Poverty, Economic Strengthening, and Mental Health Among AIDS Orphaned Children in Uganda: Mediation Model in a Randomized Clinical Trial

Background and Purpose: Some evidence points to the positive effects of asset accumulation programs on mental health of children living in low-resource contexts. However, no evidence exists as to why and how such impact occurs. The effect of these programs on accumulation of assets and reduction of poverty is, at best, inconclusive. Therefore, specific mechanisms of change through which these interventions affect child mental health is yet to be understood. Our study aims to understand whether child poverty, child work, and household wealth serve as pathways through which the economic strengthening intervention affects the mental health AIDS-orphaned children.

Methods: The study employed a cluster-randomized experimental design with a family-based economic strengthening intervention conducted among 1,410 school-going AIDS-orphaned children ages 10 and 16 years old in 48 primary schools in South Western Uganda. Main outcome of interest, child mental health, was a latent variable constructed from three correlated indicators: the Beck Hopelessness Scale, Child Depression Inventory, and Tennessee Self-Concept Scale. To test the hypothesized relationships between the intervention, mediators (i.e. household wealth, child poverty, and child’s work) and mental health, we fitted structural equation models using Mplus 8.1. The models adjusted for clustering of individuals within schools and accounted for potential correlation among the mediators. Global model fit of each SEM was evaluated using the chi-square test of exact fit, the Comparative Fit Index (CFI), the Root Mean Square Error of Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMR)

Results: We found no evidence for mediating effect of the household poverty or the child’s work in transmitting the effect of family-based economic empowerment intervention on children’s mental health. In other words, effect of the asset accumulation program on children’s mental health did not occur through reduction in household poverty or in child’s work. It did, however, occur (partially) through reduction in childhood poverty. The strongest evidence for mediation of the intervention effect by childhood poverty is seen at 24 months where statistical significance at p<.05 was observed. Though not statistically significant, the same overall pattern of results is seen at 36 and 48 months. Furthermore, our findings indicate that the variation in the latent mental health outcome accounted for by the intervention and mediators together ranged between 10% and 11%, which falls between the small and medium mediation effect.

Conclusions and Implications: This study is among the first to explore the mechanisms of change by which asset accumulation programs (such as Bridges to the Future) influence children’s mental health. Our findings suggest that anti-poverty programs that aim solely to improve household income may be less advantageous to children’s mental health as compared to those that are specifically targeted towards reducing the impact of poverty on children. Further studies using more comprehensive measures of child work and age-appropriate child mental health may shed more light on understanding the link between asset accumulation interventions, child labor and children’s mental health.