RESEARCH ARTICLE Open Access

Cash transfer interventions for sexual
health: meanings and experiences of
adolescent males and females in inner-city
Johannesburg
Nomhle Khoza1*, Jonathan Stadler1, Catherine MacPhail1,2, Admire Chikandiwa1, Heena Brahmbhatt1,3

and Sinead Delany-Moretlwe1

Abstract

Background: In sub-Saharan Africa, there is growing interest in the use of cash transfer (CT) programs for HIV
treatment and prevention. However, there is limited evidence of the consequences related to CT provision to
adolescents in low-resourced urban settings. We explored the experiences of adolescents receiving CTs to assess
the acceptability and unintended consequences of CT strategies in urban Johannesburg, South Africa.

Methods: We collected qualitative data during a pilot randomized controlled trial of three CT strategies (monthly
payments unconditional vs. conditional on school attendance vs. a once-off payment conditional on a clinic visit)
involving 120 adolescents aged 16–18 years old in the inner city of Johannesburg. Interviews were conducted in
isiZulu, Sesotho or English with a sub-sample of 49 participants who adhered to study conditions, 6 months after
receiving CT (280 ZAR/ 20 USD) and up to 12 months after the program had ended. Interviews were transcribed
and translated by three fieldworkers. Codes were generated using an inductive approach; transcripts were initially
coded based on emerging issues and subsequently coded deductively using Atlas.ti 7.4.

Results: CTs promoted a sense of independence and an adult social identity amongst recipients. CTs were used to
purchase personal and household items; however, there were gender differences in spending and saving
behaviours. Male participants’ spending reflected their preoccupation with maintaining a public social status
through which they asserted an image of the responsible adult. In contrast, female participants’ expenditure
reflected assumption of domestic responsibilities and independence from older men, with the latter highlighting
CTs’ potential to reduce transactional sexual partnerships. Cash benefits were short-lived, as adolescents reverted to
previous behavior after the program’s cessation.

Conclusion: CT programs offer adolescent males and females in low-income urban settings a sense of agency,
which is vital for their transition to adulthood. However, gender differences in the expenditure of CTs and the
effects of ending CT programs must be noted, as these may present potential unintended risks.

Keywords: Cash transfers, Adolescents, Girls, Boys, South Africa

* Correspondence: nkhoza@wrhi.ac.za
1Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health
Sciences, School of Clinical Medicine, University of the Witwatersrand,
Johannesburg, South Africa
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Khoza et al. BMC Public Health  (2018) 18:120 
DOI 10.1186/s12889-018-5027-3

http://crossmark.crossref.org/dialog/?doi=10.1186/s12889-018-5027-3&domain=pdf
mailto:nkhoza@wrhi.ac.za
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/


Background
Cash transfer (CT) programs are largely used in low- and
middle-income countries as a mechanism to alleviate pov-
erty. In the past two decades, they have been used to im-
prove health outcomes and promote healthy behavior.
Studies show that conditional and unconditional CTs have
significantly improved health-seeking behaviors and the
uptake of healthcare services [1, 2]. Following the impact
of CT programs on improved health outcomes in Latin
America, there has been a growing interest in their use for
HIV treatment and prevention [3]. It is hypothesized that
through mitigation of the underlying economic drivers of
HIV infection or incentivization of healthy behavior, CT
programs could lessen engagement in risky behavior,
thereby reducing HIV infections [4, 5].
Studies in developing countries show promising find-

ings in relation to the potential role of CTs in reducing
HIV infection by changing risky sexual behaviors [3].
Studies have also shown that CT programs could sup-
port HIV treatment by enabling recipients living with
HIV to buy food and pay for costs associated with treat-
ment access, thereby improving adherence to antiretro-
viral therapy (ART) and retention in HIV care [6, 7].
There are also debates about the potential role of CTs to
improve utilization of and retention in mother-to-child
transmission services (PMTCT) [8]. CTs conditional on
prenatal clinic visits increased retention in the PMTCT
cascade and uptake of prenatal services [9]. While CT
programs are a promising mechanism to leverage
positive HIV programme outcomes, the effectiveness of
interventions may vary according to the demographic at-
tributes of the target population [10, 11].
CT programs have historically targeted adult women

[12] and there is limited evidence on the impact of CT
programs where cash is given directly to adolescents.
Despite this limited evidence, there is a growing interest
in expanding social protection programs in the African
region and in using CTs to improve HIV outcomes in
adolescent girls and young women (AGYW), given this
group’s high incidence of HIV infection [13]. Research
findings to support the effectiveness of this approach are
limited, but promising [14]. An observational study in
South Africa showed that adolescent girls from house-
holds that were receiving a child support grant were less
likely to engage in intergenerational sex, which is a risk
factor for HIV infection [15]. A randomized controlled
trial (RCT) in Malawi showed that AGYW who received
school-conditioned CTs were less likely to become preg-
nant, marry early, and engage in risky sexual behavior
[16]. A recent South African study however showed that,
while CTs conditional on school attendance reduced risk
behaviors in adolescent girls, this did not translate into re-
ductions in HIV incidence [17]. Similarly, another trial
also in South Africa found that cash incentives conditional

to 80% participation in a life skills program, taking an HIV
test, passing academic tests, and submitting community
project report, had no effect on HIV incidence, but re-
duced HSV-2 incidence [18].
Despite the inconsistent findings, agencies such as

