Economic vulnerabilities, mental health, and coping strategies among Tanzanian youth during COVID-19.

BACKGROUND: The COVID-19 pandemic has exacerbated struggles for youth living in poor households. Youth in rural Tanzania are particularly vulnerable given widespread poverty, lack of formal sector employment opportunities, and health risks. We examine influences of the pandemic on economic insecurity and mental health and explore the coping strategies employed by youth and their households. METHODS: We conducted mixed-method data collection with youth (N = 760 quantitative and N = 44 qualitative interviews) and households (n = 542) via mobile phone among a sub-set of a cohort from an on-going longitudinal sample in two rural regions in Tanzania. In addition to phone interviews, we collected data bi-weekly via SMS messaging. We present mixed-methods, descriptive analysis of the outcomes and longitudinally compare quantitative outcomes pre- and post-COVID-19, within the same individuals. RESULTS: Adverse economic impacts were most salient, and to cope, youth engaged in more labor and domestic chores. Compared to prior the COVID-19 pandemic, youth reported spending more time caring for elderly or sick household members and gathering firewood or nuts. CONCLUSIONS: These findings underscore the potential opportunity to promote policies and programs which address risks youth face. Recommended measures include expansion and adaptation of social protection policies, strengthened food and nutrition surveillance and referral systems, and scaling up community-based mental health programming.

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.

Impact of cash transfers on the association between prenatal exposures to high temperatures and low birthweight: Retrospective analysis from the LEAP 1000 study.

OBJECTIVE: To explore the associations between prenatal temperature exposures and low birthweight (LBW) and modification by cash transfer (CT) receipt. DESIGN: Retrospective cohort study. SETTING: Five rural districts in Northern Ghana. POPULATION OR SAMPLE: A total of 3016 infants born to women interviewed as part of the Livelihood Empowerment Against Poverty (LEAP 1000) impact evaluation between 2015 and 2017. METHODS: Birthweight was collected using household surveys administered to LEAP 1000 eligible women. We used a UNICEF-developed multiple imputation approach to address missingness of birthweight and applied an empirical heaping correction to the multiply imputed birthweight data. Survey data were linked to the European Centre for Medium-Range Weather Forecasts Reanalysis 5-hourly temperature averaged to weeks for 2011-2017 using community centroids. Using distributed-lag nonlinear models, we explored the lag-specific associations between weekly average temperatures greater than 30°C and LBW, and stratified by LEAP 1000 treatment. MAIN OUTCOME MEASURES: Low birthweight (<2.5 kg). RESULTS: Twelve percent (n = 365) of infants were LBW; the mean ± SD birthweight was 3.02 ± 0.37 kg. Overall, increasing temperatures were associated with increased odds of LBW, with the greatest odds observed in the 3 weeks before birth (odds ratio 1.005-1.025). These positive associations were even larger among comparison infants and null among treatment infants. CONCLUSIONS: Our study found increased odds of LBW with high weekly average temperatures throughout pregnancy and the preconception period and demonstrate mitigated effects by the LEAP 1000 CT program. More evidence on the potential of CTs to serve as adaptation interventions in low- and middle-income countries is needed to protect pregnant persons and their infants from the impacts of climate change.

Climate distress, climate-sensitive risk factors, and mental health among Tanzanian youth: a cross-sectional study.

