“The Sky is the Limit; I am Going There”: Experiences of Hope Among Young Women Receiving a Conditional Cash Transfer in Rural South Africa Kaitlyn Atkinsa,b, Catherine MacPhailc,d,e, Suzanne Mamana, Nomhle Khozae, Rhian Twined, F. Xavier G-Olived, Audrey Pettiford,f,g, Kathleen Kahndh aDepartment of Health Behavior, University of North Carolina, Chapel Hill, NC, USA bSocial and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg, School of Public Health, Baltimore, MD, USA cSchool of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia dMRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa eWits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa fCarolina Population Center, University of North Carolina, Chapel Hill, NC, USA gDepartment of Epidemiology, University of North Carolina, Chapel Hill, NC, USA hUmeå Centre for Global Health Research, Umeå University, Umeå, Sweden Abstract Young women in South Africa face elevated risk of HIV infection compared with male peers. Cash transfers may mitigate their risk for HIV; however, there is limited understanding of mechanisms of impact. We explored hope as one potential mechanism. Longitudinal qualitative analysis was used to explore how cash transfer recipients in the HPTN 068 study conceptualised hope and how the intervention influenced their hope over time. We found that the intervention increased confidence, alleviated financial stressors and instilled in young women the belief that a better life, defined as being educated, independent and supportive to family, was attainable. Findings support hope as a critical outcome of cash transfer and other economic strengthening interventions. Keywords HIV prevention; young women; poverty; South Africa; hope Corresponding Author: Kaitlyn Atkins kait.atkins@jhu.edu. Conflicts of interest None to declare. HHS Public Access Author manuscript Cult Health Sex. Author manuscript; available in PMC 2023 August 01. Published in final edited form as: Cult Health Sex. 2022 August ; 24(8): 1077–1091. doi:10.1080/13691058.2021.1919315. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript Introduction Throughout sub-Saharan Africa, adolescent girls and young women (hereafter young women) are at increased risk for HIV (UNAIDS 2019). In South Africa, young women aged 15–24 years are infected by HIV at four times the rate of their male peers (HSRC 2018; Maughan-Brown Evans, and George 2016; Maughan-Brown, Kenyon and Lurie 2014). Along with biological vulnerabilities, they face increased risk from relational factors, such as intergenerational sex, transactional sex and violence (Maughan-Brown, Kenyon and Lurie 2014; Dunkle et al. 2004; Townsend et al. 2011; Kilburn et al. 2018); along with structural factors such as poverty and gender inequality (UNAIDS 2019). Cash transfers can socially and economically strengthen young women and thus mitigate their risk for HIV (Saul et al. 2018; Pettifor et al. 2012; Swann 2018). Evidence suggests that cash transfers, both as a standalone intervention and in combination with other interventions, can reduce HIV risk behaviour and violence (Swann 2018). Specifically, they may reduce transactional and intergenerational sex and delay sexual debut (Stoner et al. 2019; Pettifor et al. 2019; de Walque et al. 2012; Wamoyi et al. 2016). However, evidence remains sparse around the specific mechanisms through which cash transfers influence behaviours and subsequent HIV risk. Understanding this is critical to inform where and how to most effectively implement cash transfer for HIV prevention (Pettifor et al. 2012; Heise et al. 2013). One mechanism through which cash transfers may influence HIV risk is by changing young women’s experiences of hope. Hope is a positive outcome expectancy that is believed to motivate individual behaviour, related to both concrete and abstract future expectations (Snyder 1994, 1995). In HIV treatment, hope has been associated with coping, retention and improved quality of life (Bernays, Rhodes and Barnett 2007; Rhodes, Bernays and Terzic 2009). For HIV prevention, hope may mediate the relationship between environmental risk factors and HIV (Barnett et al. 2015; Barnett & Weston 2008). Environmental conditions, such as poverty, can influence hope and value of the future, which may impact behaviour and HIV transmission (Bernays, Rhodes and Barnett 2007). Interventions which alter environmental conditions, such as cash transfers, may strengthen hope and thus increase HIV preventive behaviours. Understanding this relationship can inform appropriate intervention targeting. To measure hope among young women in South Africa, Abler et al. (2017) identified three possible quantitative domains of hope in this context: anticipation of a positive future, personal motivation to achieve goals, and influence of others on hope. Our qualitative findings similarly showed these as meaningful drivers of hope for this population. Here, we explore these domains to understand how hope is experienced by young women in receipt of cash transfers in South Africa. Atkins et al. Page 2 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript Methods Study Setting and Sample This analysis was embedded in an individually randomised, phase III conditional cash transfer trial in rural South Africa (HPTN 068, or Swa Koteka; Pettifor et al. 2016). The