We report findings from a pilot study in western Kenya, using an experimental design to test whether comprehensive support to keep adolescent orphans in school can reduce HIV risk factors

Cho, Hyunsan

Hallfors, Denise D.

Halpern, Carolyn T.

Iritani, Bonita J.

Itindi, Janet

Mbai, Isabella I.

Milimo, Benson W.

Carolina Digital Repository

Keeping Adolescent Orphans in School as HIV Prevention:Evidence from a Randomized Controlled Trial in KenyaHyunsan Cho, PhD1, Denise D. Hallfors, PhD1, Isabella I. Mbai, MS Health2, Janet Itindi, BSNursing2, Benson W. Milimo, BS Nursing2, Carolyn T. Halpern, PhD3, and Bonita J. Iritani,MSS11 Pacific Institute for Research and Evaluation, Chapel Hill, NC, USA2 Moi University, Eldoret, Kenya3 Department of Maternal and Child Health, University of North Carolina, Chapel Hill, NC, USAAbstractPurpose—We report findings from a pilot study in western Kenya, using an experimental designto test whether comprehensive support to keep adolescent orphans in school can reduce HIV riskfactors.Methods—Adolescent orphans age 12–14 years (N=105) in Nyanza Province were randomizedto condition, after stratifying by household, gender, and baseline survey report of sexual behavior.The intervention comprised school fees, uniforms, and a “community visitor” who monitoredschool attendance and helped to resolve problems that would lead to absence or dropout. Datawere analyzed using Generalized Estimating Equations over two time points, controlling forgender and age.Results—Compared with controls, intervention students were less likely to drop out of school,commence sexual intercourse, or report attitudes supporting early sex. School support alsoincreased pro-social bonding and gender equity attitudes.Conclusions—After one year of exposure to the intervention, we found evidence suggestingthat comprehensive school support can prevent school dropout, delay sexual debut, and reduceHIV risk factors. More research, with much larger samples, is needed to better understand factorsthat mediate the association between educational support and delayed sexual debut, and howgender might moderate these relationships.Keywordsorphans; education; HIV prevention; Kenya; randomized controlled trialINTRODUCTIONOf the estimated 15 million children orphaned by the HIV pandemic, about 11.6 million areliving in sub-Saharan Africa [1]. Orphans are at increased risk of psychological distress,Corresponding author: Hyunsan Cho, Pacific Institute for Research and Evaluation, 1516 E. Franklin St., Suite 200, Chapel Hill, NC,27514. Phone 919-265-2620. cho@pire.org.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptJ Adolesc Health. Author manuscript; available in PMC 2012 May 1.Published in final edited form as:J Adolesc Health. 2011 May ; 48(5): 523–526. doi:10.1016/j.jadohealth.2010.08.007.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptpoverty, and school dropout [2]. Sexual behavior increases with school dropout [3], leavingadolescent orphans particularly vulnerable to HIV. Structural interventions, such asenhanced access to continued schooling, offer the promise of more effective HIV preventionstrategies for this vulnerable group [4].Several recent experimental studies have demonstrated reductions in HIV risk by improvingschool enrollment and attendance. In Kenya, an intervention consisting of school uniformsdecreased school dropout, marriage, and pregnancy compared to an intervention consistingof teacher HIV education training [5]. In Malawi, young women who received conditionalcash transfers (for staying in school) and secondary school fees were more likely to remainin school and showed some reductions in sexual risk behavior [6]. A subsample of oldergirls (average 17 years old) who had previously dropped out of school, were less likely tomarry or get pregnant than controls [6]. In Zimbabwe, comprehensive school support forrural adolescent orphan girls reduced school dropout by 78% and early marriage by 63% [7].This paper reports early findings from an experimental pilot study testing the impact ofproviding