UNAIDS and the World Bank are willing to support
governments to scale up CT programs [19]. The United
Nations Development Program (UNDP) has recom-
mended further exploration of CTs with regard to their
potential to prevent HIV among key populations [11].
Moreover, Swaziland’s Ministry of Health is considering
scaling up the implementation of CCT programs to pre-
vent HIV infection among AGYW [20].
While AGYW are a priority target group for these

sorts of structural interventions to address HIV; Gibbs
et al. (2012) highlight the need to include men in struc-
tural interventions for HIV prevention [21], as evidence
shows an association between men’s income, their views
of manhood and the risk of HIV [22, 23]. The pathways
through which perceptions of manhood and livelihood
influence HIV remain unclear [21]. Moreover, studies in-
dicate that CT interventions may impact men and
women in different ways [24]. While CTs may encourage
healthy behaviors and elicit intended behaviors among
recipients [3], CTs may also encourage unanticipated
negative behaviors such as alcohol and drug use, which
in turn increase the recipients’ health risks.
Currently, it is not known how adolescents in a low-

resourced African urban setting perceive CTs, how they
spend CTs, or what receipt of transfers means to them. In
addition, there is limited data and understanding regard-
ing the impact of cash transfers on adolescent male behav-
iours. This limits the understanding of the impact of CT
programs designed for HIV prevention and treatment in
various contexts, indicating the need for further research
in this regard. We present findings from a qualitative
study conducted among adolescent boys and girls who
participated in a CT intervention study where we explored
participants’ experiences of the CT intervention and the
meaning that they attach to the intervention.

Methods
Study population and setting
The research was conducted in inner city of Johannesburg,
South Africa, specifically in the Hillbrow, Berea, and Yeoville
areas. This location was selected because of evidence that
HIV prevalence in South Africa is highest in informal urban
areas [13, 25]. The area is characterized by dense,
overcrowded high-rise residential buildings and aban-
doned industrial buildings informally occupied by mi-
grant workers from within and outside South Africa.
Fifty-one percent of the population in the area are
males, 20% are aged <15 years, and 21% are aged 15–
24 years. The area is characterized by a high

Khoza et al. BMC Public Health  (2018) 18:120 Page 2 of 11



concentration of low-income households (<R1000 per
month) and unemployment rate of 41% (Statistics
South Africa, 2012 as cited in USAID report [26]).

Study design
This study was nested within the CHANGE study, a pilot
RCT assessing the feasibility and acceptability of CTs in
a low-resourced urban setting. The aim of the interven-
tion was to compare three different CT interventions
strategies.
We recruited male and female adolescents (n = 120)

for participation in the intervention through distribution
of pamphlets at three schools and by word of mouth.
The inclusion criteria were being aged 16–18 years, self-
identifying as sexually active, and enrolled in school.
Potential participants were contacted and invited to our
research offices (along with a parent/ legal guardian, for
those aged 16–17 years, who in the context of participa-
tion in public health research are still considered minors).
Participants were randomized into one of three cash

strategies using sealed numbered envelopes: 1)
Unconditional monthly payments of 280 ZAR (USD
20) for 6 months; 2) monthly payments of 280 ZAR
for 6 months, conditional on 80% school attendance;
3) and a single payment of 280 ZAR conditional on a
once-off clinic visit involving sexual reproductive
health education, services related to family planning
and contraception, HIV counselling and testing, HIV
risk assessment, and HIV risk reduction counselling.
Payments were made through a cardless service that
allowed cash withdrawals from an automated teller
machine (ATM) using a pin code, which was sent to
participants’ mobile phones via a short message sys-
tem (SMS). Those who either did not have a mobile
phone or had a shared phone were paid using ATM
cards with a linked pin; these were provided to
participants at enrollment. Participants completed sur-
veys at 6 and 12 months after receiving CTs; the sur-
vey results are reported elsewhere [26].

Sample and data collection procedures
From the 120 participants enrolled in the intervention,
we purposively selected a sub-sample of 49 adolescent
boys (n = 30) and girls (n = 19) to participate in-depth in-
terviews. We selected participants who adhered to study
conditions such as attending school and visiting the
clinic across the three study arms (i.e., unconditional
cash transfers, clinic-conditioned cash transfers, and
school-conditioned cash transfers).
Data were collected 6 months after participants had

received the conditional and unconditional CTs (March
2014) and up to 12 months after the intervention had
ended (March 2015). Different sets of participants were
interviewed at the two time points. The purpose of the

second interviews was to gain insights into the effects
after the cessation of a CT programme. We contacted
participants telephonically and invited them to take part
in the interviews.
Participants were interviewed in a private room at

our research offices in Hillbrow. The interviews were
conducted by one male and two female interviewers,
who were fluent in isiZulu and Sesotho. Each inter-
view took approximately 1 h, and participants were
compensated 100 ZAR (approximately USD 7) for
transport costs and their time. The interview guide
consisted of the following topics: (1) descriptions of
adolescents’ households (household membership, em-
ployment, domestic relationships); (2) experiences of
the CT program; (3) participants’ sources of income
before, during, and after the CT intervention; (4) and
spending patterns and perceived impact of CTs. All
interviews were audio-recorded and transcribed. Inter-
views in isiZulu and Sesotho were transcribed and
translated (one-step) into English by trained tran-
scribers. Personal identifiers were substituted with
pseudonyms during transcription.

