Key Findings & Programmatic Implications

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

2. 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?

3. 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

4. Prevalence of Home Visiting

5. Frequency of Visits

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. Children’s Psychosocial Well-being Kids Clubs

14. Children’s Psychosocial Well-being 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

15. 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

16. Child Care and Treatment & Guardian Psychosocial Well-being

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

18. Guardian Psychological Health How did they fare? Average scores of 2.3 -2.8 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

19. Children & Guardian’s Physical Health Outcomes Reported Health Status Use of needed health services Key Interventions Home Visiting Referralsfor Free Health Services

20. 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

21. 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

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

23. Legal Protection • No effect of Home Visiting or Support Groups • No effects on Succession Planning

24. 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

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

26. Educational Outcomes • 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)

27. Household Food Security Outcome Food Security Key Interventions Income generating Food parcels

28. Food Insecurity Two programs aimed to enhance food security

29. Household Food Insecurity

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

31. 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)

32. 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

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

34. Who is responsible for orphans?

35. Who is responsible for orphans? Significant difference (p < .05)

36. 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

37. 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

38. 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

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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. Discussion Other Implications? Questions?

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