comprehensive community-based school support on orphan adolescent sexual riskbehaviors in Nyanza Province, Kenya. Nyanza Province has the highest HIV prevalence(15%) in Kenya; the Luo tribe, which dominates in Nyanza, has the highest HIV prevalence(22%) among all ethnicities [8]. Based on the Social Development Model [9], wehypothesized that intervention students would show greater attachment to school and pro-social adults, have higher educational aspirations, more positive future expectations, moreprotective attitudes about early sex, and less sexual activity. We also hypothesized thatschool support for both girls and boys would increase equitable gender attitudes, which havebeen found to be associated with HIV prevalence in sub-Saharan Africa [10].METHODSThe study sample included 105 Luo students aged 12–14 years, who had lost one or bothparents through death by any cause in a rural location (East Kochieng) near the city ofKisumu. Local leaders identified 79 households with one or more eligible orphans. Parent/guardian consent and student assent were obtained, and all protocols were approved by thePIRE and Moi University institutional review boards.We used stratified random assignment to avoid relative deprivation and ensure that sexualexperience and gender were equivalent by study condition at baseline. First, we assigned thesame study condition to all eligible participants in the same household; we also assigned thesame condition to participants in households in very close proximity (as in polygamoushouseholds). Next, using baseline survey data, we stratified households by participant sexualdebut and gender, and then generated random numbers for random assignment.All participating households received mosquito nets and blankets, as well as twice monthlyfood supplements (maize, oil, sugar, water guard). Experimental (E) condition participantsalso received uniforms and school fees. A local adult female “community visitor” (CV) wasassigned to approximately 10 E children, to visit households at least monthly and schoolsweekly to monitor school attendance. If needed, the CV could use intervention funds toaddress problems resulting in absenteeism (e.g., sanitary napkins for girls during menses;clinic visit and medication for common problems such as malaria or parasites). Thebudgeted cost of the school support intervention was approximately $200/year/child; thebudgeted cost of food supplements and other services provided to all participants wasapproximately $100/year/child.We used factor analyses to create multi-item indices and conducted chi-square and t-tests toestablish baseline group equivalence. For intervention effects, we tested differential changeCho et al. Page 2J Adolesc Health. Author manuscript; available in PMC 2012 May 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptfrom baseline to follow-up between the E and control (C) groups using GeneralizedEstimating Equations (SAS Proc GENMOD). The models assessed condition and time maineffects and the condition by time interaction, controlling for age and gender. Due to thesmall sample size, we used a significance standard of p≤.10.RESULTSBaseline survey data were essentially equivalent between E and C groups, except formarginal differences in school uniforms and attitudes about waiting until marriage beforesex (see Table 1). Both of these were in the direction that would favor the Cs.At the one-year follow-up, 98% of participants responded to the survey. Significantdifferences by condition over time were as follows: Cs were more likely than Es to: 1) dropout of school (12% versus 4%; p=.05), 2) begin sexual intercourse (33% versus 19%; p=.07), and 3) report attitudes supporting early sex (p<.001). Es were more likely than Cs toperceive that adults in the family liked or cared about them (p=.02). Es were less likely toperceive that it is okay for a husband to beat his wife if she refuses sex (p=.07); and that it isokay for a husband to beat his wife for any reason (p=.07). All significant differences werein the hypothesized direction (see Table 