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A Cash Plus Model for Safe Transitions to
Adulthood: Impacts on the HIV, sexual &
reproductive health knowledge of
Tanzania’s youth
Jennifer Waidler, Lusajo Kajula, Ulrike Gilbert, and Tia Palermo
on behalf of the Adolescent Cash Plus Evaluation Team
APPAM International 2019, Barcelona, July 30
for every child, answers
Background
Estimated 25.7 million people living with HIV in Sub-Saharan Africa.
Risk of HIV infection increases significantly for girls in their transition to adulthood.
Less than half of Tanzanian youth have enough or accurate knowledge on how to protect themselves
against HIV.
Poverty is one of the main structural drivers of HIV & other adolescent-related risks.
Despite positive impacts of cash transfers on youth well-being, there are non-financial & health
sector barriers.
Cash transfers bundled with
complementary interventions can
improve adolescent well-being
 Potential for CASH PLUS
for every child, answers
Background
Interventions aimed at improving adolescents’ knowledge on
sexual & reproductive health, e.g. ‘life skills’ education, micro-
finance, vocational education.
Youth development programmes providing comprehensive training
on sexual & reproductive health have become popular in recent
years. Programmes had mixed effects depending on the context.
The programme analysed is targeted at the most vulnerable youth &
implemented within a national government cash transfer programme.
To our knowledge, this is the first evaluation of this kind.
for every child, answers
The Intervention
Cash Plus: A multi-sectoral project targeting adolescents 14-19 years from poor households
benefiting from Tanzania Social Action Fund’s (TASAF) Productive Social Safety Nets programme
(PSSN).
The Cash: cash transfer to the household (PSSN)
The Plus:
• 12 weeks of training on livelihoods and life skills (including HIV/SRH & gender equity) 
midline data collected 6 months after start of intervention
• Mentoring (including referrals & productive grant)
• Linkages to adolescent-friendly services (e.g. sexual and reproductive health; violence
response)
for every child, answers
Training Topics
Livelihoods
• Dreams & goals
• Entrepreneurship skills
• Business plans & record keeping
• Savings
HIV/SRH
• Coping with puberty
• Relationships
• HIV knowledge, prevention & protection
• Pregnancy & family planning
• Violence & gender-based violence
• Addressing negative gender attitudes &
norms
• Alcohol & drugs
• Healthy living & nutrition
Study Design: Cluster Randomized Control Trial
130 villages (clusters) in two districts in
Tanzania randomized into:
• Treatment: Cash+ adolescent-
focused services
• Control: Cash only
Data
• Baseline: pre-intervention/pre-
randomization survey
• Midline: 12-month follow-up survey
for every child, answers
Sample 2,104 youth (14-19 years old at
baseline) from 1,717 households
Outcome variables
• Knowledge of contraception methods
• HIV knowledge (4 true/false
statements)
• Knowledge of places where they can
get contraception or test for HIV
for every child, answers
Estimation
50% take up intent-to-treat (ITT) impacts
Low autocorrelation between outcomes at baseline and midline  Analysis of Covariance (ANCOVA)
𝒀 𝟏𝒊𝒋 = 𝜶 𝟎 + 𝜶 𝟏 𝑻𝒋 + 𝜶 𝟐 𝒀 𝟎𝒊𝒋 + 𝜶 𝟑 𝑿𝒊𝒋 + 𝜺𝒊𝒋
𝑌0𝑖𝑗 - baseline value of the outcome for adolescent i living in village j
𝑌1𝑖𝑗 - midline value of the outcome for adolescent i living in village j
Tj – treatment dummy (1-lives in a treatment village; 0 otherwise)
Xij – controls (age at baseline, gender, district x village size fixed effects)
For the indicators we only have information at midline, we estimate single difference regressions.
