This study reports the results of a comprehensive microfinance intervention which provided AIDS orphans in Uganda with a matched savings account they could use to pay for secondary schooling or to invest in family businesses, financial and business training workshops, and a mentorship program.
Participants in the Suubi intervention group showed a significant reduction in depression over time whereas participants in the control group did not. One potential concern is that, in spite of randomization, participants in the Suubi group had lower mean levels of depression at baseline than children in the control group. However, the significant differences in mean levels of depression persisted even after double robust estimation was used to attain pseudo-balance of baseline depression and other potential confounders, suggesting that the intervention did reduce depression among these high-risk youth.
These results support the hypothesis that a combined microfinance intervention, including matched savings accounts, workshops to support savings and business development, and mentorship, could be effective in reducing depression among AIDS orphaned youth in Uganda. Because the intervention was delivered as a package, we are not able to determine which component(s) of the intervention played the most important role in improving children’s mental health functioning. On the one hand, we expect that the matched savings component would play a primary role, by giving children hope that they could continue on to secondary school and by raising family incomes and reducing financial hardship. On the other hand, it is likely that the role of those matched savings accounts was augmented by children receiving the workshops and the mentorship. It is also likely that having a mentor may have had a direct effect on youth mental health. However, our study was not designed to tease apart the effects of different components and thus we can only speculate about this.
As mentioned, an important limitation to these findings is that baseline levels of depression were different across the two groups, most likely due to the small numbers of schools in this intervention pilot study. Double robust and related methods that pseudo-balance otherwise imbalanced groups are helpful to address this issue, but they are not as robust as having groups that are actually balanced at the outset of the study. This is especially true in the current study where the number of available potential confounders to include in the double robust estimation was quite limited.
Also, while levels of depression were significantly reduced in the Suubi intervention group over time while the control group’s were not, the groups’ depression slopes were not statistically different from each other, which could suggest the possibility of modest naturalistic depression reduction among Uganda AIDS-orphaned adolescents as they age. However, it is important to note that the baseline depression difference was in the same direction as the follow-up depression differences (lower mean levels of depression in the intervention group at all time points), so regression to the mean was less likely to play a role in the significant differences observed post-baseline. Moreover, the mean difference in depression scores between the groups increased over time.
Thus, despite the limitations noted above, we regard these findings as sufficiently intriguing to merit additional study of comprehensive microfinance interventions as a vehicle to reduce depression among youth in resource-poor settings. An important element of future studies will be to measure a wide array of potential mechanisms of change, with each mechanism linked to a specific element of the intervention. The current pilot study was not scaled to investigate such issues, nor did it include separate arms where children received one component of the intervention but not others. Thus, it was not possible to separate out the effects of the matched savings accounts vs. the workshops vs. the mentorship program. Future studies that include such measures linked to specific intervention components and coupled with a larger sample (more participants and especially more schools, and ideally different intervention arms), employing stratified randomization to ensure depression balance across study groups at baseline, will enable researchers to shed more light on the role such interventions might play in improving mental health functioning among these at risk youth. 38
Even with the above-mentioned limitations, our findings are suggestive and have implications relevant for researchers, pediatricians and health care practitioners. The findings indicate that over and above the traditional psychosocial approaches used to address mental health functioning among orphaned children in sub-Saharan Africa, poverty alleviation-focused approaches, such as the comprehensive microfinance intervention studied here, may play a role in lowering depression. This finding is significant, given the multidimensional nature of poverty in sub-Saharan Africa, and in light of the fact that the region is the epicenter of HIV/AIDS. While not conclusive, our results suggest that a larger randomized trial is in order. Overall, the findings of this study complement earlier studies 39, 40
that point to the role of comprehensive microfinance programs in health-promoting interventions in low resource countries.