2).DISCUSSIONAfter one year exposure to the intervention, we found evidence that comprehensive schoolsupport can prevent school dropout, delay sexual debut, and reduce HIV risk factors. Wealso found evidence that school support increases pro-social bonding and gender equityattitudes. These effects are promising, particularly given the small size of the study, theyoung adolescents, and the inclusion of both genders.A major limitation of the study is the small sample size, making it infeasible to discerngender by intervention interactions or factors that mediate the relationship between schoolsupport and HIV risk behaviors. Moreover, the study can only be generalized to Luo orphanyouth in rural western Kenya. However, this pilot study is the first known community-basedstructural intervention found to reduce HIV risk behaviors among adolescent orphan boysand girls in Sub-Saharan Africa.Our findings add to mounting evidence that school support can help reduce HIV riskbehaviors in high prevalence, low resource countries. Besides replication with a largersample size, models for widespread diffusion of comprehensive school support, withsafeguards to ensure that funding reaches and benefits orphan students, are also needed.AcknowledgmentsThis study was funded by the National Institute of Mental Health (Grant 5R34MH79749-3, Denise Hallfors, P.I.).We would like to thank Dr. Pamela McQuide for her dedication to orphan education and her support of theresearch. We also would like to thank Shane Hartman for his assistance in preparing the manuscript and ChrisWiesen for his statistical analysis consultation.References1. UNAIDS. ‘Report on the global AIDS epidemic. 2008 [Accessed August 10, 2010].2. UNICEF. Africa’s Orphaned and Vulnerable Generations: Children affected by AIDS. [AccessedMarch 25, 2010]. Available at:http://www.unicef.org/publications/files/Africas_Orphaned_and_Vulnerable_Generations_Children_Affected_by_AIDS.pdfCho et al. Page 3J Adolesc Health. Author manuscript; available in PMC 2012 May 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript3. Chiao C, Mishra V. Trends in primary and secondary abstinence among Kenyan youth. AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HIV. 2009; 21(7):881–892.4. Gupta GG, Parkhurst JO, Ogden JA, Aggleton P, Mahal A. Structural approaches to HIVprevention. Lancet. 2008; 372:764–775. [PubMed: 18687460]5. Duflo, E.; Dupas, P.; Kremer, M.; Sinei, S. Education and HIV/AIDS prevention: Evidence from arandomized evaluation in western Kenya; World Bank Policy Research Working Paper. 2006[Accessed November 4, 2009]. p. 4024Available at:http://papers.ssrn.com/sol3/papers.cfm?abstract_id=9351736. Baird S, Chirwa E, McIntosh C, Ozler B. The short-term impacts of a schooling conditional cashtransfer program on the sexual behavior of young women. Health Econ. 2009 November 27. [Epubahead of print].7. Hallfors, DD.; Cho, H.; Rusakaniko, S.; Iritani, BJ.; Mapfumo, J. Supporting Adolescent OrphanGirls to Stay in School as HIV Risk Prevention: The Evidence From Rural Zimbabwe. 2010.unpublished manuscript. (Note: currently under revise and resubmit at AJPH)8. Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro.Kenya Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro;2004.9. Catalano, RF.; Hawkins, JD. The Social Development Model: A theory of antisocial behavior. In:Hawkins, JD., editor. Delinquency and Crime: Current Theories. New York: Cambridge UniversityPress; 1996.10. Niens L, Lowery D. Gendered epidemiology: Sexual equality and the prevalence of HIV/AIDS insub-Saharan Africa. Social Science Quarterly. 