Data analysis
An interpretative phenomenological approach was employed
to explore how adolescents make sense of their experiences
of CT programs. The phenomenological approach focuses
on how people perceive and talk about objects or events
[27]. This method was useful in facilitating an understanding
of adolescents’ experiences and meanings of CT programs.
As an initial step, two of the authors of this paper (JS

and NK) reviewed the transcripts to identify preliminary
themes and sub-themes, using an interpretivist approach
to analyze the data [27]. Atlas.ti version 7.4 was used to
code and organize the transcripts. A codebook was gen-
erated using an inductive approach; transcripts were ini-
tially coded based on emerging themes and subsequent
transcripts were coded deductively. The final code frame
consisted of 61 codes. These codes were grouped into
five thematic categories, namely, demographic informa-
tion, perceptions and experiences of CT, spending pat-
terns, meanings of CT, and developments after the CT
program. After forming the thematic categories, a com-
parison between males and females was done. There-
after, common themes were identified, compared and
contrasted within and between cases.

Results
Socio-demographic characteristics
We had intended to include 30 participants at each fol-
low up, making up an envisaged total of 60 participants.
However, obtaining a balanced representation according
to gender was challenging, especially at the 12-month
visit. Some of the contact information was invalid and

Khoza et al. BMC Public Health  (2018) 18:120 Page 3 of 11



some participants had completed school, while others
had relocated. Our final sample of 49 participants, there-
fore, had more male participants and more participants
in the unconditional arm than was initially planned.
Table 1 illustrates the final study sample.
The majority (n = 21) of participants were recipients of

unconditional CTs, followed by 15 participants who
formed part of the school arm, and 13 participants in the
clinic arm. At 6 months follow-up, the age range was 16–
18 years. Participants were in grades 10–12. At 12 months
follow-up, the majority (67%) of participants had com-
pleted the 12th grade; a few (13%) participants were en-
rolled in tertiary education, some (30%) worked
temporary jobs (including informal economy), and others
(23%) were seeking employment. Most participants’
households were headed by single parents, who were in
unskilled employment or ran informal businesses. The
majority of participants lived in one-bedroomed apart-
ments. On average, there were four occupants per house-
hold, with parents sleeping in the bedroom and siblings
sharing a bed in the living room. In some instances, two
or three families shared a living space.

Experiences of the CT intervention
At the beginning of the CT program, both adolescent
boys and girls doubted its authenticity. “Receiving
money for doing nothing” seemed too good to be true;
this perception was also due to the high rate of scams
and crime in the study area. P9 (male, school) stated: “At
first, I didn’t trust it; I thought it was a scam because,
how can someone give you R250 [R280] ... just giving you
just like that?” Some of the female participants thought
that they would be expected to do something in return
for CTs. However, the mistrust and uncertainties dimin-
ished upon adolescents obtaining more information
about the intervention and receiving their payments.

Overall, the unconditional and conditional CTs were
acceptable to both boys and girls, who indicated that the
program encouraged them to be responsible and attend
school, and prevented girls from engaging in sex with
older men, and boys from committing crime to get
money. As one participant noted: “…at least there is a
project out there that is willing to help young girls and
guys and show them that they don’t have to do bad
things that are out of their comfort zone to get money.”
(P19, female, unconditional).
While the study did not offer formal lessons on sexual

reproductive health (SRH), several participants men-
tioned that they liked the information on HIV/AIDS and
sexually transmitted infections, which they received
through their participation in the study. In relation to
this, P8 (male, unconditional) illustrated: “For me, being
in the program was all about learning about HIV and
how to protect ourselves from contracting such diseases
by practicing safe sex.” Similar to other participants, P8
reported that he gained knowledge about HIV and test-
ing by completing a mobile phone-based survey in the
main trial.

Experiences of the CT conditionalities
We asked participants about their experiences of the
conditionality of CTs. Both adolescent boys and girls
were open to the school condition, since they had
been attending school before the program; so, being
compensated for this with cash was an added advan-
tage. As P32 (female, school) noted: “I was going to
school every day. It is something that I was doing
since grade 1; so, it was not like I was working for it,
because it was something that I was already doing.
So, I was just getting paid for something that I was
doing, but I was now pushing even harder because I
was getting paid for it.” Several adolescents in the
school arm reported that CTs had minimal to no im-
pact on their school attendance. Some indicated that
the program encouraged them not to miss school.
They put in extra effort into their attendance, as they
did not want to miss their cash payments; for
example, they attended school even when they were
sick. However, this was contradictory to the main
trial’s findings, which showed that participants who
received school-conditioned payments were more
likely to report missing school relative to participants
in the other study arms [28].
Among adolescents in the clinic condition arm, several

girls reported that they disliked clinic visits because of
the stigma associated with being at the clinic, but that
the friendly clinic staff had put them at ease. Receiving
clinic-conditioned CTs encouraged participants to attend
the clinic, as per study requirements, which offered the
adolescents, particularly boys, an opportunity to get