study took place in Mpumalanga, an area close to the Mozambique border which is characterised by poverty, low-quality education and limited employment (Houle et al. 2013; Kahn et al. 2012; Kahn et al. 2007; Collinson 2010; Collinson, Tollman and Kahn 2007). Many residents are the beneficiaries of state-sponsored, non-contributory social grants (Schatz et al. 2011). Participants were identified through the Agincourt Health and Socio-Demographic Surveillance System, run by the Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt). Young women were eligible for the main trial if they were aged 13 to 20 years, resided in the study site, were enrolled in grades 8–11 at site high schools, had a bank or post office account (or the ability to open one), and a caregiver was willing to consent who also had a bank or post office account. Cash was conditional on school attendance; participants in the intervention arm who attended 80% of school days in a given month received 100 Rand (~12 USD), and their caregivers received 200 Rand (~24 USD), deposited into their respective bank accounts. Participants were excluded if they reported being pregnant or married at baseline (Pettifor et al. 2016). Data Collection This qualitative study used a combination of focus group discussions with young women, young men and teachers; in-depth interviews (IDIs) with young women; and IDIs with household members (e.g. parents). Young women were purposively recruited for IDIs to ensure overrepresentation of those who were sexually active and reported transactional sex, both issues expected to be influenced by cash transfers. IDIs were conducted by trained female interviewers who were local residents, fluent xiTsonga speakers, and aged between 20 and 40. Participants were interviewed twice a year, up to six times. Each interview was conducted by the same interviewer to maintain rapport and to understand changing narratives and experiences over time. IDIs were recorded and were simultaneously translated and transcribed into English by the interviewer who conducted the interview. All transcripts were reviewed for accuracy, and a subset of 10% were reviewed against the original recording by the fieldwork manager (NK) for quality. A total of 39 young women completed qualitative interviews; because this analysis aimed to understand experiences receiving cash transfers, only young women in the intervention group were included in this analysis. Further, only those who had completed three or more IDIs were included, to assess changes over time. In total, 54 IDIs from 14 respondents were analysed, with an average of 3.38 IDIs per participant (Table 1) between May 2012 and June 2014. At their first IDIs, young women’s ages ranged from 14 to 20, most were in grades 10 or 11, and six were food insecure (Table 2). Atkins et al. Page 3 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript Analysis Analysis was led by the first and second authors. Coding involved two stages. First, topical codes were developed, based on topics covered in the guides. Then, the first author read each transcript and developed a narrative summary and timeline for each participant. These informed interpretive codes, which explored emergent hope-related themes, and in vivo codes, which were verbatim words or phrases used by participants (Saldaña 2015). After coding the data, we described themes. We used longitudinal analysis matrices (Grossoehme and Lipstein 2016) to visually depict themes over time, and to understand congruencies and contradictions within and across participants. We compared these matrices to assess similarities between participants’ experiences and expressions over time and contextualised them using narrative timelines. Throughout this process, we prepared detailed memos on emerging themes (Saldaña 2015). At each stage, we reread a selection of transcripts or narrative summaries to ensure findings reflected salient themes. Ethics Young women aged 18 and older provided written informed consent. For young women under age 18, we obtained written parental consent and assent from young women. Ethical approvals were provided by the University of North Carolina at Chapel Hill Institutional Review Board, the University of the Witwatersrand Human Research Ethics Committee, and the Mpumalanga Province Health Research Committee. Findings Our results are presented in line with the domains specified in Abler’s (2017) hope scale: anticipation of a positive future, personal motivation to achieve goals, and influence of others on hope. While respondents varied in their experiences of hope, they expressed a shared conceptualisation of it. This centred on change, including desired change and the belief that change was possible. Hope for participants meant a desire for “a better life,” involving confidence in the face of obstacles and plans to overcome those obstacles, even if plans fell outside the realm of obvious or historical possibility. Young women derived hope both from within and from others, including caregivers and siblings, who encouraged them to aspire for success beyond their own achievements, along with partners, friends and teachers. Anticipation of a Positive Future For young women in our sample, hope was related to a belief that, despite their past experiences, their futures would improve and