RESULTS
Summary of outcomes, by gender & treatment status
for every child, answers
Indicator Control Treated
Males Females Total Males Females Total
Has knowledge about contraceptives 0.93 0.83 0.88 0.91 0.86 0.90
Has knowledge about modern contraceptives 0.91 0.82 0.86 0.90 0.88 0.89
Knows that sex with one uninfected monogamous partner can reduce risk of
HIV
0.76 0.70 0.73 0.77 0.82 0.79
Thinks/ is unsure whether mosquitos transfer HIV 0.11 0.08 0.09 0.10 0.09 0.09
Knows regular condom use reduces HIV risk 0.65 0.76 0.70 0.68 0.78 0.72
Thinks/is unsure whether HIV transferred through food 0.07 0.05 0.06 0.06 0.03 0.05
Contraception at clinic 0.85 0.81 0.83 0.87 0.86 0.87
Contraception at kiosk/shop 0.11 0.02 0.07 0.13 0.04 0.09
Contraception at pharmacy 0.24 0.31 0.27 0.28 0.38 0.32
Contraception at free dispenser 0.13 0.06 0.10 0.19 0.06 0.13
Contraception do not know 0.11 0.16 0.13 0.08 0.09 0.09
Condom at clinic 0.63 0.46 0.55 0.64 0.54 0.60
Condom at kiosk/shop 0.52 0.37 0.45 0.54 0.43 0.49
Condom at pharmacy 0.54 0.45 0.50 0.51 0.49 0.50
Condom at free dispenser 0.14 0.04 0.09 0.19 0.03 0.12
Condom do not know 0.07 0.18 0.13 0.07 0.12 0.09
Test at clinic 0.95 0.95 0.95 0.94 0.96 0.95
Test at kiosk/shop 0.03 0.01 0.02 0.05 0.01 0.03
Test at pharmacy 0.09 0.04 0.06 0.11 0.03 0.08
Test at free dispenser 0.15 0.05 0.10 0.17 0.07 0.13
Test do not know 0.03 0.03 0.03 0.04 0.03 0.03
Impacts on contraception knowledge
for every child, answers
ITT
Impact
ATT
Impact
Baseline
Mean
Females
ITT impact
Males
ITT
impact
(1) (2) (3) (6) (7)
Has knowledge about
contraceptives
0.024
(0.02)
0.062
(0.04)
0.763
0.048
(0.03)
-0.002
(0.02)
Has knowledge about
modern
contraceptives
0.035*
(0.02)
0.090*
(0.05)
0.721
0.060*
(0.03)
0.007
(0.02)
N 2,053 2,053 2,053 930 1.123
Cash plus participant
-.05 0 .05 .1
Coefficient
Males Females
Knowledge of modern contraception
Impacts on contraception knowledge
for every child, answers
Cash plus participant
-.08 -.06 -.04 -.02 0
Coefficient
Males Females
Does not know where to get contraception
Cash plus participant
-.1 -.05 0 .05
Coefficient
Males Females
Does not know where to get condoms
Impacts on HIV knowledge
for every child, answers
Cash plus participant
-.05 0 .05 .1 .15 .2
Coefficient
Males Females
HIV knowledgeITT Impact
ATT
Impact
Females
ITT impact
Males
ITT impact
(1) (2)
Knows that sex with one
uninfected monogamous partner
can reduce risk of HIV
0.058*
(0.02)
0.148*
(0.06)
0.118**
(0.03)
0.007
(0.03)
Thinks/ is unsure whether
mosquitos transfer HIV
-0.003
(0.01)
-0.006
(0.04)
0.006
(0.02)
-0.010
(0.02)
Knows regular condom use
reduces HIV risk
0.024
(0.02)
0.061
(0.06)
0.024
(0.03)
0.025
(0.03)
Thinks/is unsure whether HIV
transferred through food
-0.007
(0.01)
-0.018
(0.03)
-0.011
(0.01)
-0.003
(0.02)
N 2,104 2,104 955 1,149
for every child, answers
Conclusions
Given heightened vulnerability in adolescence, the positive effect
of cash plus on girls’ knowledge deserves special attention.
This increased knowledge should be transferred into practice.
High potential for scalability Programme targets poorest, is
combined with health service strengthening, & is implemented
within government structures.