BACKGROUND: Climate change threatens youth mental health through multiple mechanisms, yet empirical studies typically focus on single pathways. We explored feelings of distress over climate change among Tanzanian youth, considering associations with climate change awareness and climate-sensitive risk factors, and assessed how these factors relate to mental health. METHODS: Tanzanian youth (aged 18-23 years) from a cluster randomised controlled trial in Mbeya and Iringa regions of Tanzania were interviewed between Jan 25, and March 3, 2021, and included in this cross-sectional study. A threshold of at least 10 on the ten-item Centre for Epidemiological Studies Depression Scale was used to classify symptom severity indicative of depression. Regardless of climate change awareness, respondents were asked about their feelings of distress on climate change using inclusive language (changing weather patterns or changing seasons). We estimated rate differences in climate change distress (slight or moderate or extreme vs none) by youth characteristics, extent of climate awareness, and climate-sensitive livelihoods (eg, agriculture, tending livestock) and climate-sensitive living conditions (eg, food or water insecurity), using generalised linear models. We compared depression prevalence by extent of climate change distress and climate-sensitive living conditions. FINDINGS: Among 2053 youth (1123 [55%] were male and 930 [45%] were female) included in this analysis, 946 (46%) had reported any distress about climate change. Distress was higher among female, more educated, more religious, older youth, and those working in extreme temperatures. Adjusting for climate awareness-a factor strongly associated with climate distress-helped to explain some of these associations. Depression was 23 percentage points (95% CI 17-28) higher among youth who had severe water insecurity than those who did not. Similarly, youth who had severe food insecurity had 23 percentage points higher depression (95% CI 17-28) compared with those who did not. Those reporting climate change distress also had worse mental health-extremely distressed youth had 18 percentage points (95% CI 6-30) higher depression than those reporting none. INTERPRETATION: Living in conditions worsened by climate change and feeling distressed over climate change have mental health implications among young people from low-resource settings, indicating that climate change can impact youth mental health through multiple pathways. FUNDING: Erasmus Trustfonds, Centre for Global Health Inequalities Research, UK's Foreign, Commonwealth, and Development Office, Oak Foundation, UNICEF, UK's Department of International Development, the Swedish Development Cooperation Agency, Irish Aid.

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.

Food Insecurity, telomere length and the potential modifying effects of social support in National Health and Nutrition Examination Survey.

OBJECTIVE: Telomere length (TL) is a posited pathway through which chronic stress results in biological dysregulation and subsequent adverse health outcomes. Food insecurity is associated with shorter TL. Social support, which is defined by the size and function of an individual's social network, is associated with better health outcomes. The present study assesses whether social support modifies the relationship between food security and TL. DESIGN: Cross-sectional study design. Linear regression was used to assess the association between food insecurity and TL, stratified by social support level. A multiplicative interacted model was used to formally test modification. SETTING: Data come from the National Health and Nutrition Examination Survey 1999-2000 and 2001-2002 waves. PARTICIPANTS: Adults aged 60 years and older who have measurements for TL. RESULTS: Our sample comprised 2674 participants, and 63·5 % of the total sample had low social support, with 13·3 % being food insecure. In fully adjusted models, food insecurity was negatively though modestly associated (P = 0·13) with TL. Associations between food insecurity and TL were significantly modified by social support (interaction P = 0·026), whereby food insecurity had a stronger effect among individuals with high social support (coefficient = -0·099 (95 % CI: -0·161, -0·038)) compared to low social support (coefficient = -0·001, (95 % CI: -0·033, 0·032)). CONCLUSION: Food insecurity is modestly associated with shorter TL. Contrary to our hypothesis, food insecurity had more deleterious effects on TL among participants with high social support than low social support. Results may indicate that the food insecure population is a higher needs population, and increased social support reflects these needs rather than providing protective effects.

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.

The dose-response association between LEAP 1000 and birthweight - no clear mechanisms: a structural equation modeling approach.