they would attain “a better life” for themselves and their families. A “better life” included a career, money, health and a family. However, descriptions of “a better life” evolved differently over time. In early interviews, most young women described a tension between two goals: independence and self-reliance or interdependence, family and mutual support. In follow-up interviews, most participants had come to more strongly embrace one of these goals over the other. A few respondents shifted dynamically between these over time, but this was uncommon. For many participants, visions of “a better life” were influenced by participation in the cash transfer programme, Atkins et al. Page 4 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript which they felt encouraged them to be more self-reliant and to change their vision of the future. Independence: Reliance on Self Over time, some young women developed a strong desire for independence. In early interviews, they briefly mentioned independence, but in later interviews independence featured more prominently in discussions. For example, in her first interview, Ruth (age 15) expressed wanting both a career and “to have my family; stay with my husband.” During later interviews, Ruth still mentioned a family, but her discussions of the future focused more on career and education. She also made more frequent mention of material goals, including “a big house” and “an expensive car.” Respondents like Ruth repeatedly used the phrase “on my own” when describing how they saw their futures; for them, independence involved earning and spending their own money to support their life decisions. A few respondents with supportive partners saw their partners as a source of hope in encouraging their aspirations, but most young women in this group expressed a desire to be “free” from men. Some saw boys and men as a distraction from school and as a barrier to short-term achievements, such as passing annual school exams, but expressed a desire to marry in the future. For example, Sarah (age 16) wanted to get married someday, but during her fifth interview expressed being happily single, saying, “I will be disturbed when I involve myself [with boyfriends] … I’m supposed to be busy with my books.” For others, desired independence extended into the long-term, and men were seen as a threat to women’s well-being and that of their future children. This was common among women who had experienced or witnessed conflict with men in the past. Lesedi (age 18) described her father’s violence and later abandonment of her family: I don’t want to get married. I have noticed the life of my mother when she was living with my father … they were fighting and my father was not buying food in the family. Meanwhile my mother gave birth to children and then he decided to drop us. I think my mother told herself, ‘I want to live with my husband and we will die together,’ but now she is disappointed. From this, Lesedi said she came to value an independent future over a future relationship. Like Lesedi, many young women described “freedom” from men as key to financial independence. They described cash transfers as a way to achieve short-term financial independence, and a first step toward more substantial earnings in the long term. Financial independence was seen as a source of protection from harmful relationships or even from romantic relationships in general. These respondents frequently said their peers should be focused on education and career, rather than on romantic or sexual relationships. Interdependence: Value of Community In contrast to those who shifted toward a narrative of independence over time, around one quarter of the sample moved toward a focus on community and interdependence. While all respondents described wanting to remain close to their birth families (i.e. caregivers, siblings) to some extent, women in this second group more overtly emphasised success as Atkins et al. Page 5 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript being able to provide for birth families. They saw having and providing for a family or wider community as measures of their own success, rather than independence. In early interviews, the language used by these women mirrored that of others in the study, who expressed a desire to “help others,” “reach my goals,” and “feel happy” when describing priorities for the future. However, over time, women in this group expanded their outlooks to include children and marriage. Some, who in earlier interviews had said they hoped to relocate in the future, later said it would be better for their families if they stayed in their hometowns. This was sometimes prompted by family events, including new motherhood, financial hardship or death. For example, during her first interview, Ayanda (age 16) was focused on establishing her independence, saying, “I want to be a person that owns herself and do what I want in my time.” She described wanting to leave her hometown for “a better life” elsewhere. Immediately following that interview, her father passed away, and in her second interview, she said she planned to bring her mother and granny with her when she moved away. By her third interview, Ayanda had decided moving away in the future was not a good plan, saying “I am no longer wanting to live in Cape Town but I will