Provides valuable information on how government interventions
can ensure a safe transition to adulthood.
@UNICEFInnocenti
unicef-irc.org
@TransferProjct
transfer.cpc.unc.edu
THANK YOU.
UNICEF Office of Research: Tia Palermo (co-Principal Investigator), Lusajo
Kajula, Jacobus de Hoop, Leah Prencipe, Valeria Groppo, Jennifer Waidler
Economic Development Initiatives: Johanna Choumert Nkolo (co-Principal
Investigator), Respichius Mitti (co-Principal Investigator), Nathan Sivewright, Koen
Leuveld, Bhoke Munanka
Tanzania Social Action Fund: Paul Luchemba, Tumpe Lukongo
Tanzania Commission for Aids: Aroldia Mulokozi
UNICEF Tanzania: Ulrike Gilbert, Paul Quarles van Ufford, Rikke Le Kirkegaard,
Frank Eetaama

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A Cash Plus Model for Safe Transitions to Adulthood: Impacts on the Sexual and Reproductive Health Knowledge of Tanzania’s Youth

  • 1. A Cash Plus Model for Safe Transitions to Adulthood: Impacts on the HIV, sexual & reproductive health knowledge of Tanzania’s youth Jennifer Waidler, Lusajo Kajula, Ulrike Gilbert, and Tia Palermo on behalf of the Adolescent Cash Plus Evaluation Team APPAM International 2019, Barcelona, July 30
  • 2. for every child, answers Background Estimated 25.7 million people living with HIV in Sub-Saharan Africa. Risk of HIV infection increases significantly for girls in their transition to adulthood. Less than half of Tanzanian youth have enough or accurate knowledge on how to protect themselves against HIV. Poverty is one of the main structural drivers of HIV & other adolescent-related risks. Despite positive impacts of cash transfers on youth well-being, there are non-financial & health sector barriers.
  • 3. Cash transfers bundled with complementary interventions can improve adolescent well-being  Potential for CASH PLUS
  • 4. for every child, answers Background Interventions aimed at improving adolescents’ knowledge on sexual & reproductive health, e.g. ‘life skills’ education, micro- finance, vocational education. Youth development programmes providing comprehensive training on sexual & reproductive health have become popular in recent years. Programmes had mixed effects depending on the context. The programme analysed is targeted at the most vulnerable youth & implemented within a national government cash transfer programme. To our knowledge, this is the first evaluation of this kind.
  • 5. for every child, answers The Intervention Cash Plus: A multi-sectoral project targeting adolescents 14-19 years from poor households benefiting from Tanzania Social Action Fund’s (TASAF) Productive Social Safety Nets programme (PSSN). The Cash: cash transfer to the household (PSSN) The Plus: • 12 weeks of training on livelihoods and life skills (including HIV/SRH & gender equity)  midline data collected 6 months after start of intervention • Mentoring (including referrals & productive grant) • Linkages to adolescent-friendly services (e.g. sexual and reproductive health; violence response)
  • 6.
  • 7. for every child, answers Training Topics Livelihoods • Dreams & goals • Entrepreneurship skills • Business plans & record keeping • Savings HIV/SRH • Coping with puberty • Relationships • HIV knowledge, prevention & protection • Pregnancy & family planning • Violence & gender-based violence • Addressing negative gender attitudes & norms • Alcohol & drugs • Healthy living & nutrition
  • 8. Study Design: Cluster Randomized Control Trial 130 villages (clusters) in two districts in Tanzania randomized into: • Treatment: Cash+ adolescent- focused services • Control: Cash only Data • Baseline: pre-intervention/pre- randomization survey • Midline: 12-month follow-up survey for every child, answers Sample 2,104 youth (14-19 years old at baseline) from 1,717 households Outcome variables • Knowledge of contraception methods • HIV knowledge (4 true/false statements) • Knowledge of places where they can get contraception or test for HIV
  • 9. for every child, answers Estimation 50% take up intent-to-treat (ITT) impacts Low autocorrelation between outcomes at baseline and midline  Analysis of Covariance (ANCOVA) 𝒀 𝟏𝒊𝒋 = 𝜶 𝟎 + 𝜶 𝟏 𝑻𝒋 + 𝜶 𝟐 𝒀 𝟎𝒊𝒋 + 𝜶 𝟑 𝑿𝒊𝒋 + 𝜺𝒊𝒋 𝑌0𝑖𝑗 - baseline value of the outcome for adolescent i living in village j 𝑌1𝑖𝑗 - midline value of the outcome for adolescent i living in village j Tj – treatment dummy (1-lives in a treatment village; 0 otherwise) Xij – controls (age at baseline, gender, district x village size fixed effects) For the indicators we only have information at midline, we estimate single difference regressions.