BACKGROUND: Birthweight is an important indicator of maternal and fetal health globally. The multifactorial origins of birthweight suggest holistic programs that target biological and social risk factors have great potential to improve birthweight. In this study, we examine the dose-response association of exposure to an unconditional cash transfer program before delivery with birthweight and explore the potential mediators of the association. METHODS: Data for this study come from the Livelihood Empowerment Against Poverty (LEAP) 1000 impact evaluation conducted between 2015 and 2017 among a panel sample of 2,331 pregnant and lactating women living in rural households of Northern Ghana. The LEAP 1000 program provided bi-monthly cash transfers and premium fee waivers to enroll in the National Health Insurance Scheme (NHIS). We used adjusted and unadjusted linear and logistic regression models to estimate the associations of months of LEAP 1000 exposure before delivery with birthweight and low birthweight, respectively. We used covariate-adjusted structural equation models (SEM) to examine mediation of the LEAP 1000 dose-response association with birthweight by household food insecurity and maternal-level (agency, NHIS enrollment, and antenatal care) factors. RESULTS: Our study included a sample of 1,439 infants with complete information on birthweight and date of birth. Nine percent of infants (N = 129) were exposed to LEAP 1000 before delivery. A 1-month increase in exposure to LEAP 1000 before delivery was associated with a 9-gram increase in birthweight and 7% reduced odds of low birthweight, on average, in adjusted models. We found no mediation effect by household food insecurity, NHIS enrollment, women's agency, or antenatal care visits. CONCLUSIONS: LEAP 1000 cash transfer exposure before delivery was positively associated with birthweight, though we did not find any mediation by household- or maternal-level factors. The results of our mediation analyses may serve to inform program operations and improve targeting and programming to optimize health and well-being among this population. TRIAL REGISTRATION: The evaluation is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations (RIDIESTUDY- ID-55942496d53af) and in the Pan African Clinical Trial Registry (PACTR202110669615387).

Ghana's Livelihood Empowerment Against Poverty (1000) Program Seasonally Impacts Birthweight: A Difference-in-Differences Analysis.

Objectives: Low birthweight (LBW) prevalence remains high in African countries and evidence of cash transfer impacts on birthweight, particularly by season of infant birth, is limited. This study examines overall and seasonal cash transfer impacts on LBW in rural Ghana. Methods: Data come from a longitudinal, quasi-experimental impact evaluation of the Livelihood Empowerment Against Poverty (LEAP) 1,000 unconditional cash transfer program for impoverished pregnant or lactating women in rural districts of Northern Ghana. LEAP1000 program impacts on average birthweight and LBW were estimated for a multiply imputed sample of 3,258 and a panel sample of 1,567 infants using differences-in-differences models and triple difference models to assess impacts by season. Results: LEAP1000 decreased LBW prevalence by 3.5 and 4.1 percentage points overall and in the dry season, respectively. LEAP1000 increased average birthweight by 94, 109, and 79 g overall, in the dry season, and in the rainy season, respectively. Conclusion: Our findings of positive LEAP1000 impacts on birthweight across seasons and on LBW in the dry season demonstrate the need to take seasonal vulnerabilities into account when designing and implementing programs for rural populations in Africa.

Impact of community-based health insurance on health services utilisation among vulnerable households in Amhara region, Ethiopia.

BACKGROUND: Ethiopia piloted community-based health insurance in 2011, and as of 2019, the programme was operating in 770 districts nationwide, covering approximately 7 million households. Enrolment in participating districts reached 50%, holding promise to achieve the goal of Universal Health Coverage in the country. Despite the government's efforts to expand community-based health insurance to all districts, evidence is lacking on how enrolment in the programme nudges health seeking behaviour among the most vulnerable rural households. This study aims to examine the effect of community-based health insurance enrolment among the most vulnerable and extremely poor households participating in Ethiopia's Productive Safety Net Programme on the utilisation of healthcare services in the Amhara region. METHODS: Data for this study came from Amhara pilot integrated safety net programme baseline survey in Ethiopia and were collected between December 2018 and February 2019 from 5,398 households. We used propensity score matching method to estimate the impacts of enrolment in community-based health insurance on outpatient, maternal, and child preventive and curative healthcare services utilisation. RESULTS: Results show that membership in community-based health insurance increases the probabilities of visiting health facilities for curative care in the past month by 8.2 percentage points (95% CI 5.3 to 11.1), seeking care from a health professional by 8.4 percentage points (95% CI 5.5 to 11.3), and visiting a health facility to seek any medical assistance for illness and check-ups in the past 12 months by 13.9 percentage points (95% CI 10.5 to 17.4). Insurance also increases the annual household per capita health facility visits by 0.84 (95% CI 0.64 to 1.04). However, we find no significant effects of community-based health insurance membership on utilisation of maternal and child healthcare services. CONCLUSIONS: Findings that community-based health insurance increased outpatient services utilisation implies that it could also contribute towards universal health coverage and health equity in rural and informal sectors. The absence of significant effects on maternal and child healthcare services may be due to the free availability of such services for everyone at the public health facilities, regardless of insurance membership. Outpatient services use among insured households is still not universal, and understanding of the barriers to use, including supply-side constraints, will help improve universal health coverage.