Table 1 Demographic characteristics of young men and
women who participated in IDIs in the CHANGE trial

Demographic
characteristics

Sample at
6 months
n (%)

Sample at
12 months
n (%)

Total sample: 6 and
12 months n (%)

Age (years) 16–18 17–19 16–19

Gender

Male 9 (47) 21 (70) 31 (64)

Female 10 (53) 9 (30) 18 (37)

Study arm

Unconditional cash
transfers

8 (42) 13 (43) 21 (43)

Clinic-conditioned cash
transfers

5 (26) 8 (27) 13 (27)

School-conditioned cash
transfers

6 (32) 9 (30) 15 (31)

Total 19 (100) 30 (100) 49 (100)

Khoza et al. BMC Public Health  (2018) 18:120 Page 4 of 11



tested for HIV, something that they would be less likely
to do if they were not receiving conditional CTs.

“Since I got the clinic part of the study, what I saw is
that they gave me a chance to go to the clinic and
actually get myself tested or just do anything that I
wanted to do, and that has never come to mind. I got
the chance to know my status and also get counseling
and be taught more about STIs.” (P14, male, clinic).

The size and frequency of the CT payment
Nearly all participants, boys and girls, were satisfied with
the sum of the CT (280 ZAR). They stated that the
amount was “more than enough”; some described it as
“neither too small nor too much.” It was sufficient to
cover their needs. P5 (male, unconditional) remarked: “It
was a lot because I am not used to having that amount
of money.” For the adolescents, the money was also suffi-
cient because it was not common for them to receive
such money without having worked for it. Only two par-
ticipants articulated that the grant was insufficient, “this
money was not enough for me … because there are things
I thought I would do but the money was not enough.”
suggesting that they should have received more or the
same amount on a weekly basis. Some participants
stated that if we offered adolescents more money, they
would misuse it. P13 (female, unconditional) commen-
ted: “It was a good amount because knowing us, youth,
we would buy alcohol. With two-eighty (280), we could
buy necessities, and not things that we want, but things
that we needed.”
While adolescents were generally satisfied with the

amount provided, the frequency with which the cash
payments were made mattered. Participants across the
three study arms stated that the program was unfair to
those who had received once-off payments. Adolescents
who had received once-off payments raised a concern
especially in relation to peers who misused the CTs on
expensive items when there were “deserving” partici-
pants who would have done anything to get the money.
The assumption was that those who “need” the cash
were more likely to spend it in a manner perceived to be
sensible compared to those for whom the transfer was
extra income.

The payment method
Adolescents received their payments using a bank card
or a cardless system at an ATM. They liked both pay-
ment methods, reporting that receiving their payments
was stress-free. Participants who utilized the card
method stated that they could withdraw money from
any ATM, and those who used the cardless method said
that they did not have to carry cards and wallets around,
which they regarded as a safe option. Making ATM

transactions offered participants a sense of maturity.
However, several reported that they could not withdraw
the entire amount; so, they bought airtime through the
ATM to use amounts that were under the limit for
withdrawals.

Patterns of spending CTs
Both adolescent boys’ and girls’ spending and saving pat-
terns reflected the desire to look and feel good about
themselves. Adolescents mostly used CTs to meet per-
sonal and household needs. Typical personal spending
was on personal care/ hygiene products, clothing, school
necessities, airtime, short-term savings, and social activ-
ities such as attending a school dance. Spending also in-
cluded contribution towards groceries or helping others,
such as giving a parent money for transport to work or
buying a t-shirt for a sibling. Table 2 illustrates typical
examples of spending behaviour.
Most adolescents stated that CTs allowed them to pay

for activities and items that their parents would not buy
them or pay for; these included expensive clothing,
make-up, mobile phones, and entertainment. In some
instances, participants could purchase essential items
that parents could barely afford; for example, a “school
jersey, food in the house, and toiletries.” Not much
spending was reported on school items, and one young
woman reported spending cash on transport to the clinic
and medication. Four participants, male and female,
mentioned that they used CTs to buy condoms to pro-
tect themselves, mentioning that it was difficult for them
to access free condoms at the clinic because of stigma.
We noted gender differences in the adolescents’ deci-

sion making regarding the use of CTs and some differ-
ences in their spending and saving patterns. Most girls
sought advice from their parents or other family mem-
bers on how to use the money. Some girls believed that
they had to discuss this with their parents first, even
though they made the ultimate decision. The most com-
mon advice that they received from parents was to
spend the money wisely, and some were encouraged to
save it. In some instances, mothers used and controlled
the CT, but even then, this had been the participants’
decision.

