Top

Published in:

Open Access 01-12-2018 | Study protocol

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

Authors: Fred M. Ssewamala, Laura Gauer Bermudez, Torsten B. Neilands, Claude A. Mellins, Mary M. McKay, Irv Garfinkel, Ozge Sensoy Bahar, Gertrude Nakigozi, Miriam Mukasa, Lindsay Stark, Christopher Damulira, Jennifer Nattabi, Apollo Kivumbi

Published in: BMC Public Health | Issue 1/2018

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).

UNAIDS. The gap report [internet]. UNAIDS; 2014. Available from: http://www.unaids.org/en/resources/documents/2014/20140716_UNAIDS_gap_report. Accessed 16 Nov. 2017.

UNICEF. Turning the tide against AIDS will require more concentrated focus on adolescents and young people [internet]. In: Adolescents and young people. UNICEF; 2017. https://data.unicef.org/topic/hivaids/adolescents-young-people.

Sherraden M. Assets and the poor: a new American welfare policy. Armonk, NY: ME Sharpe; 1991.

Sherraden M. Stakeholding: notes on a theory of welfare based on assets. Soc Serv Rev. 1990;64(4):580–601.CrossRef

Cho H, Hallfors DD, Mbai II, Itindi J, Milimo BW, Halpern CT, Iritani BJ. Keeping adolescent orphans in school to prevent human immunodeficiency virus infection: evidence from a randomized controlled trial in Kenya. J Adolesc Health. 2011;48(5):523–6. https://doi.org/10.1016/j.jadohealth.2010.08.007. PMID:21501814CrossRefPubMedPubMedCentral

Glynn JR, Caraël M, Auvert B, Kahindo M, Chege J, Musonda R, Kaona F, Buvé A, 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;15:S51–60. PMID: 11686466CrossRefPubMed

Gregson S, Garnett GP. 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;14(Supplement 3):S85–99. PMID:11086852PubMed

Hallfors D, Cho H, Rusakaniko S, Iritani B, Mapfumo J, Halpern C. Supporting adolescent orphan girls to stay in school as HIV risk prevention: evidence from a randomized controlled trial in Zimbabwe. Am J Public Health. 2011;101(6):1082–8. https://doi.org/10.2105/AJPH.2010.300042. PMID: 21493943CrossRefPubMedPubMedCentral

Hargreaves J & Boler T. Girl Power. The impact of girls' education on HIV and sexual behavior [Internet]. ActionAid International; 2006. Available from: https://www.actionaid.org.uk/sites/default/files/doc_lib/girl_power_2006.pdf. Accessed 17 Nov. 2017.

10.

Nobelius AM, Kalina B, Pool R, Whitworth J, Chesters J, Power R. Sexual partner types and related sexual health risk among out-of-school adolescents in rural south- West Uganda. AIDS Care. 2011;23(2):252–9. https://doi.org/10.1080/09540121. PMID: 21259139CrossRefPubMed

11.

Pettifor AE, Levandowski BA, Macphail C, Padian NS, Cohen MS, Rees HV. Keep them in school: the importance of education as a protective factor against HIV infection among young South African women. International Journal of Epidemiology. 2008;37(6):1266–73. https://doi.org/10.1080/09540121.2010.507736. PMID: 18614609 PMCID: PMC2734068CrossRefPubMedPubMedCentral

12.

Gunn JK, Roth AM, Center KE & Wiehe SE. Gunn JK, Roth AM, Center KE, Wiehe SE. The unanticipated benefits of behavioral assessments and interviews on anxiety, self-esteem and depression among women engaging in transactional sex. Community Ment Health J 2016;52(8):1064–1069. DOI:https://doi.org/10.1007/s10597-015-9844-x; PMID: 25712538.

13.

Meier A, Erickson GA, McLaughlin H. Older sexual partners and adolescent females’ mental health. Perspect Sex Reprod Health. 2016;48(1):25–33. https://doi.org/10.1363/48e8316. PMID:26918326CrossRefPubMedPubMedCentral

14.

Barhafumwa B, Dietrich J, Closson K, Samji H, Cescon A, Nkala B, Davis J, Hogg RS, et al. High prevalence of depression symptomology among adolescents in Soweto, South Africa associated with being female and cofactors relating to HIV transmission. Vulnerable Children and Youth Studies. 2016;11(3):263–73. https://doi.org/10.1080/17450128.2016.1198854.CrossRef

15.

