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American Journal of Public Health logoLink to American Journal of Public Health
. 2023 Mar;113(3):306–315. doi: 10.2105/AJPH.2022.307169

Economic Empowerment, HIV Risk Behavior, and Mental Health Among School-Going Adolescent Girls in Uganda: Longitudinal Cluster-Randomized Controlled Trial, 2017‒2022

Fred M Ssewamala 1,✉, Rachel Brathwaite 1, Torsten B Neilands 1
PMCID: PMC9932384  PMID: 36603167

Abstract

Objectives. To investigate the long-term (12- and 24-month) impact of an economic empowerment intervention on HIV risk behaviors and mental health among school-going adolescent girls in Uganda.

Methods. A total of 1260 girls aged 14 to 17 years were randomized at the school level to (1) standard health and sex education (controls; n = 408 students; n = 16 schools), (2) 1-to-1 matched savings youth development account (YDA; n = 471 students; n = 16 schools), or (3) combination intervention (YDA and multiple family group [YDA+MFG]; n = 15 schools; n = 381 students). Mixed-effects models were fitted.

Results. YDA and YDA+MFG girls had significantly lower depressive symptoms and better self-concept than controls at 24 months. Only YDA+MFG girls had significantly lower hopelessness levels than controls. There were no significant study group differences at 12 and 24 months for sexual risk-taking behavior and attitudes. There was no significant difference between YDA and YDA+MFG groups for all outcomes.

Conclusions. Providing YDA and MFG can positively improve adolescent girls’ mental health, but our analyses showed no significant differences across groups on sexual risk-taking behaviors. Future studies may consider replicating these interventions and analyses in older populations, including those transitioning into young adults.

Trial Registration. ClinicalTrials.gov Identifier: NCT03307226. (Am J Public Health. 2023;113(3):306–315. https://doi.org/10.2105/10.2105/AJPH.2022.307169)

Approximately 90% of all adolescents living with HIV worldwide reside in the resource-limited region of sub-Saharan Africa (SSA).1 However, the majority (70%) of new HIV infections among youths aged 15 to 19 years occur among adolescent girls.2 The SSA region also has a substantial burden of mental health problems among adolescents,3 and research shows that girls have a disproportionately higher burden of mental health problems than boys.4,5 Girls often report significantly worse internalizing disorders (reflective of the child’s psychological and emotional state) than boys, and this gender gap increases with age.6 As a consequence, adolescent girls represent an important vulnerable population at increased risk of HIV infection7 and poor mental health in SSA. Therefore, interventions designed for adolescent girls in SSA should innovatively address both HIV risk reduction and adolescent mental health because they can contribute to curbing the spread of the HIV epidemic8 and preventing progression of poor health and social problems in adulthood.

In Uganda, a resource-limited SSA country extensively affected by the HIV epidemic, approximately 800 000 girls and women are living with HIV.9 Poverty is a major factor that increases adolescent girls’ risk for HIV infection and transmission. More than half (56%) of adolescents in Uganda are exposed to multidimensional poverty and low living standards.10

Sociocultural norms and beliefs present in Ugandan communities often influence decision-making, and in scenarios where there are limited financial resources, female children are often excluded from educational opportunities, favoring male children instead.11 Financial insecurity drastically reduces families’ ability to send girls to school where vital education on HIV/AIDS prevention and access to psychosocial support and health and medical services is received.12

Indeed, out-of-school girls have increased vulnerability to HIV infection13 as they are forced to engage in risk-taking activities to improve their financial security. In Uganda, out-of-school girls are particularly vulnerable to transactional sex with older men, unprotected sex, early sexual initiation, early marriage, and adolescent pregnancy, which all heighten their risk of infection with HIV and other sexually transmitted infections (STIs).14,15 For those reasons, it is important to intervene with adolescent girls while they are still in school, to keep them in school.