'Joy, not sorrow': Men's perspectives on gender, violence, and cash transfers targeted to women in northern Ghana.

Evidence indicates that cash transfers can decrease intimate partner violence (IPV) against women, although most research has focused on women's perspectives and experiences, with less attention to men. We analyzed data from four focus group discussions with male partners of women who participated in the Ghana Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program. We elicited men's perceptions of poverty, relationship dynamics, IPV and cash transfers targeted to their wives using thematic analysis. Men largely viewed the effects of the cash transfer as positive - they felt decreased provider role strain when women used the cash to cover household expenses such as food and school fees. Men also indicated that they felt respected when women used the cash to cover sudden expenses, such as funeral costs, thus preventing the need to borrow from community members and exposing their inability to fulfill provider roles. These feelings of relief and respect helped improve men's overall wellbeing, their marital relationships and reduced the potential for IPV. Despite these positive results, men revealed that they still expected to be informed and consulted about the transfer and its expenditure, and felt disrespected when women did not do so, thus heightening the potential for household conflict. Further research and innovation in programming is needed to integrate gender transformative strategies into cash transfer programs, explicitly aimed at changing gender norms to enhance and sustain beneficial impacts on gender relations and IPV.

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 (ß = 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.

Knowledge of and access to frontline workers among poor, rural households in Amhara region, Ethiopia: a mixed-methods study.

BACKGROUND: Social protection programmes have effectively reduced poverty and improved food security. However, the effects of poverty require an intersectoral approach to adequately address poor nutrition and health. Identifying gaps in knowledge and access to frontline workers who oversee these integrations is critical for understanding the potential for integrated social protection programming to improve these outcomes. We measured levels of social protection programme participants' knowledge of and interaction with social workers (SWs) and health extension workers (HEWs) in rural Ethiopia. METHODS: This mixed-methods study uses cross-sectional data from the baseline survey of a quasi-experimental impact evaluation among a sample of 5,036 households participating in Ethiopia's Productive Safety Net Programme. Qualitative interviews include key informant interviews, in depth interviews and focus group discussions with caregivers, community members, frontline agents, and stakeholders. Using data from household questionnaires administered to household heads, quantitative analyses include univariate and bivariate descriptive statistics as well as mutually-adjusted multivariable logistic regression analyses to estimate adjusted odds ratios and 95% confidence intervals for household sociodemographic characteristics associated with 1) knowledge of SWs and HEWs and 2) interaction with SWs and HEWs in their communities. Qualitative data were analysed using thematic analysis combining both a fluid and more structured coding processes to unpack the important topics within the data supported by illustrative quotes. RESULTS: Our results show that knowledge of and interaction with SWs is limited while many knew of and interacted with HEWs quite regularly. Interactions with SWs were negatively associated with increased household size and living in Dewa Chefa. Factors associated with increased knowledge of and interaction with HEWs include having children under the age of 5 years in the household, having health insurance, and having a formal education. Qualitative analyses suggest that SWs are limited by overwhelming caseloads, limited resources to carry out their work, and high staff turnover. However, SWs are considered highly valuable in the communities where they work. CONCLUSIONS: While most of the participants reported knowing their HEW, there is room for improvement, especially around household engagement with HEWs. Although SWs support the ISNP in the treatment districts only and not formally incorporated into the structure in the region, our findings highlight a need to provide greater support to SWs to effectively facilitate improvements in health and nutritional outcomes among vulnerable households. TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR201902876946874) and the Registry for International Development Impact Evaluations (RIDIE-STUDY-ID-5bf27eb0404a0).