Agbor J. Poverty, inequality and Africa's education crisis [Internet]. Brookings; 2012. Available from: https://www.brookings.edu/opinions/poverty-inequality-and-africas-education-crisis/. Accessed 16 Nov. 2017. UNICEF & The World Bank. (2009).

16.

The World Bank. Abolishing school fees in Africa: Lessons from Ethiopia, Kenya, Malawi and Mozambique [Internet]. World Bank; 2009. Available from: http://documents.worldbank.org/curated/en/780521468250868445/Abolishing-school-fees-in-Africa-lessons-from-Ethiopia-Ghana-Kenya-Malawi-and-Mozambique. Accessed 16 Nov. 2017.

17.

Colclough C, Rose P, Tembon M. Gender inequalities in primary schooling: the roles of poverty and adverse cultural practice. Int J Educ Dev. 2000;20(1):50–27. https://doi.org/10.1016/S0738-0e593(99)00046-2.CrossRef

18.

Ombati V, Ombati M. Gender inequality in education in sub-Saharan Africa. Journal of Women's Entrepreneurship and Education. 2012;3–4:114–36.

19.

Ssewamala FM, Wang JSH, Karimli L, Nabunya P. Strengthening universal primary education in Uganda: the potential role of an asset-based development policy. Int J Educ Dev. 2011;31(5):472–7. https://doi.org/10.1016/j.ijedudev.2010.11.001.CrossRef

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. https://doi.org/10.1016/j.jadohealth.2009.08.010. PMID:20307827CrossRefPubMedPubMedCentral

21.

UNESCO. New global educatioen goals must prioritize girls. Education for all global monitoring report [Internet]. UNESCO; 2014. Available from: http://www.unesco.org/new/en/media-services/single-%20view/news/new_global_education_goals_must_prioritize_girls/#.Vnl3dvkrJph. Accessed 16 Nov. 2017.

22.

Jukes M, Simmons S, Bundy D. Education and vulnerability: the role of schools in protecting young women and girls from HIV in southern Africa. AIDS. 2008;22(4):S41–56. https://doi.org/10.1097/01.aids.0000341776.71253.04. PMID: 19033754CrossRefPubMed

23.

Nabunya P, Ssewamala FM, Ilic V. Family economic strengthening and parenting stress among caregivers of AIDS-orphaned children: results from a cluster randomized clinical trial in Uganda. Child Youth Serv Rev. 2014;44:417–21. https://doi.org/10.1016/j.childyouth.2014.07.018. PMID: 25136142CrossRefPubMedPubMedCentral

24.

Ismayilova L, Ssewamala FM, Karimli L. Family support as a mediator of change in sexual risk-taking attitudes among orphaned adolescents in rural Uganda. The Journal of Adolescent Health. 2012;50(3):228–35. https://doi.org/10.1016/j.jadohealth.2011.06.008. PMID: 22325127; PMCID: PMC3279703CrossRefPubMed

25.

Ssewamala FM, Karimli L, Chang-Keun H, Ismayilova L. Social capital, savings, and educational performance of orphaned adolescents in sub-Saharan Africa. Child Youth Serv Rev. 2010;32(12):1704–10. https://doi.org/10.1016/j.childyouth.2010.07.013.CrossRefPubMedPubMedCentral

26.

McNeely C, Shew ML, Beuhring T, Sieving R, Miller BC, Blum RW. Mothers’ influence on the timing of first sex among 14-and 15-year-olds. J Adolesc Health. 2002;31(3):256–65. https://doi.org/10.1016/S1054-139X(02)00350-6. PMID:12225738CrossRefPubMed

27.

Resnick MD, Bearman PS, Blum RW, Bauman KE, Harris KM, Jones J, Tabor J, Beuhring T, et al. Protecting adolescents from harm: findings from the national longitudinal study on adolescent health. JAMA. 1997;278(10):823–32. https://doi.org/10.1001/jama.1997.03550100049038. PMID:9293990CrossRefPubMed

28.

Amerikaner M, Monks G, Wolfe P, Thomas S. Family interaction and individual psychological health. J Couns Dev. 1994;72(6):614–20. https://doi.org/10.1002/j.1556-6676.1994.tb01691.x.CrossRef

29.

Klein M, Gordon S. Sex education in Walker CE, Roberts MC (eds). Handbook of clinical child psychology. 3rd ed. New York, NY: John Wiley & Sons, Inc.; 2001.

30.

Kotchick BA, Dorsey S, Miller KS, Forehand R. Adolescent sexual risk-taking behavior in single-parent ethnic minority families. J Fam Psychol. 1999;13(1):93–102. https://doi.org/10.1037/0893-3200.13.1.93.CrossRef

31.