Poverty is also a significant risk factor for the development and persistence of poor mental health. In the resource-limited region of SSA, there are inadequate numbers of qualified mental health professionals to diagnose and treat mental health conditions and disproportionate distribution of human resources between urban and rural areas. For example, for every 100 000 people that may need a mental health professional, there are 0.08 qualified psychiatrists.16 Moreover, only 1% of Uganda’s gross domestic product is allocated to mental health care, which is inclusive of services for children, adolescents, and adults.16 Poverty-impacted communities significantly perpetuate poor mental health because there are often high levels of environmental stressors, lack of social support, violence against children, high unemployment, food insecurity, and other social and health problems that are all risk factors for children’s and adolescents’ poor mental health.17,18

Adolescence is a period marked by increased vulnerability to mental and substance-use disorders,19 and there are concerns that early sexual debut often results in sexual risk-taking (i.e. inconsistent condom use, unsafe sex, multiple sexual partners), making one vulnerable to acquiring HIV.20–22 Furthermore, living with HIV as a chronic, highly stigmatized, and transmittable illness can increase one’s risk of poor mental health.23 Hence, extra attention should be placed on adolescent girls in low-resource SSA communities who are already vulnerable given their economic disadvantage.

Research on effective evidence-based interventions to prevent poor mental health and reduce HIV risk among adolescent girls residing in Uganda and other resource-limited SSA countries are lacking.24 The Suubi4Her study was designed to help fill this gap while simultaneously addressing the main underlying risk factors for HIV risk and poor mental health among adolescent girls in Uganda.25 Suubi4Her is a 3-arm cluster-randomized controlled trial designed to reduce HIV risk behaviors and improve mental health among adolescent girls across 47 public secondary schools in Uganda.

Given the economic factors driving HIV risk and poor mental health among adolescents in low-resource communities, the interventions implemented in the Suubi4Her study are guided by asset theory.26,27 Asset theory posits that individuals with financial assets have improved economic security and report psychological benefits such as future-oriented thinking, feelings of self-efficacy, and security. Thus, girls in the intervention arms of the Suubi4Her study received youth development accounts (YDAs), 1-to-1 matched savings accounts. The matched funds can be used to pay for girls’ education and skills training fees (up to 70%) or family-based income-generating activities (up to 30% of matched savings). All participants received training on principles of financial management, which covered saving, asset-building, using financial institutions, and income generation.

Furthermore, because families residing in deprived communities are likely to experience high stress, lack of social support, and social isolation, which all negatively influence parenting and family relationships,28 the Suubi4Her study also incorporated multiple family groups (MFGs) as an intervention. MFGs aim to strengthen family communication and reduce stigma by providing a safe space for parents and children to communicate with themselves and other families.29 Research showed that good parent‒child relationships and frequent and open communication (including about sex) between children and their caregivers (especially mothers) is associated with later sexual debut and less engagement in risk behaviors.30–32 As such, adolescent girls in the second intervention arm received a combination intervention comprising YDAs plus MFGs (YDA+MFG).

In this study, we investigated the long-term impact of the Suubi4Her intervention on HIV risk behaviors (i.e., sexual risk-taking) and mental health (depressive symptoms, hopelessness, self-esteem, and self-concept) among school-going adolescent girls. We hypothesized that (1) girls in the YDA group would have better mental health outcomes and less sexual risk-taking behaviors than those in the control condition, (2) girls in the YDA+MFG group will show better mental health and less sexual risk-taking behaviors than counterparts in the control condition, and (3) girls in the YDA+MFG group would have better outcomes than their counterparts in the YDA group alone.

METHODS

The Suubi4her study is a longitudinal 3-arm cluster-randomized controlled trial conducted in 47 public secondary schools in the central region of Uganda (Rakai, Kyotera, Masaka, Lwengo, and Kalungu districts; 2017–2022).25 This region has a heavy burden of HIV (prevalence of 10.6% vs 7.4% in Uganda).33 This is also a geographically stable region with infrequent migration, enabling easy tracking of participants over the study period.

A total of 1260 adolescent girls aged 14 to 17 years were enrolled and followed up at 12 and 24 months (Appendix, Figure A, available as a supplement to the online version of this article at https://ajph.org). To reduce contamination, randomization was done at the school level to 1 of 3 study conditions. The first condition was a usual care or control arm that received standard health and sex education (n = 16 schools; n = 408 students). All girls in each study group received this standard health and sex education component. In Uganda, this is a mandatory curriculum authorized by the Ministry of Education, which covers adolescent sexual and reproductive health. Topics included delaying sex, using condoms and contraception, preventing forced sex, preventing substance use, gender equality, and importance of delaying marriage.