Health services availability and readiness moderate cash transfer impacts on health insurance enrolment: evidence from the LEAP 1000 cash transfer program in Ghana.

BACKGROUND: Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services. METHODS: We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities' service availability and readiness. RESULTS: We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points). CONCLUSIONS: We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors. TRIAL REGISTRATION: This study is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations ( RIDIE-STUDY-ID-55942496d53af ).

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

We assessed the impacts of Tanzania's adolescent-focused Cash Plus intervention on depression. In this pragmatic cluster-randomized controlled trial, 130 villages were randomly allocated to an intervention or control arm (1:1). Youth aged 14-19 years living in households receiving governmental cash transfers were invited to participate. The intervention included an intensive period (a 12-session course) and an aftercare period (9 months of mentoring, productive grants, and strengthened health services). We examined intervention impacts on a depressive symptoms scale (10-item Center for Epidemiologic Studies Depression Scale score (range, 0-30)) and rates of depressive symptomatology (score ≥10 points on the scale), recorded at study baseline (April-June 2017), midline (May-July 2018), and endline (June-August 2019). Using intention-to-treat methodology, we employed logistic and generalized linear models to estimate effects for binary and continuous outcomes, respectively. Quantile regression was used to estimate effects across the scale. From 2,458 baseline participants, 941 intervention and 992 control adolescents were reinterviewed at both follow-ups. At endline, the intervention reduced the odds of depressive symptomatology (adjusted odds ratio = 0.67, 95% confidence interval: 0.52, 0.86), with an undetectable mean scale difference (risk difference = -0.36, 95% confidence interval: -0.84, 0.11). Quantile regression results demonstrated an intervention effect along the upper distribution of the scale. Integration of multisectoral initiatives within existing social protection systems shows potential to improve mental health among youth in low-resource settings.

A "Plus" Model for Safe Transitions to Adulthood: Impacts of an Integrated Intervention Layered onto A National Social Protection Program on Sexual Behavior and Health Seeking among Tanzania's Youth.

Poverty is a structural driver of risky sexual behaviors. While cash transfers can mitigate some of this risk, complementary interventions have been posited as a way to further reduce multidimensional vulnerability. We examine the impacts of a multicomponent intervention targeted to Tanzanian adolescents on their sexual behaviors and reproductive health. The intervention comprised livelihood and life skills training, mentoring, and health facilities' strengthening. Data come from a cluster randomized controlled trial, where one study arm received the intervention and the other was randomized to control, but both arms participated in a government cash transfer program. Among 1,933 adolescents interviewed over three rounds, we found increases in contraceptive and HIV knowledge. The program also increased health seeking and HIV testing among boys, but slightly reduced age at sexual debut among girls. There were no impacts on contraceptive use, number of sexual partners, or pregnancy. Findings support the value of an adolescent intervention, and the fact that it was delivered within a social protection platform suggests a potential for scalability. Additional efforts are required to delay sexual debut and reduce the number of sexual partners and pregnancy, possibly through addressing supply-side barriers and social norms, or through additional linkages to economic opportunities.

The impact of unconditional cash transfers on morbidity and health-seeking behaviour in Africa: evidence from Ghana, Malawi, Zambia and Zimbabwe.