Miller KS, Forehand R, Kotchick BA. Adolescent sexual behavior in two ethnic minority samples: the role of family variables. J Marriage Fam. 1999;61(1):85–98. https://doi.org/10.2307/353885.CrossRef

32.

Brooks-Gunn J, Furstenberg FF Jr. Adolescent sexual behavior. Am Psychol. 1989;44(2):249–57. https://doi.org/10.1037/0003-066X.44.2.249.CrossRefPubMed

33.

The Republic of Uganda. The HIV and AIDS Uganda Country Progress Report [Internet]. The Republic of Uganda; 2014. Available from: http://www.unaids.org/sites/default/files/country/documents/UGA_narrative_report_2015.pdf. Accessed 16 Nov. 2017.

34.

UNAIDS, UNICEF. UNICEF Annu Rep, Uganda [Internet]. UNAIDS, UNICEF; 2014. Available from: https://reliefweb.int/sites/reliefweb.int/files/resources/Uganda_2.pdf. Accessed 16 Nov. 2017.

35.

Bellamy SL. A dynamic block-randomization algorithm for group-randomized clinical trials when the composition of blocking factors is not known in advance. Contemporary Clinical Trials. 2005;26(4):469–79. https://doi.org/10.1016/j.cct.2005.02.005. PMID:16054579CrossRefPubMed

36.

Bandura A. Health promotion by social cognitive means. Health Educ Behav. 2004 Apr;31(2):143–64.CrossRefPubMed

37.

Fisher WA, Fisher JD, Rye BJ. Understanding and promoting AIDS-preventive behavior: insights from the theory of reasoned action. Health Psychol. 1995;14(3):255.CrossRefPubMed

38.

Dennison ST. A multiple family group therapy program for at risk adolescents and their families. 1st ed. Springfield, Illinois: Charles C Thomas Publisher; 2005.

39.

Mellins CA, Nestadt D, Bhana A, Petersen I, Abrams EJ, Alicea S, Holst H, Myeza N, John S, Small L, McKay M. Adapting evidence-based interventions to meet the needs of adolescents growing up with HIV in South Africa: the VUKA case example. Global Social Welfare. 2014;1(3):97–110.CrossRefPubMedPubMedCentral

40.

McKay MM, Gonzales JJ, Stone S, Ryland D, Kohner K. Multiple family therapy groups: a responsive intervention model for inner city families. Social Work with Groups. 1995;18(4):41–56. https://doi.org/10.1300/J009v18n04_04.CrossRef

41.

Keiley MK. The development and implementation of an affect regulation and attachment intervention for incarcerated adolescents and their parents. Fam J. 2002;10(2):177–89. https://doi.org/10.1177/1066480702102007.CrossRef

42.

Kumpfer KL, Alvarado R, Smith P, Bellamy N. Cultural sensitivity and adaptation in family-based prevention interventions. Prev Sci. 2002;3(3):241–6. https://doi.org/10.1023/A:1019902902119. PMID:12387558CrossRefPubMed

43.

Wahler RG, Dumas JE. Attentional problems in dysfunctional mother-child interactions: an interbehavioral model. Psychol Bull. 1989;105(1):116–30. https://doi.org/10.1037/0033-2909.105.1.116; PMID:2648437CrossRefPubMed

44.

Jewell TC, Downing D, McFarlane WR. Partnering with families: multiple family group psychoeducation for schizophrenia. J Clin Psychol. 2009;65(8):868–78. https://doi.org/10.1002/jclp.20610; PMID: 19530233.CrossRefPubMed

45.

UNESCO, UNFPA. Sexuality education: A ten-country review of school curricula in East and Southern Africa [Internet]. UNESCO, UNFPA; 2012. Available from: http://unesdoc.unesco.org/images/0022/002211/221121e.pdf. Accessed 16 Nov. 2017.

46.

Hayes R, Moulton LH. Cluster randomized trials.1st ed. Boca Raton. Florida: CRC Press; 2009.CrossRef

47.

Crosby RA, Rothenberg R. In STI interventions, size matters. Sex Transm Infect. 2004;80(2):82–5.CrossRefPubMedPubMedCentral

48.

Gallo MF, Steiner MJ, Hobbs MM, Warner L, Jamieson DJ, Macaluso M. Biological markers of sexual activity: tools for improving measurement in HIV/sexually transmitted infection prevention research. Sex Transm Dis. 2013;40(6):447–52. https://doi.org/10.1097/OLQ.0b013e31828b2f77; PMID: 23677018.CrossRefPubMed

49.