still take care of [my mother]. I think is necessary to stay close with my family.” For participants like Ayanda, gaining independence was not a measure of success; instead, being able to provide care for families was viewed as successful and indicative of having sufficient resources. While Ayanda’s hope trajectory was influenced by a major life event, not all women shared such experiences. For some, a growing desire for community and family rather than independence was motivated by the realisation that, as recipients of the cash transfers, they were in a position to better care for their birth (caregivers, siblings) and future (spouses, children) families. Two participants in the study, Precious (age 16) and Iminathi (age 17), were mothers. Both young women, during their early interviews, emphasised their hope to achieve independence as a marker of future success. Iminathi, during her first interview, stated that her goal in the future was to have “the job that I like in the future and be able to have enough money to buy what I want.” In later interviews, both Precious and Iminathi expressed continued hope for achievement in their education and careers, but more greatly emphasised marriage and family as measures of success. Iminathi, during her third interview, described the need to “be responsible” and rely on her partner to care for their child and future family. Swa Koteka: A “Sky is the Limit” Mentality Respondents in both groups indicated that cash transfers changed their perspective on life, and that receiving cash transfer funds made them feel trustworthy and successful. For these participants, being part of Swa Koteka reinforced the idea that “a better life” was not only attainable but was better than they had previously imagined. In her first interview, when asked how her dreams had changed since joining the programme, Margaret (age 16) said she had a new sense of optimism. She expressed feeling that “the sky is the limit, I am going there,” later saying that “nothing can stop me” and “I have hope in everything that I am doing.” Other participants similarly described how, before joining the programme, they felt “unable to reach” their goals, but now felt empowered and confident as cash transfers Atkins et al. Page 6 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript opened doors to future savings and relieved smaller, daily financial stressors. Mia (age 15) said during her first interview: Since I started to get the money from Swa Koteka I have confidence in everything … I have registered an ID book with the Swa Koteka money, honestly I feel great about getting the money. In the past I was feeling like I’m down when I’m with my friends ... I was uncomfortable about myself. [Now] when the other young women buy something at school I also buy because I do have money. She described how the cash allowed her to purchase new clothes and bring pocket money to school, which made her feel more confident around her friends. She also used the funds to obtain her national identity document, which gave her easier access to higher education, social grants and other services to facilitate future goals. Like Mia, other respondents emphasised how the cash gave them confidence and inspired them to pursue new goals. For many, these were opportunities their older family members had limited access to, such as higher education. Grace (age 16) discussed saving the cash transfer money during her first interview, saying that “it can help me to reach my goals as I will use it to further my studies.” Others discussed how the cash helped them better manage their current education by purchasing school uniforms or food at school, as well as smaller items such as cosmetics which improved their social standing at school. Some young women were inspired by the cash to see themselves as household providers. Many expressed feeling relieved not to have to ask family members or partners for money, particularly if their home finances were strained. This reduction in financial stress promoted hope by helping participants perceive savings as more attainable. Some participants, like Grace, discussed saving toward education as a way to ensure future independence. Others, like Ayanda, whose father had passed away between interviews, discussed saving as a way to not only take care of themselves but of others. While few respondents discussed actually saving the money, they said that having that option gave them confidence in their ability to be prepared for the future. Personal Motivation to Achieve Goals For most respondents, a key element of hope was feeling motivated to achieve goals, taking concrete steps to achieve them, and remembering what achievement would bring themselves and their communities. Young women saw education as a key step toward achieving “a better life” and actualising their goals. As they strived to achieve this, they were motivated by an overarching desire to help others and to fulfil a sense of obligation to family and community. Respondents described hope for the future as action-oriented and mentioned education as a way of enacting hope. This involved both committing to their present studies and not giving up in the face of academic or related challenges, but also pursuing higher education in the future. Many respondents expressed a desire to be around