  • 11. Summary of outcomes, by gender & treatment status for every child, answers Indicator Control Treated Males Females Total Males Females Total Has knowledge about contraceptives 0.93 0.83 0.88 0.91 0.86 0.90 Has knowledge about modern contraceptives 0.91 0.82 0.86 0.90 0.88 0.89 Knows that sex with one uninfected monogamous partner can reduce risk of HIV 0.76 0.70 0.73 0.77 0.82 0.79 Thinks/ is unsure whether mosquitos transfer HIV 0.11 0.08 0.09 0.10 0.09 0.09 Knows regular condom use reduces HIV risk 0.65 0.76 0.70 0.68 0.78 0.72 Thinks/is unsure whether HIV transferred through food 0.07 0.05 0.06 0.06 0.03 0.05 Contraception at clinic 0.85 0.81 0.83 0.87 0.86 0.87 Contraception at kiosk/shop 0.11 0.02 0.07 0.13 0.04 0.09 Contraception at pharmacy 0.24 0.31 0.27 0.28 0.38 0.32 Contraception at free dispenser 0.13 0.06 0.10 0.19 0.06 0.13 Contraception do not know 0.11 0.16 0.13 0.08 0.09 0.09 Condom at clinic 0.63 0.46 0.55 0.64 0.54 0.60 Condom at kiosk/shop 0.52 0.37 0.45 0.54 0.43 0.49 Condom at pharmacy 0.54 0.45 0.50 0.51 0.49 0.50 Condom at free dispenser 0.14 0.04 0.09 0.19 0.03 0.12 Condom do not know 0.07 0.18 0.13 0.07 0.12 0.09 Test at clinic 0.95 0.95 0.95 0.94 0.96 0.95 Test at kiosk/shop 0.03 0.01 0.02 0.05 0.01 0.03 Test at pharmacy 0.09 0.04 0.06 0.11 0.03 0.08 Test at free dispenser 0.15 0.05 0.10 0.17 0.07 0.13 Test do not know 0.03 0.03 0.03 0.04 0.03 0.03
  • 12. Impacts on contraception knowledge for every child, answers ITT Impact ATT Impact Baseline Mean Females ITT impact Males ITT impact (1) (2) (3) (6) (7) Has knowledge about contraceptives 0.024 (0.02) 0.062 (0.04) 0.763 0.048 (0.03) -0.002 (0.02) Has knowledge about modern contraceptives 0.035* (0.02) 0.090* (0.05) 0.721 0.060* (0.03) 0.007 (0.02) N 2,053 2,053 2,053 930 1.123 Cash plus participant -.05 0 .05 .1 Coefficient Males Females Knowledge of modern contraception
  • 13. Impacts on contraception knowledge for every child, answers Cash plus participant -.08 -.06 -.04 -.02 0 Coefficient Males Females Does not know where to get contraception Cash plus participant -.1 -.05 0 .05 Coefficient Males Females Does not know where to get condoms
  • 14. Impacts on HIV knowledge for every child, answers Cash plus participant -.05 0 .05 .1 .15 .2 Coefficient Males Females HIV knowledgeITT Impact ATT Impact Females ITT impact Males ITT impact (1) (2) Knows that sex with one uninfected monogamous partner can reduce risk of HIV 0.058* (0.02) 0.148* (0.06) 0.118** (0.03) 0.007 (0.03) Thinks/ is unsure whether mosquitos transfer HIV -0.003 (0.01) -0.006 (0.04) 0.006 (0.02) -0.010 (0.02) Knows regular condom use reduces HIV risk 0.024 (0.02) 0.061 (0.06) 0.024 (0.03) 0.025 (0.03) Thinks/is unsure whether HIV transferred through food -0.007 (0.01) -0.018 (0.03) -0.011 (0.01) -0.003 (0.02) N 2,104 2,104 955 1,149
  • 15. for every child, answers Conclusions Given heightened vulnerability in adolescence, the positive effect of cash plus on girls’ knowledge deserves special attention. This increased knowledge should be transferred into practice. High potential for scalability Programme targets poorest, is combined with health service strengthening, & is implemented within government structures. Provides valuable information on how government interventions can ensure a safe transition to adulthood.
