitudes Toward Sexual Risk-Taking Among AIDS-Orphaned Adolescent Youth in Uganda