people who were similarly interested in education, rather than those engaged in so-called “bad behaviour” like dating men or going to taverns. Some women expressed disdain for their peers who were less Atkins et al. Page 7 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript focused on education, associating “bad behaviour” in the present with giving up on the possibility of “a better life.” During initial interviews, we asked young women to describe their goals and aspirations for the future. Most participants described these goals in a specific order: finish high school, pursue higher education, and start a family through marriage and childbearing. For these women, education was an important step and precursor to other important milestones. For example, Liyana (age 14) described her goals in sequence, saying in her first interview, “I want to finish grade 12 and pass with exemption and go to university. I want to study medicine because I want to be a doctor. I will have everything I need … [Then] I want to get married and have children.” For Liyana, completing school was a first step that would prepare her to achieve her family-related goals. Some respondents experienced challenges at school over the course of the study, failing a grade level or struggling with coursework. However, no participants dropped higher education from their list of priorities over time. Indeed, whether women saw themselves as seeking independence or interdependence in the future, all viewed education as the first step toward achieving “a better life.” Beyond their own education, young women wanted a future that involved helping others. They envisaged themselves overcoming obstacles to change their own lives, but also wanted to help their communities, caregivers, and, for some, their children. This mindset extended to career goals, and most participants in this study were interested in health and social service professions. When probed about their desire to work in these fields, respondents typically stated that they wanted to help people, specifically people living in poverty. Those who were interested in these fields tended not to change their career goals over time, whereas the few women who were interested in other fields, such as accounting, human resources, or law, tended to change their career goals over time. In addition to helping others in their communities, participants wanted to help their birth families, whether that involved caring for an ill family member or providing financial support to caregivers, who may have had fewer opportunities during apartheid in South Africa. Some participants, particularly those who were more interdependence-minded, also discussed wanting to provide for future children, and saw a direct association between their own higher education and their future children’s well-being. However, a few respondents also expressed a desire to care for their families in the future. For example, Lesedi (age 18), who lived with her mother and stepfather, attributed her own family’s “suffering” to her mother’s lack of education: “I think if I can be educated, it could be better for me. Even if I can get married, I don’t think a man could abuse me with my education. My children won’t be suffering. Look, my mother is not educated and that is why she is suffering.” While Lesedi was motivated to achieve future independence, she emphasised that achieving this goal would benefit not only herself but her family. Other participants echoed this desire to achieve a “better life” for the sake of their future children, whether achieved through a focus on self-reliance or through reliance on others. Atkins et al. Page 8 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript Influence of Others on Hope Beyond their own belief in “a better life” and motivation to achieve it, AGYW’s hope was influenced by others. Family members, caretakers, and friends played a critical role in how AGYW saw their future and whether they prioritised independence or interdependence. AGYW’s perspectives on their futures were highly reliant on their experiences or relationships with others; they often attributed changes in their visions for the future to changes in their family, encouragement or lack thereof, or exposure to people they viewed as good examples for the future. The primary driver of hope for respondents was support from others. This included both financial support (whereby participants received school money, supplies, mobile phone credit, and the like) and emotional support. Changes in financial support over time played a role in influencing hope; women whose families experienced financial losses or whose caregivers faced job instability often dwelt on financial barriers to their achievement and focused on a need to gain financial independence in order to achieve a better life. Emotional and instrumental support from family members regarding school also influenced respondents’ discussions of hope. Several young women described receiving assistance from family members (siblings, caregivers, and others) with homework or other educational issues. For example, Margaret (age 16) said her mother helped her find an outside tutor when she needed extra support with her studies, which motivated her to perform well in school. In her second interview, Margaret described receiving