Key Findings & Programmatic Implications Tonya Renee Thurman, MPH, PhD Tulane University School of Public Health & Tropical Medicine/ MEASURE Evaluation Dissemination Meeting, September 3 rd, 2009 Washington, DC OVC Program Evaluations in Kenya & Tanzania Tulane University School of Public Health and Tropical Medicine

Overview  What is the level of program coverage?  What influence are interventions having on the well-being of children and guardians?  Are there any unintended consequences?  What does it all mean?

Program Coverage  A small number of beneficiaries confirmed that they received key interventions employed  For example, while TSA sample were drawn from the Kids Club Registry:  Only 27% reported attending  57% indicated they had never heard of Kids Clubs  Prevalence and frequency of home visits was also less than expected

Prevalence of Home Visiting

Frequency of Visits

Key Outcomes & Interventions Key Interventions  School-based HIV education  Kids clubs  Home visits  Guardian support groups  Distribution of goods: school supplies & food  Income-generating activities  Community education: OVC care & support Key Outcomes  HIV knowledge  Psychosocial well-being of children & guardians  Care & treatment of children  Physical health of children & guardians  Legal protection  Children ’ s education  Household food security  Community support

Hypotheses Tested  School-based HIV programs: Child HIV knowledge  Kids clubs: Children ’ s HIV knowledge & psychosocial well-being  Home visits: Children & guardians psychosocial wellbeing & physical health, child ’ s care and treatment, educational outcomes & legal protection  Guardian support groups: Children & guardian ’ s psychosocial well-being, child care and treatment & legal protection

Hypotheses Tested  Distribution of goods: School supplies & children ’ s educational & psychosocial outcomes; food provision & food security  Income-generating activities: Food security  Community education, OVC Care & Support: Community support & child ’ s legal protection

HIV Knowledge Outcomes  Heard of AIDS  Number of known prevention methods  Mistaken beliefs Key Interventions  School-based programs  Kids Clubs

HIV Knowledge  Two programs offered school-based HIV education (CRS & IAP)  Both were associated with increased number of HIV prevention methods known by child participants  However, gaps in knowledge remained  Few mentioned sexually-related protective behaviors  No difference in prevalence of children ’ s mistaken beliefs

HIV Knowledge  Two programs offered Kids Clubs (Allamano & TSA)  Better awareness of HIV among participants in one of the two Kids Clubs (TSA)  But only one-third knew at least 1 prevention method

Children’s Psychosocial Well-being Outcomes  Self esteem  Pro-social behavior  Emotional problems  Total difficulties  Adult support  Social isolation Key Interventions  Kids Clubs  Home Visiting  Guardian Support Groups

Children ’ s Psychosocial Well-being Allamano Effect No Effect Outcomes Emotional symptoms Pro-social behavior Adult support Global self-esteem Social isolation TSA No Effect Kids Clubs

Children ’ s Psychosocial Well-being Child Outcomes Pro-social behavior Total Difficulties Adult support Global self-esteem Social isolation Support Group Effect No Effect Home Visiting No Effect Effect Three Programs offered Home Visiting & Two offered Guardian Support Groups  Effects not consistent across programs– only one outcome affected by two programs  No more than two outcomes per program

Care and Treatment of Children & Guardian Psychosocial Well-being Outcomes Child Care & Treatment  Feelings Towards Child  Family Functioning  Child Abuse Guardian Psychosocial  Marginalization  Negative Feelings  Positive Feelings Key Interventions  Home Visiting  Support groups

Child Care and Treatment & Guardian Psychosocial Well-being Feelings re child Family Functioning Child abuse Negative Feelings Positive Feelings Marginalization Home Visiting (3 programs) No Effect Effect (CRS) No Effect CRS Support Group No Effect Effect No Effect Effect IAP Support Group No Effect Effect No Effect

Support Groups & Home Visiting? One study demonstrated the added benefit of exposure to multiple interventions (CRS)

Guardian Psychological Health  How did they fare?  Average scores of in Kenya and Tanzania  Relative data from healthy adults in Zimbabwe: > 3.5  Preliminary analyses also suggest it’s importance  Between OVC to non-OVC guardians  Impact of guardian psychological health on children’s psychological health

Children & Guardian’s Physical Health Outcomes  Reported Health Status  Use of needed health services Key Interventions  Home Visiting  Referrals for Free Health Services

Home Visiting & Physical Health  None of the programs were associated with an improvement in the reported physical health status of guardians  Only one program demonstrated an association between home visiting and better reported health status for children

Health Referrals Frequency of Referral Use for Free Healthcare among program participants at one study site (CRS) Uptake of referrals was fairly poor even if the service was free

