Effects of Adolescent-Focused Integrated Social Protection on Depression: A Pragmatic Cluster-Randomized Controlled Trial of Tanzania's Cash Plus Intervention

Post-intervention gendered impacts and moderating factors of a government cash plus intervention for adolescents in Tanzania

Introduction

Reducing poverty (including multidimensional poverty) and gender inequality can improve social development outcomes. Studies have sought to understand how poverty reduction and intersectoral programming targeted to adolescents can facilitate safe transitions to adulthood among adolescents. However, most intersectoral interventions for adolescents to date have been implemented by non-governmental actors with limited generalizability and potential for scale-up. In the current study, we examine 22-month post intervention impacts of the "plus components" of a cash plus intervention, Ujana Salama (Swahili for "Safe Youth") targeted to adolescents ages 14-19 years (males and females) in households participating in a government social protection program in Tanzania. The government-implemented cash plus intervention, comprised of livelihoods and life skills training, a productive grant, mentoring, and linkages to adolescent-friendly health services, was implemented over 18 months in 2018 and 2019.

Methods

Using a cluster randomized controlled trial, we estimated post-intervention impacts in 2021 on the following domains: relationships, modern contraception, health seeking and HIV knowledge and risk, psychosocial outcomes and attitude, and violence. We further examined whether contextual factors, including gender norms and quality of health services, moderated these post-intervention impacts.

Results

Few impacts found at earlier rounds were still evident post-intervention. Exceptions include protective impacts on lifetime sexual violence risk among females and increases in sexual and reproductive health services utilization among males. Moreover, newly detected adverse impacts on mental health contrasted with earlier protective impacts.

Conclusion

While external factors such as lengthy delays of cash transfer payments to adolescents' households and the COVID-19 pandemic may have mitigated the potential for sustained impacts of this intervention, findings suggest that future programs may need to provide different combinations of programming, provide support longer-term, or intervene at more levels of the social ecological model to influence many of the outcomes examined and to effect more lasting change.

Why we need to pursue both universal and targeted prevention to reduce the incidence of affective and psychotic disorders: Systematic review and meta-analysis

The effectiveness of universal preventive approaches in reducing the incidence of affective/psychotic disorders is unclear. We therefore aimed to synthesise the available evidence from randomised controlled trials. For studies reporting change in prevalence, we simulated all possible scenarios for the proportion of individuals with the disorder at baseline and at follow-up to exclude them. We then combined these data with studies directly measuring incidence and conducted random effects meta-analysis with relative risk (RR) to estimate the incidence in the intervention group compared to the control group. Eighteen studies (k=21 samples) were included investigating the universal prevention of depression in 66,625 individuals. No studies were available investigating universal prevention on the incidence of bipolar/psychotic disorders. 63 % of simulated scenarios showed a significant preventive effect on reducing the incidence of depression (k=9 - 19, RR=0.75-0.94, 95 %CIs=0.55-0.87,0.93-1.15, p=0.007-0.246) but did not survive sensitivity analyses. There is some limited evidence for the effectiveness of universal interventions for reducing the incidence of depression but not for bipolar/psychotic disorders.

Systematic review of cash plus or bundled interventions targeting adolescents in Africa to reduce HIV risk

BACKGROUND

HIV remains a leading cause of death for adolescents and young people aged 10-24 years. HIV prevention requires multisectoral approaches that target adolescents and young people, addressing HIV risk pathways (e.g., transactional sex, gender-based violence, and school attendance) through bundled interventions that combine economic strengthening, health capabilities, and gender equality education. However, best practices are unknown because evidence on multisectoral programming targeted to adolescents and combining these components has not been systematically reviewed.

METHODS

We conducted a systematic review to summarize the evidence on bundled interventions combining health and economic strengthening components for adolescents and young people and their effects on HIV/STI incidence and risk factors. We included studies from Africa published between 2005 and 2023, combining at least one economic strengthening and one health component, directed toward adolescents and young people aged 10-24 years. Included studies measured programmatic impacts on primary outcomes: HIV and STI incidence/prevalence; and mediators as secondary outcomes: sexual behaviours, sexual and reproductive health, school attendance, health-seeking behaviours, and violence. We conducted key word searches in PubMed, EMBASE, and Web of Science, imported titles/abstracts from the initial search, and reviewed them using the inclusion criteria. Full texts of selected articles were reviewed and information was extracted for analysis. Findings from the full texts identified were summarized.

RESULTS

We reviewed 58 studies, including 43 quantitative studies and 15 qualitative studies, evaluating 26 unique interventions. A majority of studies reviewed were conducted in Eastern and Southern Africa. Interventions reviewed showed a greater number of significant results in improving economic outcomes; mental health and psychosocial outcomes; sexual and reproductive health knowledge and services utilization; and HIV prevention knowledge and testing. They showed fewer significant results in improving outcomes related to HIV incidence/prevalence; sexual risk behaviours; gender-based violence; gender attitudes; education; STI incidence, prevalence and testing; and sexual debut.

CONCLUSIONS

Our review demonstrated the potential for bundled, multisectoral interventions for preventing HIV and facilitating safe transitions to adulthood. Findings have implications for designing HIV sensitive programmes on a larger scale, including how interventions may need to address multiple strata of the social ecological model to achieve success in the prevention of HIV and related pathways.