“I sat down with my mom and told her that I have got
the money, and she asked what I have decided to do
with it, and I told her that I would give her half of the
money to buy what she needs in the house, while I
would use the other half to buy toiletries for myself.”
(P4, female, clinic)

Contrary to girls, most boys made independent decisions
regarding expenditure. They did, however, mention dis-
cussing the use of CTs with their peers. Boys were also

Khoza et al. BMC Public Health  (2018) 18:120 Page 5 of 11



most likely to spend CTs on airtime, mobile phones and
social activities such as “going out with the boys” and
the school dance, which was quite a popular and expen-
sive event. They also spent CTs on clothing, gym, and
technology. P18, a young man enrolled in the school-
conditioned arm, described how he spent the money
each month:

“I just spent the first payment on useless things, going
to the movies with friends. Then, I used it to go to the
camp. The second payment, I asked my mom to add
more money onto it, and I bought sneakers for R450
… the third month … that was when I wanted a
phone. I asked my mom to add more money onto it,
then I purchased a phone for R500 … the fourth
payment was like the first payment … I just spent it; I
just bought anything I saw that I was interested in ...
it was like earphones and a memory card and all that.
The last two months ... that’s when I saved my
money.”

In contrast to the above, girls spent some of their CTs on
their personal necessities and shared some with family
members. They mostly spent the cash on domestic neces-
sities, for example, buying food, helping their parents with
transport money, and helping siblings with pocket money.
They also paid for personal necessities such as personal
care/hygiene products, savings, and clothing. P6, a girl
who had received school-conditional payments, illustrated
how she spent her monthly payments:

“… the first payment, I bought a school jersey, then
the second payment, there were things that we needed

Table 2 Typical examples of adolescents’ spending behavior

Intervention arm
(amount & duration)

Participant
ID, gender

Items bought/
activities
paid for

Amount
spent (ZAR)

School attendance
condition (280 ZAR
for 6 months)

P41, male Gym 200

Nutritional supplements
Airtime

400

Toiletries 50

Pocket money 50

Savings a

P20, male Going out with friends a

Clothes 800

Petrol 350

Movies 200

P1, female Transport to school &
lunch

100

Shoes 80

Savings (school
holidays)

100

Table 2 Typical examples of adolescents’ spending behavior
(Continued)

Intervention arm
(amount & duration)

Participant
ID, gender

Items bought/
activities
paid for

Amount
spent (ZAR)

Household groceries a

P6, female School jersey 100

Household groceries 100

Transport for her
mother

a

Stationery a

Pocket money a

Airtime 30

Unconditional (280
ZAR for 6 months)

P26, male Clothes for matric
dance

1330

Entry fee for matric
dance

350

P20, male Eating out a

Movies 350

Petrol 350

Gym supplements a

Gym gear a

Clothes 800

Airtime a

P13, female Savings (matric dance) a

Birthday gift a

Household groceries a

P10, female Other personal items 100

Household electricity 50

Cosmetics 50

Snacks 50

Airtime 30

Picnic 50

Clinic visit condition
(280 ZAR once-off
payment)

P21, male Gym 180

Airtime a

P27, male Entry fee & clothes
for matric dance

260

Lunch at school 20

P4, female Gave her mom
for groceries

140

Movies 60

Savings (trip with
friends)

50

Cosmetics (perfume,
makeup)

40

P3, female Shoes a

Savings (cellphone) 60

Lunch at school 60

Airtime for her siblings 50
aIndicate that exact amount was not specified

Khoza et al. BMC Public Health  (2018) 18:120 Page 6 of 11



in the house; so, I bought the things that we needed.
At other times I lent to my mom if she did not have
money for transport to go to work. When others had
money, they liked [to buy] Kentucky [fried chicken];
so, I would go and buy vegetables or a tray of chicken,
and go home, cook, and eat with my mom.”

Generally there were similarities in patterns of expend-
iture across intervention arms. Similar to girls who had
received monthly payments for 6 months, those who
had received a single payment also spent CTs on their
personal needs and to support family members.

“I gave half of the money to my mom to buy groceries
in the house, and then I used some of the money for
entertainment. I went to the movies with my friends,
and I used some of it for toiletries like perfume,
make-up and other things that I needed.” (P4, female,
clinic)

Only two male participants reported spending CTs on
alcohol, to entertain themselves. However, adolescents
highlighted that expenditure of CTs on alcohol was
common among their friends and acquaintances. They
spoke of peers who used CTs on “alcohol and drugs”
and “gambling,” and “falling prey to money lenders,”
which reflected some form of moral judgment. “Most of
the young people that I know used their money for drugs
and alcohol.” (P20, male, unconditional).
We also noted that the meanings attached to CTs

could influence how adolescents spent the money. Some
participants in the unconditional arm considered CTs
“free money” because they “did not work for it” and
there were no conditions for receiving the cash. This is
how P44, a young man, perceived unconditional CTs:
“To me, it was just free money. (Laughs) So, it didn't
matter ... like, it was just free money.” Some participants
who had received a once-off payment viewed it as “luck
money”; one participant in the clinic arm described it as
money that you pick up on the street. The notion of
“free money” or “luck money” yielded two possibilities
among participants. For most, free money was supposed
to be saved or spent wisely on necessary items, and for a
few, it was to be spent randomly and not carefully
planned for.