Legal Protection Outcomes  Identity documents  Succession planning Key Interventions  Home Visiting  Support Groups  Community education: OVC Care & Support

Legal Protection Home Visiting (3 programs) Support Groups (2 programs) Community Education (2 programs) Identity Documents NS Effect Succession Planning NS  No effect of Home Visiting or Support Groups  No effects on Succession Planning

Legal Protection  High prevalence of OVC lacking identity documents  About 65% in Tanzania and nearly half in Kenya  OVC found less likely to have such documents than non-OVC  60% of maternal orphans relative to 84% of other children; similar among other OVC groups  Succession Planning was very low  Less than 20% even among ill caregivers

Children’s Educational Outcomes Outcomes  Enrollment  Attendance Key Interventions  Provision of School Supplies  Home Visiting

Educational Outcomes Home Visiting AllamanoCRSTSA EnrollmentEffectNS AttendanceNSEffectNS  Enrollment fairly high (> 95%) across each site  Provision of school supplies not associated with enrollment or attendance  Cross-cutting: Possession of school supplies was associated with better self-esteem across two program sites (Allamano & PACT)

Household Food Security Outcome  Food Security Key Interventions  Income generating  Food parcels

Food Insecurity Two programs aimed to enhance food security

Household Food Insecurity Interventions: Food Parcels & IGA Inconsistent Food Parcels (CRS) Consistent Food Parcels (Allamano) IGA: Savings and Internal Lending Committees (CRS) IGA: Bio-intensive Gardening Training with Supply Provision (Allamano) Reduced food insecurity? No effect Effect

Community Support Outcomes  Perceived Stigma  In-kind support Key Intervention  Community education: OVC Care & Support

Community Support  Two programs had Community Education regarding OVC Care & Support (IAP & PACT)  Guardians living in communities with a high concentration of OVC Care & Support Mtgs reported more receipt of in-kind support (PACT)  Attendance at an OVC Care & Support Mtg associated with marginal effects on participants stigma concerning OVC and HIV affected families (IAP)  Notably, children living in high stigma communities were found to be worse off (IAP)

Unintended Consequences?  In one study, guardians of Kids Club participants reported more negative feelings towards the child  In another study, worse perceived stigma found among Kids Club participants and those with a home visitor  High levels of perceived jealousy reported across almost all sites

Jealousy of service provision For PACT, perceived jealousy was significantly higher in the Intervention Group

Who is responsible for orphans?

Significant difference (p <.05)

Summary: Service Provision  Program exposure was lower than anticipated  Beneficiaries may not always capitalize on services available to them  Services targeting one domain of well-being may affect another domain  Exposure to multiple interventions has additive effects  Emerging unintended consequences of program engagement

Summary: Key Interventions  Kids Clubs and distribution of school supplies can have a positive influence on children’s psychosocial wellbeing  Home visiting had more effects on children’s outcomes than guardian outcomes and inconsistent effects across programs  Support groups for guardians associated with positive child, guardian and family outcomes  Meeting basic needs consistently can be effective  But are they sustainable?  Income generating can build the family’s capacity to support themselves

Summary: Unmet Needs  Comprehensive HIV education remains necessary for youth  Stigma is powerful influence on child outcomes and remains largely unaddressed  Guardian’s psychological health unaffected across each of the interventions  No effects on child & guardian’s physical health  Limited influence on children ’ s legal protection, particularly succession planning

Programmatic Implications What does it all mean for the improvement of OVC programs?  Drawing upon quantitative results & case studies

Programmatic Implications Reliance on volunteers:  Standardized volunteer training on OVC care is absent  Volunteers possess limited skills to address psychological and legal issues  Caseloads may be to high to expect anticipated coverage and outcomes

Programmatic Implications Service Provision:  Barriers to accessing services, beyond cost, need to be addressed  Additional interventions required to address unmet needs  Combination of interventions can have the greatest influence

Programmatic Implications Child focused interventions:  Adolescent needs are largely unaddressed  Ensure a comprehensive and age appropriate curriculum along with routine technical guidance  Inclusion of community children in recreational interventions  Engage guardians in interventions addressing OVC needs

Program Implications Guardian focused interventions:  Supporting guardians can translate into benefits for children under their care  Home visiting needs to move beyond an emphasis on children to include guardians  Beyond training, supplemental resources & support may be needed to ensure effectiveness of IGA

Program Implications Community interventions  Efforts to reduce community stigma holds promise if intensified  Unintended consequences should be anticipated with initiatives in place to reduce them

Programmatic Implications Program Monitoring  Regular assessments of program coverage and client participation are needed  Tracking referral uptake  Ongoing monitoring systems to register and track beneficiaries are needed

Discussion Other Implications? Questions?

Thank You We ultimately hope that this study benefits the adults & children in need across SSA