  • 16. @UNICEFInnocenti unicef-irc.org @TransferProjct transfer.cpc.unc.edu THANK YOU. UNICEF Office of Research: Tia Palermo (co-Principal Investigator), Lusajo Kajula, Jacobus de Hoop, Leah Prencipe, Valeria Groppo, Jennifer Waidler Economic Development Initiatives: Johanna Choumert Nkolo (co-Principal Investigator), Respichius Mitti (co-Principal Investigator), Nathan Sivewright, Koen Leuveld, Bhoke Munanka Tanzania Social Action Fund: Paul Luchemba, Tumpe Lukongo Tanzania Commission for Aids: Aroldia Mulokozi UNICEF Tanzania: Ulrike Gilbert, Paul Quarles van Ufford, Rikke Le Kirkegaard, Frank Eetaama

Editor's Notes

  1. There are an estimated 25.7 people living with HIV in Sub-Saharan Africa (UNAIDS 2018). The risk of HIV infection increases significantly for girls in their transition to adulthood. Less than half of Tanzanian youth have enough or accurate knowledge on how to protect themselves against HIV (according to the Tanzania 2016-2017 HIV Impact survey, less than 37% responded to all HIV questions correctly). Poverty is one of the main structural drivers of HIV and other adolescent-related risks. Despite cash transfers can positively affect youth well-being, there are non-financial and health sector barriers.  Potential for CASH PLUS (cash transfers bundled with complementary interventions) to improve adolescent well-being
  2. Interventions aimed at improving adolescents’ knowledge on sexual and reproductive health include ‘life skills’ education, micro-finance, vocational education (most of these are in-school or NGO-led). In recent years, youth development programs (targeting in-school and out of school adolescents) providing a comprehensive training on sexual and reproductive health became popular (ELA in Uganda and Tanzania, TRY in Kenya, SHAZ! in Zimbabwe). Programs had mixed effects depending on the context. The program analysed in this paper is targeted at the most vulnerable youth and implemented within a national government cash transfer program. To our knowledge, this is the first evaluation of this kind.
  3. 130 villages (clusters) in two PAAs in Tanzania Mufingi/Mafinga in Iringa (n=1,287) and Rungwe/Busokelo in Mbeya (n=1,171) randomized into: -Treatment: Cash + adolescent-focused services -Control: Cash only Data -Baseline (pre-intervention/pre-randomization) survey -Midline (12-month follow-up) survey Sample The youth study consists of a panel sample of 2,104 youth (14-19 years old at baseline) from 1,717 households Outcome variables -Knowledge of contraception methods -HIV knowledge (4 true/false statements) -Knowledge of places where they can get contraception or test for HIV
  4. Given that girls face heightened vulnerability in adolescence, the findings that the cash plus intervention had a more positive effect on girls’ knowledge deserves special attention However, they should transfer the increased knowledge into practice (behavioral impacts will be evaluated after the additional components have been implemented) This program targets the poorest segment of the population and is combined with health service strengthening and implemented within government structures, which results in a high potential for scalability Therefore, this study can provide valuable information on how government interventions can ensure a safe transition to adulthood