Faculty Bibliography

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.

Background/UNASSIGNED:(NICHD) funded, cluster randomized-controlled trial to evaluate a combination intervention, titled Suubi + Adherence, aimed at improving ART adherence among HIV perinatally infected adolescents (ages 10-16 at study enrollment) in Uganda. Methods/UNASSIGNED:Suubi + Adherence was evaluated via a two-arm cluster randomized-controlled trial design in 39 health clinics, with a total enrollment of 702 HIV + adolescents (ages 10-16 at enrollment). The study addresses two primary outcomes: 1) adherence to HIV treatment regimen and 2) HIV knowledge and attitudes. Secondary outcomes include family functioning, sexual risk-taking behavior, and financial savings behavior. For potential scale-up, cost effectiveness analysis was employed to compare the relative costs and outcomes associated with each study arm: family economic strengthening comprising matched savings accounts, financial management training and small business development, all intended for family economic security versus bolstered usual care (SOC) comprising enhanced adherence sessions to ensure more standardized and sufficient adherence counseling. Discussion/UNASSIGNED:This study aims to advance knowledge and inform the development of the next generation of programs aimed at increasing adherence to HIV treatment for HIV + adolescents in low-resource regions such as SSA. To our knowledge, the proposed study is the first to integrate and test family economic empowerment and stability-focused interventions for HIV + adolescents in Uganda (and much of SSA)-so families would have the necessary finances to manage HIV/AIDS as a chronic illness. The study would provide crucial evidence about the effects of an economic empowerment program on short and long-term impact, which is essential if such interventions are to be taken to scale. Trial registration/UNASSIGNED:This trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.

In Uganda, 660,000 children have lost a parent to HIV/AIDS. Family economic empowerment interventions can improve health and developmental outcomes among children in communities impacted by AIDS and mitigate the risks they face. In resource-limited settings, it is important to identify cost-effective, scalable and sustainable interventions to inform allocation of resources given competing health priorities. Yet, evidence is limited on the cost-effectiveness (CE) of interventions aimed at improving adolescents' physical and mental health. We present a CE analysis of Bridges, a NIH-funded savings-led economic empowerment intervention among children and adolescents impacted by AIDS in Uganda. We use longitudinal data corrected at 4 time-points: 12, 24, 36 and 48 month-follow-up (2012-2016). Intent-to-treat analyses using multi-level difference-in-differences models compared the effects on self-rated health, mental health functioning, and sexual health of the two treatment arms: 1:1 (Bridges) and 2:1 (BridgesPLUS) incentivized savings match to usual care over the 48 months. 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 the incremental CE ratios (ICERs). 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 scores (-0.28, 95% CI -0.43-0.125); 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) compared to usual care. ICERs ranged from $224 for hopelessness to $298 for HIV knowledge. Intervention effects were measurable two years post-intervention, with higher savings match (2:1) positively impacting more outcomes than lower savings match (1:1). Our findings support the incorporation of economic empowerment interventions for poor AIDSimpacted children and communities within national social protection frameworks in low- and middle-income countries. 645A EVALUATION OF THE IMPACT OF THE CERTIFIED OPHTHALMIC PARAMEDIC PROGRAM AT A LARGE CHARITY EYE HOSPITAL IN DELHI, INDIA Vimal Konduri1, Ishaana Sood2, Shalinder Sabherwal2, Sunita Arora2, Parul Datta2, Kyle McDaniel1, Suresh R. Chandra1, Cat N. Burkat1 1University of Wisconsin School of Medicine and Public Health, Madison, WI, United States, 2Dr. Shroff's Charity Eye Hospital, Delhi, India Vision loss is a major healthcare issue in India, driven by lack of access to care. In 2014, the Certified Ophthalmic Paramedic (COP) Program based at Dr. Shroff's Charity Eye Hospital (SCEH) in Delhi, supported by Combat Blindness International, began training young women from Delhi and rural North India to become paramedics (COPs) through a free 2-year program. Afterwards, COPs work at SCEH facilities in their communities. The program aims to improve SCEH's reach and quality of care and advance COPs' socioeconomic mobility and gender equity. This mixed-methods study examined the program's impact on graduates, their families, and delivery of care. Program graduates from Delhi and 5 SCEH secondary centers (located in outlying rural areas) who completed training at least 1 year prior were considered. All answered ?before? and ?after? questionnaires with over 200 total questions, reflecting previous and current socioeconomic status (SES), gender equity, healthcare choices, and confidence. Qualitative interviews were administered to some subjects and their family members. The program's impact on care was assessed using hospital data on procedures and screenings. 53 of 69 eligible graduates were included in the study. 18 family members of 16 COP subjects were interviewed. Questionnaire responses showed that COP program participation was associated with a significant (p=1.037x10-5) increase in participants' SES, measured by principal component analysis of household asset ownership, with a greater increase at secondary centers (p=7.508x10-5) than in Delhi (p=0.03094). Program graduates also reported a significant (p=2.152x10-5) increase in their contribution to family economic decision-making. Interviewed graduates and their families had positive opinions of the program, also offering some suggestions for improvement. At secondary centers, surgery volume increased by 164% and outpatient visits increased by 109% between 2013 and 2017. Overall surgery volume at SCEH increased by 62% and number of patients screened increased by 64% over same period, indicating a substantial increase in patient volumes since the COP program began