The influence of gender-equitable attitudes on sexual behaviour among unmarried adolescents in rural Tanzania: a longitudinal study

PLAIN LANGUAGE STATEMENT

Gender norms that centre men and disadvantage women create gender inequality, which can lead to risky sexual behaviour. This study examined how both community and individual attitudes toward gender norms influenced risky sexual behaviour in adolescents, and whether that influence was different between males and females. We found that higher gender-equitable attitudes were linked to increased odds of HIV testing in the last 12 months, and decreased odds of engaging in a sexual relationship with a much older partner. Individual high gender-equitable attitudes among girls were also linked to higher odds of them using condoms and contraceptives. Gender-equitable attitudes did not seem to influence early sexual debut, engagement in transactional sex, having multiple sexual partners at the same time, or the number of sexual partners a participant had in the last 12 months. Based on these findings, programming designed to increase gender-equitable attitudes might be helpful in increasing HIV testing and condom and contraceptive use, but it needs to involve the entire community, not just individual boys and girls.

Short Video-Based Mental Health Intervention for Depressive Symptoms in Junior High School Students: A Cluster Randomized Controlled Trial

Purpose

Digital interventions for adolescent mental health are emerging in high-income countries, but have faced challenges and are scarce in China. This study investigated the effect of a short video-based mental health intervention on depressive symptoms in Chinese adolescents.

Methods

A three-arm cluster randomized controlled trial was conducted in four junior high schools in Shanghai from December 2020 to December 2021 with the measurement at baseline, 6 months after study entry, and 12 months. Outcomes were collected by self-completed questionnaires administered by teachers masked to allocation. The primary outcome was depressive symptoms assessed by the Depression Self-Rating Scale for Children (DSRSC). Mixed effects models were used to compare psychologist-led intervention (n=428 students) and teacher-led intervention (n=385) including six short video-based sessions to usual school provision (n=751).

Results

Using intention-to-treat analyses, psychologist-led intervention showed more reduction in depressive symptoms compared to usual school provision at 6 months (coefficient -1.00, 95% CI -1.94 to -0.05), but not at 12 months. Using per-protocol analyses among participants who watched at least three video episodes, both psychologist-led (-1.14, -2.20 to -0.09) and teacher-led intervention (-1.23, -2.45 to -0.02) reduced depressive symptoms compared to usual school provision at 6 months, and the effect of teacher-led intervention persisted at 12 months (-1.58, -3.13 to -0.03). Further exploration found that compared with urban students, the between-group differences for depressive symptoms in rural students were more significant (p<0.05 for interaction) and the effects were maintained at 12 months.

Conclusion

The short video-based mental health intervention showed potential to reduce depressive symptoms among Chinese adolescents, and the effects were more significant if the minimum video viewing frequency was reached.

Impacts of cash transfer and "cash plus" programs on self- perceived stress in Africa: Evidence from Ghana, Malawi, and Tanzania

Poverty and poor mental health are closely linked. Cash transfers have significantly expanded globally. Given their objectives around poverty reduction and improving food security, a major chronic stressor in Africa, cash transfers may affect mental health outcomes. We examine impacts of three large-scale government cash transfer or cash plus programs in Ghana, Malawi, and Tanzania on self-perceived stress using an innovative, newly adapted measure for rural African settings. Linear regression models were used to estimate treatment impacts. We find that cash transfers reduced self-perceived stress in Malawi, but programs in Ghana and Tanzania had no impacts on self-perceived stress. These mixed findings, combined with recent reviews on cash transfers and mental health, suggest that cash transfers may play a role in improving mental health. However, cash alone may not be sufficient to overcome many challenges related to poverty, and complementary programming may also be needed to improve mental health.

Transactional sex among adolescent girls and young women enrolled in a cash plus intervention in rural Tanzania: a mixed-methods study

INTRODUCTION

Transactional sex or material exchange for sex is associated with HIV infection among adolescent girls and young women in sub-Saharan Africa. The motivations for engaging in transactional sex vary from the fulfilment of basic needs, to enhancing social status or for romantic reasons with the expectation that men should provide. Transactional sex is also associated with HIV risk behaviours, such as multiple sexual partners and other determinants of HIV risk, including partner violence and abuse, alcohol consumption and inconsistent condom use.

METHODS

We use data from a mixed-method, cluster randomised controlled trial of the Ujana Salama cash "plus" intervention in rural Tanzania. The data are from the first and third rounds of data collection (2017-2019). The impact evaluation consisted of a parallel mixed-methods design where the quantitative and qualitative data collection occurred simultaneously, and integration of the findings was done during the discussion. We first examine contextual factors associated with transactional sex using multivariable logistic regression models and then estimate whether the "plus" intervention reduced transactional sex among adolescent girls and young women using analysis of covariance. We used thematic content analysis for analysing qualitative transcripts.

RESULTS

The prevalence of transactional sex among unmarried adolescent girls and young women at round 3 was 26%. Findings show that increasing age is a risk factor for transactional sex (OR = 1.80; 95% CI: [1.50, 2.17]), staying in school was negatively associated with engagement in transactional sex (OR = 0.24; 95% CI: [0.14, 0.40]). The cash plus intervention showed no impacts on reducing transactional sex (β = 0.003, p = 0.905).

CONCLUSIONS

The mechanisms of impact for a cash plus intervention on transactional sex are complex; economic insecurity is an important driver of transactional sex and HIV infection, but psychosocial factors and gendered social norms need consideration in intervention development. Our findings suggest that combination prevention interventions to address the structural drivers of HIV infection should focus on efforts to increase school enrolment and completion.