The second condition was treatment arm 1: YDA. Each participant was enrolled in a 1-to-1 match rate savings program (n = 16 schools; n = 471 students). The third condition was treatment arm 2: participants received a combination intervention composed of YDA and an evidence-based family strengthening intervention designed to enhance youth behavioral health delivered using an MFG format (YDA+MFG; n = 15 schools; n = 381 students; Appendix, pages 1‒3 and Table A).

Within each school, adolescent girls were included if they were (1) enrolled in first year of secondary school and (2) not living in an institution or orphanage but within a family (as orphanages would have different characteristics than families). Girls were excluded if they (1) showed severe cognitive or psychiatric impairment that prohibited their ability to provide informed consent or comprehension of study requirements, (2) were unable or unwilling to complete the study, or (3) were not enrolled in school. Written informed consent from caregivers and assent from adolescents were obtained separately to prevent coercion.

Outcome Measures

We examined the impact of the intervention on 2 broad outcomes: (1) sexual risk-taking and (2) mental health among school-going adolescent girls. We evaluated study group differences in biomarker-based measures and self-reported sexual risk-taking behaviors and attitudes toward sexual risk-taking behaviors at postbaseline time points (i.e., 12 and 24 months).

Biomarker-based sexual risk

Adolescent girls who tested positive for HIV, gonorrhea, trichomoniasis, chlamydia, genital warts, or pregnancy were categorized as having a positive biomarker test for sexual risk-taking behavior (binary outcome). Because of the COVID-19 pandemic and the resulting school closures and social distancing requirements, study investigators adjusted the data collection protocol to minimize COVID-19 transmission. Hence, biomarker tests for HIV, STIs, and pregnancy were not conducted at 24 months but only at baseline and 12 months.

Self-reported sexual risk

Adolescent girls were asked the following questions:

  • 1.

    Have you ever had sexual intercourse? (Yes or no)

  • 2.

    The last time you had sexual intercourse (willingly or unwillingly), did you or your partner use a condom? (Yes or no)

  • 3.

    Have you ever been diagnosed with any sexually transmitted disease (STDs)? (Yes or no) If yes, what disease? Chlamydia, herpes, trichomoniasis, syphilis, gonorrhea, genital warts, nonspecific disease, other (check all that apply).

If adolescent girls responded “yes” to “ever had sexual intercourse,” indicated a diagnosis of STI, or did not use a condom during last sexual intercourse, they were categorized as engaging in sexual risk-taking based on self-reports (binary outcome).

Intentions and attitudes toward sexual risk-taking behaviors

We utilized 2 measures to assess intentions and attitudes toward sexual risk-taking. The first measure, “sexual risk-taking intentions” was evaluated by a continuous summed score of 5 items (Cronbach α = 0.72 at 12 and 24 months).34 Participants were asked to rate their agreement with the following 5 statements:

  • 1.

    I believe it’s OK for people my age to have sex with someone they’ve just met.

  • 2.

    I believe it’s OK for people my age to have sex with someone they love.

  • 3.

    I believe it’s OK for people to have sex before marriage.

  • 4.

    I agree it’s OK to force a girlfriend/boyfriend to have sex even when they don’t want to.

  • 5.

    I believe it’s OK to have sex without protection with someone you know.

Response options for each statement were never = 1; sometimes = 2; about half the time = 3; most of the time = 4; or always = 5. These 5 statements were summed and analyzed as a continuous variable, with higher scores indicative of greater agreement with sexual risk-taking.

The second measure assessed “Attitudes toward condom use” and comprised the following 3 items:

  • 1.

    I think all people my age who have sex should use condoms.

  • 2.

    Even if you know your partner very well you should use a condom.

  • 3.

    I think it is very important to use condoms every time one has sex.

Response options were agree a great deal = 5; agree a lot = 4; moderately agree = 3; agree a little = 2; or not at all agree = 1. The 3 items had Cronbach α = 0.69 (12 months) and 0.72 (24 months) and were summed and analyzed as a continuous score, with higher scores suggesting favorable attitudes toward condom use.