Low-income youths in KwaZulu-Natal, South Africa, face elevated risks to their well-being from exposure to neighborhood conditions correlated with engaging in risky behaviors. These risks can be mitigated through adult caregivers who serve as protective shields, buffering adverse conditions. However, this protective role is dependent on the caregivers' mental health and well-being. This secondary analysis uses baseline data from 475 child-caregiver dyads in an HIV-prevention program to examine the mediating effects of caregiver mental health on the relationship between neighborhood conditions and child risk-behaviors. Multivariate analyses identify the direct and indirect effects of neighborhood stressors and caregiver mental health on child risk-behavior. Findings suggest that caregivers mitigate the impact of neighborhood conditions on their children, but caregivers' mental health is directly affected by neighborhood conditions. Therefore, caregivers' mental health and well-being must be considered key elements in developing youth risk-behavior interventions.

BACKGROUND:Disruptive Behavioral Disorders (DBDs) and Attention Deficit/Hyperactivity Disorder (ADHD) are chronic, impairing, and costly child and adolescent mental health challenges which, when untreated, can result in disruptions in school performance, friendships and family relations. Yet, there is dearth of prevalence data on child and adolescent behavioral challenges within sub-Saharan Africa, including Uganda. This study aims to estimate the prevalence rate of behavioral challenges and ADHD among young school going children and early adolescents (ages 8-13 at study enrollment), utilizing a school-based sample in southwest Uganda. METHODS:We present screening results from a 5-year scale-up study titled SMART Africa-Uganda (2016-2021), set across 30 public primary schools located in the greater Masaka region in Uganda, a region heavily impacted by poverty and HIV/AIDS. Specifically, we draw on screening data from caregivers of 2434 children that used well-established standardized measures that had been pre-tested in the region. These were: 1) oppositional defiant disorder (ODD) and conduct disorder (CD) subscales of the Disruptive Behavior Disorders (DBD) scale; and 2) the Iowa Connors and Impairment scales. Slightly over half of the children in the sample were female (52%), with a mean age of 10.27 years. RESULTS:Of the 2434 participants screened for disruptive behaviors: 1) 6% (n = 136) scored positive on ODD and 2% (n = 42) scored positive on CD subscales of the DBD scale; 2) 9.61% (n = 234), and 2.67% (n = 65) were reported to have elevated symptoms of ODD and ADHD on the Iowa Connors caregiver report scale respectively. Twenty-five percent (n = 586) of children were described by their caregivers as having experienced some form of impairment in at least four domains of the Impairment scale. CONCLUSION/CONCLUSIONS:The results indicate the presence of behavioral challenges and ADHD among school going children, aged 8-13 years, in Uganda. Given the negative outcomes associated with behavioral challenges as children transition to adolescence and adulthood, detecting these emerging behavioral challenges early is critical in developing appropriate interventions. School settings could be considered as one of the contextually-relevant, culturally-appropriate, and non-stigmatizing venues to implement screening procedures and to detect emerging behavioral challenges and to make necessary referrals.

