Utilizing a family-based economic strengthening intervention to improve mental health wellbeing among female adolescent orphans in Uganda

Worldwide, an estimated 10–20% of adolescents and youth between 14 and 24 years old struggle with mental health issues [1]. Among these, depression is the third leading disability among adolescents between the ages of 15–19 years [2]. Available data from Sub-Saharan Africa (SSA) indicates that 1 in 7 children and adolescents (between 0 and 16 years) had a mental health difficulty [3]. Disease and poverty have intrinsically exacerbated mental health problems [3]. For example, available data from cross sectional surveys indicate that 21% of adolescents in Uganda suffer from mental disorders like depression [4].

Among orphaned and vulnerable children (OVCs), it has been widely documented that poor mental health functioning is associated with several negative health and social outcomes which persists even into adulthood [5‐8]. Specifically, orphaned adolescents, especially those orphaned due to HIV/AIDS, experience higher levels of mental health problems and exhibit higher levels of psychological distress compared to those orphaned due to other causes [9‐11]. Parental illness and death increase economic burden, loss of social support, and despair about the future [12‐15]. Orphaned adolescents may not directly express their worries and anxieties, leading to feelings of anger, resentment as well as a sense of alienation and desperation [16]. Such emotions can result in risk taking behaviors and withdrawal [16]. As such, orphaned adolescents need extra social support to help them cope with these challenges as they transition into adulthood.

In addition, studies have documented that female adolescents are more likely to exhibit severe emotional and behavioral distress compared to adolescent boys. For example, Rescorla et al. [17] found that female adolescents reported higher levels of overall emotional distress and more depressive symptoms than did male adolescents. Other studies have documented that female orphans exhibit higher levels of psychological distress, social isolation, loss of education, and risky behaviors compared to boys [10, 18]. Therefore, it is critical to examine programs and interventions that address mental health risks among female adolescents made vulnerable by HIV and AIDS.

Household and community-level poverty exacerbate the mental health challenges of orphaned female adolescents. In the face of this reality, researchers have been testing asset-based interventions that utilize Child Development Accounts (CDAs) to address some of the mental health challenges associated with orphanhood [19, 20]. These efforts utilize asset theory, which suggests that there is a positive link between economic assets and psychological wellbeing [21, 22]. Specifically, owning assets, such as savings, educational opportunities, economic opportunities, including microenterprise activities, has important social, economic and psychological benefits. In addition, owning assets positively impacts the individuals’ behaviors, attitudes, future orientation and hopes for the future [23]. Indeed, these studies have found that economic opportunities results in positive mental health outcomes among orphaned adolescents in SSA, including reduced depressive symptoms and hopelessness [20, 24] and improving future orientation and self-concept [19]. Other positive social and economic outcomes relate to savings, improved educational outcomes, and reduced risk taking behaviors [25, 26].

Building upon asset theory and previous findings, this current study examines both the short-and long-term impact of a family-based economic strengthening intervention on the mental health wellbeing of female adolescents orphaned by HIV/AIDS. We argue that female adolescents participating in an economic empowerment intervention that combines matched savings, peer mentorship, financial management trainings and income generating activities will be more likely to report higher levels of self-concept, lower depression levels and more hopefulness about the future compared to their counterparts in the control condition. Unlike previous findings, this study utilized data from a relatively larger sample of adolescents, and outcomes are tracked over a longer period of time. The results from this study expand on similar findings from other SSA countries and provide practical implications that can inform efforts aimed at developing comprehensive programs for female orphans.

From Table 1, the total number of girls in the study was 789 with 273 (36.6%) in the control arm and 516 (63.4%) in the combined treatment arms. Among the participants, 80.6% (n =220) and 78.5% (n = 405) in control and treatment arms respectively considered themselves to be in good to excellent physical health. Among the participants in the treatment arm, most reported their caretaker as a living biological parent (40.3%, n =208) while for those in control, 38.5% (n = 38.5) are taken care of by grandparents. Respondents who had lost both parents were 21.3% (n = 58) and 17.2% (n = 89) in control and treatment study arms respectively. Individual savings were reported to be at 21.3% (n = 58) and 23.8% (n = 123) among respondents in control and treatment arms respectively. The average age of respondents in the control group was 12.58 years, whereas that average age of respondent in the combined treatment arms was 12.34 years (p-value 0.007). There was no significant difference (p-value 0.455) in family cohesion mean scores between control (23.52) and treatment (23.33) groups. The average number of adults (above 18 years) per household was 6.52 and 6.24 for control and treatment respondents respectively, while children per household (less than 18 years excluding the participant) were 3.32 for control and 3.15 for treatment respondents on average.

From Table 2, respondents demonstrated an average reduced risk of depression with the intervention in both the unadjusted − 1.35 (95% CI − 2.55, − 0.15, p ≤ 0.05) and adjusted models − 1.262 (95% CI − 2.476, − 0.047, p ≤ 0.05) between waves I and II. The same average risk reduction in depression was observed between waves I and III in both unadjusted − 2.004 (95% CI − 3.247, 0.761, p ≤ 0.01) and adjusted models − 1.907 (95% CI − 3.192, − 0.622, p ≤ 0.01). However, respondents did not show significant change in risk reduction in depression between wave II and wave III. In terms of self-concept, there was an average significant increase in the self-concept of respondents in the treatment arm compared to those in the control arm between waves I and II in both the unadjusted and adjusted models; 3.714 (95% CI 1.53, 5.898, p ≤ 0.01) and 3.503 (95% CI 1.469, 5.538, p ≤ 0.001) respectively. The observed average improvement in self-concept in the unadjusted model between wave 1 and III, 2.631 (95% CI 0.056, 5.206) was not observed in the adjusted model, 2.272 (95% CI − 0.261, 4.804). No risk difference in hopelessness was observed among participants at any point in time.

While several interventions have been utilized to improve the mental health functioning for female adolescents, this study focused on utilizing an economic empowerment approach to reduce depression levels and hopelessness and improve the self-concept of school-going female adolescent orphans made vulnerable by HIV/AIDS. Female adolescents who received the economic empowerment intervention in the form of a CDA combined with peer mentorship, IGA training and financial education, reported lower levels of depression and higher self-concept over time compared to their counter parts in the control condition. The changes in participants’ mental health functioning could be attributed to the fact that participating in empowerment programs provided a sense of hope, positive views of the future and economic resources needed to deal with daily financial challenges that cause stress among female adolescents. Findings have documented that lacking familial support, poverty [3, 19, 31, 32], and being affected by HIV and AIDS [14, 15] negatively impact mental health among children made affected by HIV and AIDS. Additionally, access to economic resources led to an increase in female adolescents’ decision-making abilities over a number of life events, which is quality that results in better mental health functioning, as has been documented by other studies [24]. Therefore, the provision of economic means to deal with the stressors caused by poverty and death of parents can potentially lower depression levels. Furthermore, participating in economic empowerment brings families together to discuss strategies for saving and making investment plans. Consistently, research indicates that parents and/or caregivers that provide emotional and informational support to their children can help lower their depression and enhance their self-concept [9, 33].

The major limitation of this study is the reliance on self-report which is susceptible to social desirability bias. In addition, given than this was a combination intervention, it is difficult to singularly assess the effects of each intervention component on the wellbeing of female adolescents.