For mental health, we examined whether there were significant differences between groups only at 24 months after the intervention because findings on group differences at 12 months are reported in other papers published35 and currently in press.36 To get a comprehensive view of adolescents’ overall mental well-being, we assessed 4 measures of mental health among adolescent girls: hopelessness, depressive symptoms, self-concept, and self-esteem. The psychological construct of hopelessness (whether girls have negative attitudes about the future) was measured using the 20-item Beck Hopelessness Scale (Cronbach α = 0.73).37 Girls were required to endorse pessimistic or deny optimistic statements. Hopelessness is common among depressed individuals and is associated with increased suicide risk.39 Depressive symptoms were assessed using the 21-item Beck Depression Inventory (Cronbach α = 0.80).39 Depression is associated with sexual risk-taking behavior and other negative outcomes including suicidal ideation.40 Self-concept (how girls think and feel about themselves) was evaluated using the 20-item Tennessee Self-Concept Scale (Cronbach α = 0.85).41 For this, girls self-reported ratings on their perception of identity and self-satisfaction. We used the 10-item Rosenberg Self-Esteem Scale to assess participants’ self-esteem (Cronbach α = 0.71).42 This scale measures girls’ self-worth by assessing both positive and negative feelings about the self. All items were reverse coded where required, and all items were summed and analyzed as continuous variables. Lower scores on the Beck Hopelessness Scale and the Beck Depressive Inventory are indicative of better mental health because these indicate less hopelessness and depressive symptoms. By contrast, higher scores on the Tennessee Self-Concept and Rosenberg Self-Esteem scales are better because these reflect higher levels of self-concept and self-esteem.

Statistical Analysis

All analyses were conducted in Stata version 17.0.43 Characteristics of study participants at baseline are described in Table 1. We examined if there were any significant differences across study groups on baseline covariates listed in Table 1 (while adjusting for clustering by schools) and conducted sensitivity analyses to adjust for covariates that were significantly different across study groups.

TABLE 1—

Baseline Characteristics of Study Population: Suubi4her Study, Central Uganda, 2017–2022

Characteristics Total (n = 1260), Mean ±SD or No. (%) Usual Care (n = 408), Mean ±SD or No. (%) YDA (n = 471), Mean ±SD or No. (%) YDA+MFG (n = 381), Mean ±SD or No. (%)
Age, y 15.4 ±0.9 15.2 ±0.9 15.5 ±0.8 15.4 ±0.9
Orphanhood statusa
 Double orphan 24 (1.9) 7 (1.7) 8 (1.7) 9 (2.4)
 Single orphan 191 (15.2) 59 (14.5) 72 (15.3) 60 (15.8)
 Nonorphan 1045 (82.9) 342 (83.8) 391 (83.0) 312 (81.9)
Primary caregiver
 Biological parents 965 (76.6) 312 (76.5) 370 (78.6) 283 (74.3)
 Grandparents 140 (11.1) 46 (11.3) 54 (11.5) 40 (10.5)
 Other relatives or nonrelatives 155 (12.3) 50 (12.2) 47 (10.0) 58 (15.2)
Primary caregiver employment status
 Formally employed 292 (23.2) 102 (25.0) 104 (22.1) 86 (22.6)
 Not formally employed 968 (76.8) 306 (75.0) 367 (77.9) 295 (77.4)
Primary caregiver education level
 Did not go to school or completed all or part of primary-level education 496 (39.4) 144 (35.3) 186 (39.5) 166 (43.6)
 Completed all or part of secondary- level education 319 (25.3) 115 (28.2) 110 (23.3) 94 (24.7)
 Completed technical diploma or university degree 137 (10.9) 40 (9.8) 59 (12.5) 38 (10.0)
 Don’t know 308 (24.4) 109 (26.7) 116 (24.6) 83 (21.8)
Household size 7.0 ±2.7 6.8 ±2.6 7.0 ±2.7 7.2 ±2.9
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Note. MFG = multiple family group; YDA = youth development account.

a

Single orphan refers to 1 parent is still alive; double orphan refers to both parents are not alive.