The meaning of CTs for adolescents
Financial autonomy
One of the most prominent themes cited by the adoles-
cent boys and girls in this study was the sense of economic
independence that they experienced upon receiving CTs.
P43 (male, unconditional) remarked: “I felt great because
it made me more independent.” Likewise, P34 (female, un-
conditional) stated: “… it taught us how to be independent,

and not to rely on boys.” Adolescents described CTs as
helpful, convenient, and providing access to resources that
they needed. “We need clothes; some of us use make-up,
and we may need money to party with our friends; so,
sometimes our parents can’t afford to give us money.” (P4,
female, clinic). Therefore, the cash provided them with re-
sources that they would not otherwise have accessed.
Before the intervention, adolescents depended on their

parents and family members, and some girls relied on
their sexual partners for financial support. For most par-
ticipants, this was stressful and caused conflicts, particu-
larly in instances where funds were insufficient. When
asked to describe her family relationships while receiving
the CT, P38 (female, school), who lived with her sister
responded: “There are no [conflicts], because I don’t ask
her [sister] for money. Sometimes ... you see, sometimes
it’s bad when you start asking for money from people. If
you don’t [ask] it’s okay.”
Participants recognized the financial constraints faced

by their parents, who were mostly single parents and
held informal jobs or ran small businesses. Hence, they
were mindful of putting extra financial pressure on their
parents. Receipt of CTs lessened financial demands on
participants’ parents. Moreover, to some extent, CTs
provided resources that parents would have had to pay
for; this meant that they could focus on other competing
domestic needs, as the extract below indicates:

“It was one less stress for her. She was not worried
about the matric dance anymore … She wasn’t going
to be paying for it anymore. Because she was already
worried about buying the books.” (P26, male,
unconditional)

Feeling independent and responsible enhanced partici-
pants’ self-esteem and decision making, as P4 noted: “It
[CT] boosted many young peoples’ confidence by showing
them that they can do things on their own without asking
for help or working hard.” CTs seemingly offered adoles-
cents choices, including choices about their behavior.
Some of the girls spoke about how receipt of CTs chan-
ged their behavior. P35, a young woman who received
school-conditional payments, reported that, before the
intervention, she counted on her boyfriend for financial
support, since her mother was unemployed. As a way of
showing appreciation to her boyfriend, she felt pressured
to have sex with him. When she received CTs, she did
not ask her boyfriend for money because she could
support herself. She decided not to have sex with her
boyfriend. She said:

“It helped me because I didn’t have to sleep with my
boyfriend when I asked him for money … No, he
never forced me to have sex with him, but I know

Khoza et al. BMC Public Health  (2018) 18:120 Page 7 of 11



that it makes him happy, you know … he said that if I
want him to make me happy, then I must also make
him happy.”

P35 continued to do things for herself, even after the
intervention; she found part-time employment. Similarly,
P1 stopped having multiple relationships and dating
older men for financial support, and remained with one
partner.

“The first one was the cash I received because it
helped me stop doing many things that I used to do
to get cash … Like dating older men, who usually gave
me money to buy myself things.” (P1, female, school)

Cash management skills
Adolescents spoke about the gains that they had made
from their involvement in the program. The majority
mentioned that day-to-day administration of CTs
equipped them with financial management skills. These
skills included drawing up a budget, saving, and making
independent financial decisions. “It taught me things ...
like, I can now budget for my money appropriately and
know when to spend on the right things ...” (P11, female,
unconditional). Some participants reported saving their
transfers over a short-term period for essential purchases
or for an event that they wanted to attend. Participants
felt in “control” and “responsible.” Some reported that
had become open-minded, could help others, and had
gained self-confidence.

Developments after the intervention
Most adolescents, particularly those who had received a
once-off single payment, reported that everything
remained the same as it was prior to the program, stat-
ing that they knew that receipt of CTs was temporary.
“Nothing [changed]… I knew that I was going to get it
once. It was like picking up money; you never know you
are going to be lucky enough to pick it up again…” (P21,
male, clinic). Adolescents of both genders in the school
and unconditional arm felt that a valuable resource had
been taken away and that they are back to where they
had started, relying on other people. This was stressful,
as they had grown accustomed to having their own
money and doing things for themselves, as the quotation
below illustrates:

“Right now, everything that I come across that has to
do with finances, I have to ask my parents, and
sometimes this is difficult because they have their own
things to pay for. So, I can say that my life has now
changed, since I don’t have that money. Yeah, I can
say that it went back to where I started. I’m used to

having money I made myself.” (P40, male,
unconditional)

Receipt of CTs appears to have somewhat compelled
adolescent boys to earn an income. Two male partici-
pants reported that after the intervention, they saw a
need to find employment, so as to meet their personal
and families’ needs.

“I have to hustle to get money … When in the study,
there was no need. But when the money stopped,
there was a need because I still had those needs; so, I
had to get more money to patch up that empty
space.” (P28, male, unconditional)

The end of the CT program made a few of the boys
think of easy ways of making money, such as engaging
in criminal activities. However, only one criminal inci-
dent was reported.

“Money is an addiction for some people; so, the less
they had, the more they wanted. Some had to try and
steal other peoples’ goods to get the money for
whatever they had to buy. I remember there was an
incident by one person that stopped receiving the
money; he mugged someone, took the person’s phone,
and sold it to get money.”