additional encouragement toward her education at school, where the headteacher noticed her academic performance: There is a school shop, so I was working there and I was also doing bookkeeping … Sometimes [the headmaster] asks me and comes with problems of his money and says to me give me a solution and what was surprising I gave him the solution … He also told my mom that I am brilliant. Although Margaret’s family was not saving money for her higher education, she opened a savings account and said she planned to save a portion of each cash transfer toward her university application fees. Receiving encouragement and emotional support from others in her community gave her confidence about the possibility of attending university and inspired her to take steps toward achieving that goal. For participants like Margaret, emotional support seemed to have a more meaningful influence on hope than financial support. For example, Lesedi (age 18), whose mother was actively engaged in her schooling by ensuring she attended and supervising her homework, said she felt positive about her future, despite her family’s financial challenges. When discussing her dream of being a social worker, she said, “That’s my future career; I will push until I get it … God will help me find someone who will assist with the payments.” Later in the interview, when probed about her positive outlook, she said, “I’m wishing myself the good things in life … whether life is difficult or not I accept it.” Like Lesedi and Margaret, participants who received support felt encouraged and hopeful about their futures. While the Swa Koteka intervention did not include any behaviour change or educational components, women often said the HIV counselling and testing during data collection Atkins et al. Page 9 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript further encouraged them to engage in “good behaviour.” For many, this played a larger role in their hope for the future than any financial gains from the cash transfer itself. Respondents expressed the desire to regularly test for HIV, use condoms, avoid boyfriends and attend school. Many attributed this desire to their participation in the intervention. Blessing (age 14) described this in her first interview: This study is helping me because it makes me not to misbehave because they give me the money. So, I don’t misbehave because they give me the money … I don’t have boyfriends because they will give me money. I don’t date because this study helps me because they give me money. In her second interview, Blessing again emphasised the benefit of avoiding romantic relationships, saying that “to be in a relationship it makes you not to concentrate on your studies.” By her fourth interview, Blessing had a boyfriend, but still felt the study was helping her to behave well, this time comparing herself to peers who had already had children. She said, “The good things [from the study] is … I don’t misbehave because I’ve never fallen pregnant. This study is still helping me.” Many respondents, like Blessing, named avoiding pregnancy as a “good behaviour” they felt was encouraged by the programme. Participants stated that both the cash itself and its conditionality on school attendance influenced this change. For example, in her first interview, Ayanda (age 16) suggested that involvement in the study had made education more desirable: Now people see things in a right way, and they wish to be educated and leave the fashion that when you get a child while still young is a style … People that are getting the money feel satisfied in life and they can do anything they want. So those that don’t get it [money], some of them are still doing bad things like to hang around with old men so they can get money. Actions taken by young women like Ayanda were, for nearly all participants, described as important ways to enact hope and prepare for “a better life.” The intervention, in combination with support received from others, played an important role in establishing this hope and encouraging participants to seek out a positive future. Discussion This analysis adds to the growing body of research about the mechanisms by which cash transfers influence HIV risk among young women in Sub-Saharan Africa. For participants in this study, hope involved anticipation of either self-reliance or mutual support from others, was motivated by education and the desire to help others, and was influenced by the support of friends and household members and by the cash transfer. One group of young women derived their hope first and foremost from themselves, and from their ability to overcome day-to-day challenges. For others, hope centred around families and communities. For these young women, receiving cash transfers was viewed not as a way to gain independence, but rather a way to provide for birth families and prepare for children in the future. Atkins et al. Page 10 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript In both groups, the cash transfers were said to foster hope. Though the transfer was a small amount, it enabled respondents to overcome daily challenges (including those related to buying school uniform, purchasing airtime, buying food, or providing for their children) and thus gain confidence in their ability to overcome larger challenges in the future. HPTN 