We summarized the outcomes by study group and time point using means and standard deviations for continuous outcomes and numbers and percentages for categorical outcomes (Table 2). For continuous outcomes, we fitted 3-level mixed-effects models. Each model contained a fixed categorical effect for study group and time, the group-by-time interaction, and a random intercept at the school level. An unstructured residual-error covariance matrix of the residuals from the repeated assessments taken on the same participants was fitted, and the assumption of equal variances and covariances across groups was relaxed. For binary outcomes, each model contained fixed effects for study group and time, a group-by-time interaction term, and random intercepts at the school and participant levels, yielding a multilevel logistic regression model.

TABLE 2—

Summary of Sexual Risk-Taking and Mental Health Outcomes by Study Group and Timepoint: Suubi4her Study, Central Uganda, 2017–2022

Outcome Study Arm Baseline 12 mo 24 mo
No. No. (%) or Mean ±SD No. No. (%) or Mean ±SD No. No. (%) or Mean ±SD
Sexual risk-taking
 Biomarker-based sexual risk Control 408 29 (7.1) 396 15 (3.7) NA NA
YDA 471 43 (9.1) 457 22 (4.7) NA NA
YDA+MFG 381 20 (5.3) 366 22 (5.8) NA NA
Entire sample 1260 92 (7.3) 1219 59 (4.8) NA NA
 Self-reported sexual risk Control 408 23 (5.6) 396 34 (8.6) 380 44 (10.8)
YDA 471 15 (3.2) 457 52 (11.4) 441 75 (15.9)
YDA+MFG 381 19 (5.0) 366 29 (7.9) 344 55 (14.4)
Entire sample 1260 57 (4.5) 1219 115 (9.4) 1165 174 (14.9)
 Sexual risk-taking intentions (5-item scale) Control 408 7.5 ±3.9 396 8.5 ±4.0 380 7.9 ±3.7
YDA 471 7.5 ±3.6 457 8.6 ±4.3 441 7.7 ±3.4
YDA+MFG 381 7.5 ±3.8 366 8.2 ±4.1 344 7.8 ±3.6
Entire sample 1260 7.5 ±3.7 1219 8.5 ±4.1 1165 7.8 ±3.5
 Attitudes toward condom use (3-item scale) Control 408 10.4 ±4.4 396 11.3 ±3.6 380 12.0 ±3.5
YDA 471 10.9 ±4.3 457 11.2 ±3.7 441 11.8 ±3.7
YDA+MFG 381 11.1 ±4.2 366 11.0 ±3.7 344 11.9 ±3.6
Entire sample 1260 10.8 ±4.3 1219 11.2 ±3.7 1165 11.9 ±3.6
Mental health
 Hopelessness Control 408 4.9 ±2.8 396 4.4 ±2.7 380 4.7 ±2.9
YDA 471 5.0 ±2.8 457 4.0 ±2.5 441 4.2 ±2.7
YDA+MFG 381 5.1 ±2.9 366 4.0 ±2.5 344 4.0 ±2.5
Entire sample 1260 5.0 ±2.9 1219 4.1 ±2.5 1165 4.2 ±2.5
 Depression Control 408 19.2 ±10.3 396 16.6 ±9.8 380 14.8 ±9.3
YDA 471 17.8 ±10.2 457 14.3 ±8.8 441 13.5 ±8.6
YDA+MFG 381 18.5 ±10.1 366 13.8 ±9.1 344 12.0 ±8.8
Entire sample 1260 18.5 ±10.2 1219 14.8 ±9.1 1165 13.5 ±8.8
 Self-concept Control 408 80.6 ±11.5 379 81.9 ±12.0 347 81.3 ±12.4
YDA 471 81.1 ±11.8 408 84.4 ±10.5 377 83.3 ±11.8
YDA+MFG 381 80.7 ±12.7 335 84.0 ±10.5 303 84.4 ±11.5
Entire sample 1260 80.8 ±12.0 1122 83.4 ±11.1 1027 82.4 ±11.5
 Self-esteem Control 408 32.9 ±5.6 396 33.0 ±5.7 380 35.8 ±4.4
YDA 471 33.3 ±5.6 457 34.5 ±4.5 441 36.2 ±3.9
YDA+MFG 380 32.7 ±5.4 366 34.6 ±4.2 344 36.4 ±3.9
Entire sample 1259 33.0 ±5.4 1219 34.0 ±4.9 1165 36.4 ±3.9
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Note. MFG = multiple family group; NA = not applicable (biological tests for HIV and other sexually transmitted infections were not conducted at 24-month follow-up because of study protocol adjustments made to reduce the spread of COVID-19); YDA = youth development account.