One male participant (P45, male, school) reported that
he was used to getting easy cash, money that he did not
work for; so, after the program ended, he considered en-
gaging in criminal activities to get quick cash without
putting in much effort. It also appears that such
thoughts and frustrations were experienced mostly by
those who were neither in school nor employed after the
program.

Discussion
This qualitative study of CTs in a low-resourced, inner-
city neighborhood explored adolescent recipients’ expe-
riences and meanings of CTs. It also provides insight
into adolescents’ spending patterns and outcomes after
cessation of the CT program. This is important, as often
long term outcomes after cessation of research studies
are not known.
In our study context, CTs mostly generated positive

experiences and meanings when transfers were offered
directly to adolescents of both genders. Specific benefits
included a sense of independence, financial freedom,
and social growth; these attributes form a crucial com-
ponent of adolescents’ development, as related to the
transition from childhood to adulthood [29]. In low-
middle income households, it is not always feasible for
families to meet some adolescents’ needs, as these may

Khoza et al. BMC Public Health  (2018) 18:120 Page 8 of 11



be regarded as luxuries, in comparison to other compet-
ing household essentials. In our study, CTs enabled ado-
lescents to purchase necessities such as toiletries,
clothes, airtime, and make-up, and to pay for entertain-
ment. CTs enhanced their financial stability and enabled
them to participate in social and economic groups,
thereby boosting their self-esteem. Increased self-
confidence, autonomy, and decision-making among CT
recipients influence women’s decisions to engage in pro-
tective sexual behavior [30, 31].
Most studies have shown that CTs offered to par-

ents/guardians improved children’s outcomes [32].
However, we hypothesized that when beneficiaries are
adolescents, the impact and outcomes may differ, as
do adolescents’ needs from those of caregivers, result-
ing in adolescents using the money differently. In our
study context, adolescents generally controlled the
CTs and made decisions regarding expenditure; how-
ever, we observed some notable gender differences re-
garding these decisions. Boys were inclined to make
independent decisions regarding expenditure, whereas
girls discussed their expenditure plans with close fam-
ily members; this is consistent with studies of adult
women [33]. The extent of the independence with
which adolescents made spending decisions might
have influenced their spending and saving patterns.
Although boys and girls generally spent the transfers
in a similar manner, we observed some gender
differences. Boys’ expenses reflected a concern with
maintaining a social identity —to fit in with their
peers— they were more likely to buy expensive cloth-
ing and spent the cash on socializing. These findings
complement other research that found CTs enhanced
men’s social status [34]. On the contrary, girls’ spend-
ing was more likely to reflect concern for domestic
affairs and provision of support to other household
members. This finding supports evidence showing
that transfers directed to women tend to benefit the
household and support family members.
While the adolescents in our study mostly reported

positive expenditure; it is important to consider the
implications of their expenditures in the local context.
Research has shown high levels of alcohol consumption
among young South African men [35]; thus, entertain-
ment and socialization are likely to involve alcohol con-
sumption by adolescent boys. Alcohol may not always
elicit antisocial behavior; in fact, in some instances—as
in our study—it enhanced men’s social status in the
community; however, research shows that alcohol in-
creases violence and the risk of HIV infection [36]. In
our study, the issue of alcohol was raised by adolescents,
as they spoke of friends or acquaintances who had spent
CTs on alcohol. However, this did not emerge in the
quantitative data, and only two young men reported

personal use of CTs on alcohol. Additionally, regarding
adolescent girls’ spending on domestic affairs, some
argue that targeting women as beneficiaries of CT pro-
grams may perpetuate traditional gender roles, adding to
the existing domestic responsibilities that women already
carry [37].
The sustainability of the CT program’s effects after

the program’s cessation remains questionable. In our
study, the benefits to adolescents’ appeared to be
short–lived, as they reverted to old behaviors and
relying on their parents; this was probably because of
the short intervention period. In a few instances, the
intervention introduced pressure to earn money, par-
ticularly among boys. Pressure to make money may
be either a positive or an adverse outcome; positive
in the sense that, after the program had ended, some
adolescents had also completed schooling, so they
had found employment to sustain themselves. How-
ever, for others, the program created a need to make
easy money, and could lead to committing crime as
reported by two participants.
The experience of the program and its processes,

conditionalities, cash delivery strategies, and the grant
size were acceptable to the majority of boys and girls.
Our findings show that conditionalities based on rou-
tine activities such as school attendance was not felt,
since they do not require additional effort, unlike if
unusual or dreaded activities had been set as condi-
tions. However, if conditions include activities that
adolescents consider necessary (i.e., knowing one’s
health status), then CTs are more likely to encourage
uptake of the dreaded service. Contradictory to other
studies that reported jealousy and tension between re-
cipients of CTs and participants in the control group
[38], no adverse outcomes for social relationships
were reported in our study. This could be because we
conducted the project in a limited number of schools,
and not many people in the participants’ neighbor-
hoods knew about the study. Moreover, all partici-
pants in the trial received transfers.