A lack or low level of social capital is associated with negative outcomes for communities impacted by poverty. However, less is known about how different types of social capital operate on the ground in poverty-impacted urban neighborhoods. This article explores the ways in which bonding, bridging, and linking capital manifest among residents of two poverty-impacted neighborhoods in New York City. Findings of the study reveal that urban neighborhood characteristics, more than individual-level factors, compromise the ability to develop and utilize the leveraging role of bridging and linking capital. Lack of safety resulted in limited trust, and involvement in community life limit bonding capital. Opportunities for bridging are restricted by the socioeconomically homogenous and spatially segregated nature of the communities. Linking capital is undermined by the lack of resources in the neighborhoods. These structural barriers prevent communities from breaking the cycle of poverty and should be explicitly targeted when developing interventions focused on building social capital.

Several studies in sub-Saharan Africa have linked social support to better ART (antiretroviral therapy) adherence among adults living with HIV. Less is known about the role of social support and family cohesion in ART adherence among children below 18 years. This paper focuses on HIV-infected adolescents as they transition through the vulnerable developmental stage of adolescence to examine the association between family cohesion and social support, and ART adherence in southern Uganda. We utilized baseline data from Suubi+Adherence study, a five-year randomized longitudinal clinical trial with the overall goal of examining the impact and cost associated with an innovative asset-based social intervention to increase adherence to HIV treatment for HIV-infected adolescents in Uganda. This study employed self-reports to measure social support, family cohesion and ART adherence to treatment from 702 participants in 39 clinics situated in southern Uganda. Regression results indicated that after adjusting for sociodemographic characteristics that family cohesion and social support from caregivers/family were associated with self-reported adherence to ART among HIV-infected adolescents. Social support from classmates, teachers, and friends were not associated with ART adherence. Study results suggest that strengthening family relationships and promoting social support within families caring for adolescents living with HIV can be crucial in addressing ART adherence challenges among adolescents in sub-Saharan Africa.

BACKGROUND: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. METHODS: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). FINDINGS/RESULTS: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. CONCLUSIONS: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.

BACKGROUND:Children in Sub-Saharan Africa (SSA) comprise half of the total regional population, yet existing mental health services are severely under-equipped to meet their needs. Although effective interventions for the treatment of disruptive behavioral disorders (DBDs) in youth have been tested in high-poverty and high-stress communities in developed countries, and are relevant for widespread dissemination in low- and middle-income countries (LMICs), most of these evidence-based practices (EBPs) have not been utilized in SSA, a region heavily impacted by poverty, diseases including HIV/AIDS, and violence. Thus, this paper presents a protocol for a scale-up longitudinal experimental study that uses a mixed-methods, hybrid type II, effectiveness implementation design to test the effectiveness of an EBP, called Multiple Family Group (MFG) aimed at improving child behavioral challenges in Uganda while concurrently examining the multi-level factors that influence uptake, implementation, sustainment, and youth outcomes. METHODS:The MFG intervention will be implemented and tested via a longitudinal experimental study conducted across 30 public primary schools located in both semi-urban and rural communities. The schools will be randomly assigned to three study conditions (n = 10 per study condition): (1) MFG delivered by trained family peers; (2) MFG delivered by community health workers; or; (3) comparison: usual care comprising mental health care support materials, bolstered with school support materials. A total of 3000 children (ages 8 to 13 years; grades 2 to 7) and their caregivers (N = 3000 dyads); 60 parent peers, and 60 community health workers will be recruited. Each study condition will comprise of 1000 child-caregiver dyads. Data will be collected at baseline, 8 and 16 weeks, and 6-month follow-up. DISCUSSION/CONCLUSIONS:This project is the first to test the effectiveness of the MFG intervention while concurrently examining multi-level factors that influence overall implementation of a family-based intervention provided in schools and aimed at reaching the large child population with mental health service needs in Uganda. Moreover, the study draws upon an EBP that has already been tested for delivery by parent peers and community facilitators, and hence will take advantage of the advancing science behind task-shifting. If successful, the project has great potential to address global child mental health needs. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov, ID: NCT03081195 . Registered on 16 March 2017.

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/BACKGROUND:Clinical Trials NCT03307226 (Registered: 10/11/17).