Unconditional cash transfers have demonstrated widespread, positive impacts on consumption, food security, productive activities and schooling. However, the evidence to date on cash transfers and health-seeking behaviours and morbidity is not only mixed, but the evidence base is biased towards conditional programmes from Latin America and is more limited in the context of Africa. Given contextual and programmatic design differences between the regions, more evidence from Africa is warranted. We investigate the impact of unconditional cash transfers on morbidity and health-seeking behaviour using data from experimental and quasi-experimental study designs of five government cash transfer programs in Ghana, Malawi, Zambia and Zimbabwe. Programme impacts were estimated using difference-in-differences models with longitudinal data. The results indicate positive programme impacts on health seeking when ill and on health expenditures. Our findings suggest that while unconditional cash transfers can improve health seeking when ill, morbidity impacts were mixed. More research is needed on longer-term impacts, mechanisms of impact and moderating factors. Additionally, taken together with existing evidence, our findings suggest that when summarizing the impacts of cash transfers on health, findings from conditional and unconditional programmes should be disaggregated.

'Poverty can break a home': Exploring mechanisms linking cash plus programming and intimate partner violence in Ghana.

A growing body of research in West Africa and globally shows that cash transfers can decrease intimate partner violence (IPV). The purpose of this study was to explore how the government of Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 program, an unconditional cash transfer plus health insurance premium waiver targeted at pregnant women and women with young children, influenced IPV experiences. Existing program theory hypothesizes three pathways through which cash transfers influence IPV, including: 1) increased economic security and emotional wellbeing; 2) reduced intra-household conflict; and 3) increased women's empowerment. Informed by this theory, we conducted qualitative in-depth interviews with women in northern Ghana (n = 30) who were or had been beneficiaries of LEAP 1000 and had reported declines in IPV in an earlier impact evaluation. We used narrative and thematic analytic techniques to examine these pathways in the context of gender norms and household dynamics, as well as a fourth potential pathway focused on interactions with healthcare providers. Overall, the most prominent narrative was that poverty is the main determinant of physical IPV and that by reducing poverty, LEAP 1000 reduced conflict and violence in households and communities and improved emotional wellbeing. Participant narratives also supported pathways of reduced intra-household conflict and increased empowerment, as well as interplay between these three pathways. However, participants also reflected that cash transfers did not fundamentally change gender norms or reduce gender-role strain in a context of ongoing economic insecurity, which could limit the gender transformative potential and sustainability of IPV reductions. Finally, while health insurance increased access to healthcare, local norms, shame, fear, and minimal provider screening deterred IPV disclosure to healthcare providers. Additional research is needed to explore interplay between pathways of impact across programs with different design features and implementation contexts to continue informing effective programming to maximize impact.

Effects of Government-Implemented Cash Plus Model on Violence Experiences and Perpetration Among Adolescents in Tanzania, 2018‒2019.

Objectives. To examine the impacts of a government-implemented cash plus program on violence experiences and perpetration among Tanzanian adolescents. Methods. We used data from a cluster randomized controlled trial (n = 130 communities) conducted in the Mbeya and Iringa regions of Tanzania to isolate impacts of the "plus" components of the cash plus intervention. The panel sample comprised 904 adolescents aged 14 to 19 years living in households receiving a government cash transfer. We estimated intent-to-treat impacts on violence experiences, violence perpetration, and pathways of impact. Results. The plus intervention reduced female participants' experiences of sexual violence by 5 percentage points and male participants' perpetration of physical violence by 6 percentage points. There were no intervention impacts on emotional violence, physical violence, or help seeking. Examining pathways, we found positive impacts on self-esteem and participation in livestock tending and, among female participants, a positive impact on sexual debut delays and a negative effect on school attendance. Conclusions. By addressing poverty and multidimensional vulnerability, integrated social protection can reduce violence. Public Health Implications. There is high potential for scale-up and sustainability, and this program reaches some of the most vulnerable and marginalized adolescents. (Am J Public Health. 2021;111(12):2227-2238. https://doi.org/10.2105/AJPH.2021.306509).