Process and Outcome Evaluation of a Community Intervention for Orphan Adolescents in Western Kenya

Abstract

We conducted a 2-year pilot randomized controlled trial (N = 105) in a high HIV-prevalence area in rural western Kenya to test whether providing young orphan adolescents with uniforms, school fees, and community visitors improves school retention and reduces HIV risk factors. The trial was a community intervention, limited to one community. In this paper, we examined intervention implementation and its association with outcomes using longitudinal data. We used both quantitative and qualitative methods to evaluate the community-based model for orphan HIV prevention, with recommendations for future studies. Despite promising effects after 1 year, GEE analyses showed null effects after 2 years. Volunteer community visitors, a key element of the intervention, showed little of the expected effect although qualitative reports documented active assistance to prevent orphans' school absence. For future research, we recommend capturing the transition to high school, a larger sample size, and biomarker data to add strength to the research design. We also recommend a school-based intervention approach to improve implementation and reduce infrastructure costs. Finally, we recommend evaluating nurses as agents for improving school attendance and preventing dropout because of their unique ability to address critical biopsychosocial problems.

Interventions to improve psychosocial well-being for children affected by HIV and AIDS: a systematic review

“…This may have affected the reported results of the identified studies. For example, in Hallfors et al (2012) the length of follow up was shown to be crucial in understanding the impact of the intervention. The material support intervention that the authors described showed a positive impact after one year, but the impact had disappeared by two years post-intervention.…”

Effects of Interventions Addressing School Environments or Educational Assets on Adolescent Sexual Health: Systematic Review and Meta‐analysis

“…The authors of one quasi‐experimental study confirmed that they did not adjust for school‐level clustering because the study included only two schools . For one randomized trial, it was not clear from the study reports whether effects were adjusted for household‐level clustering, and the authors did not respond to inquiries.…”

“…Some limitations of the interventions and evaluations, as well as of our analysis, may have hindered our ability to assess the theory of human functioning and school organization in the context of sexual health. In some studies—particularly of interventions targeting student‐level educational assets—differences between treatment groups may have been masked by sample sizes that were inadequate to detect effects or by contextual factors (such as the availability of subsidies, unrelated to the intervention, to students in the control group) . Other studies may have been limited by a singular focus on increasing enrollment, and thus failed to address or overcome other factors important for sexual decision making, such as cultural norms that devalue females’ education and sexual autonomy, support early marriage and stigmatize access to sexual health information .…”

Process Evaluation of a Clinical Trial to Test School Support as HIV Prevention Among Orphaned Adolescents in Western Kenya

“…Other variations, such as the intervention described here, have supplied uniforms and paid tuition and exam fees directly to schools, testing the concept that because school is a structured, prosocial environment, extending school enrollment through high school would improve future expectations and health behaviors, including delaying sexual debut and reducing sexual infection risk (Cho et al, 2011; Hallfors, Cho, Rusakaniko, Iritani, Mapfumo, & Halpern, 2011; Hallfors et al, 2015). The studies cited above focused on orphans, who were expected to benefit more from school support, as well as from the structured setting of the school environment, than non-orphans, because of their greater vulnerability (Hallfors, Cho, Mbai, Milimo, & Itindi, 2012; Luseno et al, 2015). …”

“…Study design was informed by earlier pilot work with process evaluation suggesting five improvements: randomization of schools rather than households, no treatment for the control group; selecting orphans in Grades 7 and 8 rather than by age; registered nurse visits rather than lay community visitors; and HIV/HSV-2 biomarkers at baseline and endline (Hallfors et al, 2012). The subsequent randomized controlled trial (RCT; parent study) incorporated all of these design modifications.…”