In both linear and logistic models, we estimated the variance‒covariance matrices of parameter estimates by using robust Huber‒White standard errors. We estimated the omnibus effects for study group, time, and the group-by-time interaction. We computed group-within-time effects regardless of the significance of the group-by-time interaction effect. To further elucidate time effects, we followed the statistically significant main effects for time with time-within-group simple effects comparisons. Because of the multiple pairwise comparisons, we performed adjustments to the P values using Sidak’s method.

RESULTS

At baseline, 1260 school-going adolescent girls of mean age 15.4 years were enrolled. A total of 408 girls received usual care, 471 received YDA, and 381 received the combination intervention (YDA+MFG). There were no significant differences across study groups at baseline, except for participants’ age (P = .031) with YDA group 0.31 years older than controls and no difference between other groups. Overall, most girls were nonorphans (82.9%) and being cared for by biological parents (76.6%; Table 1). Approximately 77% of primary caregivers were not formally employed, and approximately 11% completed a technical diploma or university degree. On average, girls resided in households with 7 people. At baseline, 7.3% (n = 92) of adolescent girls had a positive biological test for HIV, STIs, or pregnancy (Appendix, Table B). The most common STI diagnosis was for trichomoniasis (5.2%; n = 65). While only 8 girls (0.6%) were positive for HIV at baseline, 14 (1.1%) had a positive pregnancy test. At 24 months, the retention rate was 92.4%. The distribution of sexual risk-taking outcomes by study group and time point are presented in Table 2 and in the Appendix, Tables B and C.

Sexual Risk-Taking Behavior and Attitudes

For biomarker-based sexual risk, self-reported sexual risk, sexual risk-taking intentions, and attitudes toward condom use outcomes, we observed no significant differences between study groups at 12 and 24 months (Table 3).

TABLE 3—

Study Group Differences of Predicted Probabilities and Estimated Mean Differences Within Each Time Point for Sexual Risk-Taking Behavior: Suubi4her Study, Central Uganda, 2017–2022

Timepoint Group Comparison Biomarker-Based Sexual Risk, RD (95% CI) Self-Reported Sexual Risk, RD (95% CI) Sexual Risk-Taking Intentions, EMD (95% CI) Attitudes Toward Condom Use, EMD (95% CI)
12 mo YDA vs control 0.01 (−0.07, 0.10) 0.02 (−0.04, 0.09) 0.09 (−0.47, 0.66) −0.13 (−1.28, 1.01)
YDA+MFG vs control −0.01 (−0.08, 0.04) −0.01 (−0.06, 0.04) −0.36 (−1.03, 0.33) −0.36 (−1.36, 0.64)
YDA+MFG vs YDA −0.03 (−0.11, 0.04) −0.03 (−0.10, 0.03) −0.44 (−1.08, 0.19) −0.22 (−0.98, 0.53)
24 mo YDA vs control NA 0.05 (−0.01, 0.11) −0.17 (−0.86, 0.50) −0.36 (−0.98, 0.26)
YDA+MFG vs control NA 0.04 (−0.01, 0.08) −0.18 (−1.32, 0.96) −0.13 (−0.77, 0.50)
YDA+MFG vs YDA NA −0.01 (−0.08, 0.52) −0.00 (−1.03, 1.01) 0.23 (−0.41, 0.87)
No. of participants 1260 1260 1260 2260
No. of observations 2520 3780 3644 3644
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Note. CI = confidence interval; EMD = differences of estimated marginal means; MFG = multiple family group; NA = not applicable (biological tests for HIV and sexually transmitted infections were not conducted at 24-month follow-up because of study protocol adjustments made to reduce the spread of COVID-19); RD = differences of predicted probabilities; YDA = youth development account. Group-within-time simple effects.