Sobell LC, Sobell MB. Timeline Followback (TLFB) User's manual. Toronto: Addiction Research Foundation; 1994.

50.

Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol. 1974;42(6):861–5. 4436473CrossRefPubMed

51.

Fitts WH, Roid GH. Tennessee self concept scale. Nashville, TN: Counselor Recordings and Tests; 1964.

52.

Kovacs M. The child depression inventory (CDI). North Tonawanda, NY: Multi-Health Systems, Inc; 1992.

53.

Levy SR, Lampman C, Handle A. Young adolescent attitudes towards sex and substance abuse: implications for AIDS prevention. AIDS Educ Prev. 1993;5(4):340–51. 19207597PubMed

54.

Vaux A, Riedel S, Stewart D. Modes of social support: the social support behaviors (SS-B) scale. Am J Community Psychol. 1987;15(2):210–37. https://doi.org/10.1007/BF00919279. CrossRef

55.

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 Suppl C:131–7. DOI:https://doi.org/10.1016/j.childyouth.2014.05.011; PMID:25067869.

56.

Krauss BJ. Calm down, Mom, let’s talk about sex, drugs, and HIV: 10–13 year old girls prescription for HIV Preventieon Conversations in their high HIV seroprevalence neighborhood. Washington DC: Paper presented at the HIV Infection in Women Conference; 1995.

57.

Gerard AB. Parent-child relationship inventory (PCRI). 1st ed. Los Angeles: western. Psychol Serv. 1994;

58.

Rosenberg M. Rosenberg self-esteem scale (RSE) [Internet]. Acceptance and commitment therapy. Measures package, 61; 1965. Available from: http://fetzer.org/sites/default/files/images/stories/pdf/selfmeasures/Self_Measures_for_Self-Esteem_ROSENBERG_SELF-ESTEEM.pdf Accessed 16 Nov. 2017.

59.

Nanda G. Compendium of gender scales [internet]. Nanda G.; 2011. Available from: https://www.c-changeprogram.org/content/gender-scales-compendium/pdfs/C-Change_Gender_Scales_Compendium.pdf. Accessed 16 Nov. 2017.

60.

Wingood GM, DiClemente RJ. The influence of psychosocial factors, alcohol, drug use on African-American women’s high-risk sexual behavior. Am J Prev Med. 1998;15(1):54–9. 9651639CrossRefPubMed

61.

Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Assess. 1988;52(1):30–41. https://doi.org/10.1207/s15327752jpa5201_2.CrossRef

62.

Microfinance Opportunities. Global financial education program [internet]. Microfinance Opportunities; 2002. Available from: https://www.microfinanceopportunities.org/4-work-with-us/mfo-in-the-field/project-list/fecc/. Accessed 16 Nov. 2017.

63.

National Institute on Drug Abuse. Risk behavior assessment, 3rd ed. [Internet]. National Institute on Drug Abuse; 1993. Retrieved from http://bit.ly/RBA_inst.

Title: 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
Authors: Fred M. Ssewamala
Laura Gauer Bermudez
Torsten B. Neilands
Claude A. Mellins
Mary M. McKay
Irv Garfinkel
Ozge Sensoy Bahar
Gertrude Nakigozi
Miriam Mukasa
Lindsay Stark
Christopher Damulira
Jennifer Nattabi
Apollo Kivumbi
Publication date: 01-12-2018
Publisher: BioMed Central
Published in: BMC Public Health / Issue 1/2018
Electronic ISSN: 1471-2458
DOI: https://doi.org/10.1186/s12889-018-5604-5

At a glance: The STEP trials

Springer Medicine

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

Methods

Conclusions

Trial registration

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Conclusions

Trial registration

Please log in to get access to this content

Other articles of this Issue 1/2018

Exercise and cancer mortality in Korean men and women: a prospective cohort study

Epidemiology of Listeria monocytogenes prevalence in foods, animals and human origin from Iran: a systematic review and meta-analysis

Self-perceived ability to cope with stress and depressive mood without smoking predicts successful smoking cessation 12 months later in a quitline setting: a secondary analysis of a randomized trial

Raising cigarette excise tax to reduce consumption in low-and middle-income countries of the Asia-Pacific region:a simulation of the anticipated health and taxation revenues impacts

Attitude and subjective wellbeing of non-compliant mothers to childhood oral polio vaccine supplemental immunization in Northern Nigeria

Effects of alternate day calorie restriction and exercise on cardio-metabolic risk factors in overweight and obese adults: an exploratory randomized controlled study