2009; 90(5):1134–1144.Cho et al. Page 4J Adolesc Health. Author manuscript; available in PMC 2012 May 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptCho et al. Page 5Table 1Baseline Equivalence between Experimental Group and Control GroupGroup Experimental N=53 Control N=52 Total N=105Mean (SD)Number (%)Mean (SD)Number (%) T/chi-square (p-value)Demographic variablesAge in 2008 12.94(0.16) 12.92 (0.16) −0.09 (0.93)Grade 6.04(0.19) 5.73(0.20) −1.12(0.27)Gender (% female) 31(58.5%) 31(59.6%) 0.01(0.91)Orphan status 2.74 (0.25) Paternal 35 (66%) 26 (51%) Maternal 5 (9%) 9 (18%) Double orphan 13 (25%) 16 (31%)SES count index (alpha=.62, 13 items) 2.75(0.28) 3.31(0.23) 1.52(0.13)School uniform 24(46%) 31 (66%) 3.92 (0.05)**School absence 1.92 (0.16) 1.94(0.16) 0.06(0.95)Perception of Caring AdultsTeachers care 4.00(0.19) 3.78(0.24) −0.73(0.45)Adults in family care 3.60(0.21) 3.81(0.20) 0.71(0.48)Adults in community care 3.56(0.21) 3.46(0.21) −0.35(0.72)Education aspiration (higher than secondary school vs. others) 44 (83%) 38 (73%) 2.50 (0.29)Future Expectations:Graduate from Secondary school 4.11(0.19) 4.06(0.20) −0.21(0.84)Graduate from College/Univ. 4.30(0.15) 4.12(0.18) −0.80(0.42)Enough salary by age 30 3.45(0.22) 3.38(0.20) −0.23(0.82)Live to age 35 3.83(0.19) 3.75(0.20) −0.29(0.77)Gender Equity index (alpha=.71) 11.3 (5.4) 12.2 (4.7%) 0.92 (0.36)Wife Beating: It is okay for husband to beat his wife: YesIf she neglects the children 31(58.5%) 30(57.7%) 0.01(0.93)If she argues with him 33(62.3%) 30(57.7%) 0.23(0.63)If she refuses sex with him 5(9.4%) 6(11.5%) 0.30(0.59)If she burns the food 9(17.0%) 11(21.2%) 0.30(0.59)For any reason 8(15.1%) 5(9.6%) 0.73(0.39)Sexual AttitudesDisagree with early sex (alpha=.65) 3.79(0.12) 4.04(0.11) 1.56(0.12)Believe in waiting until marriage before sex 1.89(0.18) 2.42(0.23) 1.85(0.07)*Sexual Debut (yes) 9 (17%) 9 (17%) 0.0 (1.00)*p = ≤.10;**p = ≤.05J Adolesc Health. Author manuscript; available in PMC 2012 May 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptCho et al. Page 6Table 2Intervention Effects over Two Time PointsExperimental GroupControl GroupCondition *  TimeTime 1 (n=53)Time 2 (n=52)Time 1 (n=52)Time 2 (n=51)Freq (%) MeanFreq (%) MeanFreq (%) MeanFreq (%) MeanParameter est. (P-value)School dropout in 2009aNA2(3.77%)NA6(11.54%)AOR=3.66 (CI=0.7–19.9) (0.05)*School absence1.921.741.941.910.41(0.26)Perception of Caring AdultsTeachers care4.134.103.723.740.20(0.42)Adults in family care3.613.823.793.442.09(0.02)**Adults in community care3.543.483.433.350.08(0.47)Education aspiration (higher than secondary school)2.782.912.622.740.39(0.35)Future ExpectationsGraduate from Secondary school4.074.004.023.640.51(0.31)Graduate from College/Univ.4.294.294.103.720.86(0.19)Good salary by age 303.503.503.413.51−0.74(0.23)Live to age 353.823.823.693.91−0.85(0.20)Gender equity (alpha=.71)2.262.792.442.850.69(0.24)Wife Beating: It is okay for a husband to beat his wife?If she neglects the children31(58.5%)31(59.6%)30(57.7%)35(68.6%)−0.95(0.17)If she argues with him33(62.3%)21(40.4%)30(57.7%)17(33.3%)0.22(0.41)If she refuses sex with him5(9.4%)1(1.9%)6(11.5%)7(13.7%)−1.48(0.07)*If she burns the food9(17.0%)9(17.3%)11(21.2%)10(19.6%)0.33(0.37)For any reason8(15.1%)3(5.8%)5(9.6%)6(11.8%)−1.51(0.07)*Sex AttitudesDisagree with early sex (alpha=65.)3.814.294.053.774.16(<.00)**Believe in waiting until marriage before sex1.891.962.432.131.24(0.11)Virginity because of values1.281.311.251.340.71(0.20)Virginity because of consequence1.141.171.221.220.07(0.40)J Adolesc Health. Author manuscript; available in PMC 2012 May 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptCho et al. Page 7Experimental GroupControl GroupCondition *  TimeTime 1 (n=53)Time 2 (n=52)Time 1 (n=52)Time 2 (n=51)Freq (%) MeanFreq (%) MeanFreq (%) MeanFreq (%) MeanParameter est. (P-value)Sexual debut9(17.3%)10(19.2%)9(17.0%)17(33.3%)−1.50(0.07)*One tailed test at* p = ≤.10;**p = ≤.05;a Logistic regression was conducted for school dropoutAOR=adjusted odds ratio; CI= confidence intervals; Models controlled for age and gender.J Adolesc Health. Author manuscript; available in PMC 2012 May 1.

Keeping Adolescent Orphans in School to Prevent Human Immunodeficiency Virus Infection: Evidence From a Randomized Controlled Trial in Kenya

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Keeping Adolescent Orphans in School to Prevent Human Immunodeficiency Virus Infection: Evidence From a Randomized Controlled Trial in Kenya

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