Effects on Mental Health

There were significant group-by-time interaction effects for all mental health outcomes (Appendix, Table D). At 24 months, we observed adolescent girls in both YDA and YDA+MFG intervention groups had significantly lower levels of depressive symptoms and significantly better self-concept than controls. For hopelessness, only girls in the combination intervention arm (YDA+MFG) had significantly lower levels of hopelessness than controls (Table 4). However, there were no study group differences for self-esteem. For all the sexual risk-taking and mental health outcomes, there were no significant differences between the YDA and YDA+MFG intervention groups. Simple effects comparing follow-ups to baseline within the significant time main effect appear in the Appendix, Table E.

TABLE 4—

Study Group Differences of Estimated Marginal Means Within Each Time Point for Mental Health Outcomes: Suubi4her Study, Central Uganda, 2017–2022

Timepoint Group Comparison Hopelessness, EMD (95% CI) Depression, EMD (95% CI) Self-Concept, EMD (95% CI) Self-Esteem, EMD (95% CI)
24 mo YDA vs control −0.29 (−0.71, 0.12) −1.38 (−2.63, −0.12) 1.96 (0.07, 3.85) 0.34 (−0.24, 0.92)
YDA+MFG vs control −0.45 (−0.90, −0.01) −2.80 (−4.29, −1.32) 3.04 (0.95, 5.12) 0.53 (−0.12, 1.19)
YDA+MFG vs YDA −0.15 (−0.54, 0.23) −1.42 (−2.95, 0.11) 1.08 (−0.90, 3.05) 0.19 (−0.36, 0.75)
No. of participants 1260 1260 1260 1260
No. of observations 3644 3644 3409 3643
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Note. CI = confidence interval; EMD = differences of estimated marginal means; MFG = multiple family group; YDA = youth development account. Group-within-time simple effects.

Sensitivity analysis results were substantively unchanged after we adjusted for age (Appendix, Tables F‒I).

DISCUSSION

School-going adolescent girls in SSA require special attention to reduce their vulnerability to HIV infection and poor mental health. Economic empowerment and family strengthening interventions can play an important role in improving financial resources44,45 while equipping families to deal with the stressors of living in poverty-impacted environments.46 In this population of secondary school‒going adolescent girls, we observed no significant differences between study groups at postbaseline time points for objective biomarker-based and self-reported sexual risk-taking behaviors and attitudes. This finding aligns with a previous study among adolescents living with HIV in which no differences in sexual risk-taking attitudes were observed between the intervention and control group.34

Research conducted among adolescents in the Rakai district of Uganda over a 17-year period consistently showed the highest prevalence of sexual experience was among adolescents aged 19 years and the lowest among adolescents aged 15 years.47 The prevalence was significantly lower among adolescents enrolled in school versus adolescents out of school across all ages. Hence, the lack of significant findings could be attributable to the young age of participants and because all participants were in school and residing within families. Given these reasons, it is not surprising only a small proportion of adolescent girls had a positive self-report of engaging in sexual risk-taking behavior (4.5% at baseline, 9.4% at 12 months, and 14.9% at 24 months) or had a positive biomarker test for HIV, other STIs, or pregnancy (7.3% at baseline and 4.8% at 12 months). Furthermore, only 3.3% were sexually active at baseline and, as expected, this increased to 9.4% at 24 months.

Similarly, for sexual risk-taking intentions and attitudes toward condom use, we observed no significant differences by study group. However, for girls in the YDA group, our time-within-group analyses located a slight increase in sexual risk-taking intentions at 12 months but more favorable attitudes to condom use at 24 months compared with baseline. Girls in the YDA+MFG group had more favorable attitudes toward condom use at 24 months compared with baseline (Appendix, Table E). This highlights the urgent need for better refined sexual risk-reduction interventions for adolescent girls in the transition period. Over time, the YDA and family strengthening activities appeared to improve attitudes toward condom use, although sexual risk-taking intentions appear to have increased.

