Exploring the social consequences of cash transfers on adolescent recipients and their relationships

Ndimande-Khoza, Makhosazane Nomhle
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Introduction: Cash transfers (CTs) directed to adolescent girls and young women in subSaharan Africa for sexual health and HIV prevention have shown mixed but promising results. Despite the goal for CT programmes to address social and structural barriers to HIV prevention, little is known about their unintended psychosocial impact when paid directly to adolescents. This PhD aimed to explore the CTs' personal, gender, and relational consequences for HIV prevention among adolescents in low-resourced settings in South Africa. While the PhD focus is mainly on CT interventions targeting AGYW, some findings focused on adolescent boys are also included as a novel contribution to the CT literature. Methods: This PhD study is embedded in two randomised controlled trials, HPTN 068 and CHANGE, conducted in two South African provinces, Mpumalanga and Gauteng, between 2012-2015. These trials assessed the effectiveness of conditional and unconditional CTs on HIV prevention, mainly in AGYW. The PhD study used primary and secondary qualitative data collected as part of these two trials. Data collection included in-depth interviews and/or focus group discussions with male and female CT beneficiaries, nonbeneficiaries, caregivers, intimate partners, and peers to gather perspectives on the psychosocial impact of CTs. Questions explored during data collection included: experiences and meanings of CTs, spending patterns of CTs, perceived psychosocial impact of CTs on adolescent recipients, and their relationships with family, peers, and intimate partners. Data was collected by the researcher and trained research assistants in local languages and audio recorded. Audio-files were transcribed and translated to English. Codebooks were generated using an inductive approach based on emerging themes, and subsequent transcripts were coded deductively. Data was organised and analysed using Atlas-TI version 7.4. Findings: This study contributes several new findings to the current literature on the psychosocial implications of CTs paid to adolescents. We found that CTs directed to adolescents generally had unintended psychosocial benefits among adolescent beneficiaries, although with minimal negative consequences. CTs promote a sense of agency and selfworth among beneficiaries by facilitating spending on basic needs and items their parents could not afford. Receipt of CTs enabled AGYW to contribute to their intimate relationships. Intimate partners and male peers, therefore, supported CTs paid directly to girls and young women. However, it appears that if young women’s receipt of CTs could significantly change the power balance in women’s favour, they may be unacceptable to men. We also found that CTs strengthened social relations by facilitating resource exchange and reciprocity and promoting participation in peer networks which increase peer identity and social status. However, our findings show that CTs may also have an unintended negative impact on social relationships, such as potential backlash related to altering gender norms that favour men superiority, perpetuating inequitable gender norms, disrupting norms of homogeneity if targeting one group and ‘excluding’ others. All the unintended consequences identified in the study can potentially influence adolescents’ HIV risk, positively or negatively. Conclusion: The key findings inform the literature on adolescent-directed CTs and provide evidence to inform future programmes. Future studies on CTs for sexual health and HIV prevention in adolescents should consider the unintended social consequences. These interventions should recognise that unintended social implications may affect the overall impact of the CTs on targeted behavioural and biomedical outcomes — this may be the initial step to understanding the pathways through which the CTs effect change on targeted outcomes or a way to explain lack of programme impact.
A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, 2022