Study limitations
This study was not without limitations. We acknow-
ledge that interviewing a different set of individuals at
12 months follow-up limited the depth of understand-
ing of individual experiences. Participants provided
self-reports on how the transfers were used; thus,
there is potential for bias in their reports of their
spending patterns, with the possibility that responses
perceived as desirable were provided. For example,
although the majority of participants in the school
condition reported positive outcomes we cannot rule
out the potential social desirability bias particularly

Khoza et al. BMC Public Health  (2018) 18:120 Page 9 of 11



because the findings from the main trial indicate that
participants in the school conditioned study arm were
more likely to miss school.

Conclusion
Our findings demonstrate that from the perspective of
young men and women, adolescent-directed CT pro-
grams are acceptable and benefit individuals as well as
households in low-resourced urban environments. They
instill a sense of agency and responsibility in adolescents,
facilitating transition to adulthood. The gender differ-
ences in adolescents’ spending decisions and expenditure
regarding CTs are worth noting. Spending on domestic
domains in girls and public domain in boys show that
CTs could potentially reaffirm traditional gender norms
in this population. Program implementers need to take
this into consideration, and think strategically about
targeting adolescent girls with the provision of CTs.
However, we also recommend that boys be considered
for CT programs. Despite no data being available on the
effects of CTs on HIV prevalence or incidences among
males, access to transfers contributes towards their
psychosocial development, although this needs to be
balanced against the risks of expenditure on alcohol and
alternative money-making strategies that could lead to
consideration of criminal activities when the CT pro-
gram ends. These, however, require further exploration.
These findings provide additional insights to studies that
highlight the importance of adding more supplemental
funds to the already existing social grants for vulnerable
children in South Africa.

Abbreviations
ART: Antiretroviral therapy; CCT: Conditional Cash Transfer; CT: Cash transfer;
PMTCT: Prevention of mother-to-child transmission; RCT: Randomized
Controlled Trial; UNDP: United Nations Development Program

Acknowledgements
We are grateful to all the adolescent girls and boys who agreed to take part
in this study. We also thank the project team: Mmarashia Beleng, Lawrence
Mashimbye, Henry Moultrie, Emilie Venables for implementation, monitoring
of research and data collection. The Youth Community Advisory Board
(YCAB) members. John Imrie, Maria Cabrera, Moira Beery provided comments
on final draft manuscript.

Funding
This project was funded by UKaid USAID- GHH-I-00-07-00032-00. NK, SD, and
JS were supported in part by UKaid from the Department for International
Development (DfID) through the STRIVE Research Programme Consortium
(Ref: Po 5244). The analysis and write-up of this research was also supported
by the Consortium for Advanced Research Training in Africa (CARTA). CARTA
is jointly led by the African Population and Health Research Center and the
University of the Witwatersrand and funded by the Wellcome Trust (UK)
(Grant No: 087547/Z/08/Z), the Carnegie Corporation of the New York (Grant
No—B 8606.R02, Sida (Grant No: 54100029). However, the statements made
and views expressed do not necessarily reflect the department’s official
policies; they are solely the responsibility of the fellow.

Availability of data and materials
All audiotapes and transcripts of interviews are stored at Wits Reproductive
Health and HIV Institute, South Africa. They are available from the study
corresponding author on reasonable request.

Authors’ contributions
The study was designed by SDM and HB. Data was analyzed and interpreted
by NK and JS, with help from CM and SMD. NK prepared the first draft, and
all co-authors provided input and assisted in finalizing the manuscript. All
authors read and approved the final manuscript.

Ethics approval and consent to participate
This study was approved by the Human Research Ethics Committee of the
University of the Witwatersrand and the John Hopkins School of Public Health.
The study involved human subjects, they all provided written consent and
assent. For participants <18 years, we obtained parental written consent before
seeking participant assent. All participants were reimbursed 100 ZAR.

Consent for publication
During consent/assent for interviews, participants provided permission for
their interviews to be published verbatim, but were assured that their
identity would remain confidential.

Competing interests
The authors declare that they have no competing interests.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.

Author details
1Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health
Sciences, School of Clinical Medicine, University of the Witwatersrand,
Johannesburg, South Africa. 2School of Health and Society, University of
Wollongong, Wollongong, NSW, Australia. 3Department of Population
Reproductive and Family Health, John Hopkins Bloomberg School of Public
Health, Baltimore, USA.

Received: 20 February 2017 Accepted: 3 January 2018

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http://www.cashlearning.org/downloads/undp-cash-transfers-and-hiv-prevention-web-final.pdf
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https://www.concern.net/sites/default/files/resource/2011/05/cash_transfers_in_gender_relations.pdf

	Abstract
	Background
	Methods
	Results
	Conclusion

	Background
	Methods
	Study population and setting
	Study design
	Sample and data collection procedures
	Data analysis

	Results
	Socio-demographic characteristics
	Experiences of the CT intervention
	Experiences of the CT conditionalities
	The size and frequency of the CT payment
	The payment method

	Patterns of spending CTs
	The meaning of CTs for adolescents
	Financial autonomy
	Cash management skills

	Developments after the intervention

	Discussion
	Study limitations

	Conclusion
	Abbreviations
	Funding
	Availability of data and materials
	Authors’ contributions
	Ethics approval and consent to participate
	Consent for publication
	Competing interests
	Publisher’s Note
	Author details
	References