At 24-month follow-up, we observed differential effects by study group for all mental health outcomes except self-esteem. The YDA and YDA+MFG interventions were more efficacious in reducing girls’ depressive symptoms and improving self-concept than usual care. This meant that both YDA and YDA+MFG interventions had sustained effects on reducing depressive symptoms and improving self-concept among adolescent girls at 24 months. Moreover, only the YDA+MFG intervention was effective in reducing feelings of hopelessness among girls compared with usual care at 24 months. These are important findings that reinforce the need for economic empowerment interventions that improve families’ financial resources as important for improving adolescents’ mental health.

Our findings align with previous studies that found economic empowerment interventions positively improved mental health of vulnerable populations in SSA.44 They also speak to the wide applicability and effectiveness of MFG interventions. Previous studies observed the beneficial impact of MFG interventions on reducing depressive symptoms, improving self-concept, and reducing oppositional defiant disorder and impaired functioning among children with disruptive behavior disorders in Uganda.45 Similarly, MFG interventions have been adapted and implemented among youth living with HIV in the United States and South Africa, with positive results.48,49 The open communication, shared experiences, and social support networks built during Suubi4Her MFG sessions are likely to have contributed to better mental health even among adolescent girls. Given that MFG is sensitive to cultural norms and tailored to the local environment, incorporating MFG components into future interventions designed to prevent sexual risk-taking and prevent poor mental health may have tremendous potential.

Limitations

Despite numerous strengths in the study design, there were a few limitations worth highlighting. First, self-reported findings (specifically, self-reported sexual risk and intentions and attitudes toward sexual risk-taking behaviors) may be subject to underreporting with adolescents providing socially desirable responses. Sexual behavior and mental health are topics that are heavily stigmatized in conservative African communities.50,51 Although we did conduct biological tests for other STIs, this was done once per year, and so it is likely that we could have missed some infection windows if participants became infected and then received STI treatment and the illness resolved between the assessment intervals—although STI treatment among poor school-going adolescents like the ones included in the study is rare.

Second, our findings are not generalizable to out-of-school adolescent girls, at the time of study recruitment, who may be at higher risk of sexual risk-taking and poor mental health. Third, this analysis was done on the entire sample of all adolescent girls, including investigating sexual risk-taking intentions among those who were not sexually active. Analyses may show different trends and a different impact of the intervention on sexual risk-taking attitudes and behaviors if the sample comprised only girls who were sexually active.

Conclusions

On one hand, we found that providing YDA in addition to family strengthening activities to adolescent girls in secondary schools in poverty-impacted communities in Uganda has the potential to positively improve their mental health. However, our analyses show no significant differences across groups on sexual risk-taking behaviors, something that could be explained by the relatively young age of the participants enrolled in the study. Future studies may consider replicating these interventions and analyses in an older population of adolescent girls, including those transitioning into young adults who are likely to be more sexually active.

ACKNOWLEDGMENTS

The study outlined in this protocol is supported by the National Institute of Mental Health (NIMH) under award 1R01MH113486-01 (PI: Fred M. Ssewamala, PhD).

We are grateful to Abel Mwebembezi at Reach the Youth–Uganda, Joseph Kato Bakulu at Masaka Catholic Diocese, Gertrude Nakigozi and Godfrey Kigozi at Rakai Health Sciences Program in Uganda, and Phionah Namatovu and Sarah Namutebi at the International Center for Child Health and Development for their respective contributions to the study design and implementation. In addition, we are grateful to the financial institutions that agreed to work with the adolescent girls in opening savings accounts and the extension workers who have committed time to train the adolescent girls in conducting income-generating activities. Our thanks also go to the Ugandan Government Ministry of Education and the 47 secondary schools that have agreed to participate in the Suubi4Her study.

Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIMH or the National Institutes of Health.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

HUMAN PARTICIPANT PROTECTION

The Suubi4Her study was conducted in accordance with the Declaration of Helsinki and approved by the Washington University in St Louis institutional review board (IRB no. 201703102), the Uganda Virus Research Institute (GC/127/17/07/619), and the Uganda National Council of Science and Technology (SS4406). The study is also registered in the ClinicalTrials.gov database (Identifier: NCT03307226).

Footnotes

See also Baumann and Devkota, p. 246.

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