068 quantitative findings demonstrated that, for young women in poor families, cash transfers increased hope for the future (Kilburn et al. 2019). This was not the case for participants who came from wealthier families. While respondents did not extensively discuss family wealth during IDIs, we did see that family support, including both financial and emotional forms of support, played a role in how participants experienced hope over time. The influence of families and broader networks on hope supports theory that poor environmental conditions, including social environment, can weaken hope, and that strong social environments can strengthen it (Snyder 1994; Bernays, Rhodes and Barnett 2007). When assessing outside influences, we found that contextual factors, including family circumstances and support, played an equal role in influencing hope to the cash transfer itself, if not a larger one. This aligns with recent findings from a study in Tanzania, where social support from family and programme mentors helped participants achieve their goals (Pettifor et al. 2019). Further, recent evidence from Nigeria (Ajayi and Somefun 2019) suggests that for some young women, family support may play a larger role than economic support in reducing key HIV risk behaviour such as transactional sex. As young women spent more time in the programme, and as they aged, many began to focus more on their own independence. Experiencing independence on a small scale helped participants believe that larger-scale independence, including through education, was possible. This is unsurprising, given the relative poverty experienced by many respondents (Kahn et al. 2012; Kahn et al. 2007; Collinson, Tollman and Kahn 2007). Importantly, while focus on independence was related to involvement in the Swa Koteka programme, it was likely also influenced by natural development that occurs in this period of young women’s lives (Pozuelo et al. 2020). A mixed-methods analysis of how women in Swa Koteka spent the cash transfer money found that the cash played a significant role in AGYW gaining not only financial independence, but developmental independence as well (MacPhail et al. 2017). The analysis also suggested that the impact of cash transfers may vary based on age; similar findings have been reported in Tanzania (Wamoyi et al. 2020). A smaller group of young women in our study more strongly maintained a value of supporting communities and families over time. This may reflect a natural shift in priorities as young women move toward adulthood, highlighting the importance of a developmental perspective when implementing cash transfer programmes (Pozuelo et al. 2020). It may also have been influenced by cultural norms, whereby it was expected that successful individuals, regardless of gender, would give financial support to their families and communities. These young women may have viewed supporting their families as a way of further asserting their agency in their communities. Indeed, respondents in this group described supporting their families as a key indicator of “a better life” in the future. However, respondents also discussed receiving support from family members, even those living in serious poverty or whose families dealt with job instability. This aligns with Atkins et al. Page 11 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript additional evidence from South Africa suggesting that, even in the face of great difficulty, families provide an important and expected level of security (Knight, Hosegood and Timaeus 2016). Furthermore, though household obligations have been made complex by political changes, migration and shifting family compositions, in South African contexts these obligations have been shown to play an important role in support, assistance and organisation of family resources (Knight, Hosegood and Timaeus 2016; Nkosi and Daniels 2007). Findings about how girls and young women envisioned a better life mirror evidence from other settings, where young people have been found to view education as a strategic accomplishment that will secure independent success in the future (Francis 2002; Senior and Chenhall 2008). Furthermore, our respondents were uniquely positioned as children of parents raised in the racially-determined constraints of apartheid in South Africa, which may have influenced their views that a better life was possible and that it was linked to educational attainment. The ability to save money was another source of confidence for young women in this study. Findings from a cash transfer programme in Tanzania have also highlighted the value of savings and savings groups as a way for young women to not only achieve financial stability, but exercise empowered financial decision-making and receive support (Wamoyi et al. 2020). However, other analyses have found that few women in Swa Koteka saved money from the cash transfers (MacPhail et al. 2017). Limitations This study has several limitations. This analysis was not included in the original study design. Because of this, IDIs did not include standard questions about hope, which may have influenced the extent to which the subject was discussed individually. Interviews were simultaneously transcribed and translated. While translators were fluent in both xiTsonga and English and rechecked transcripts, it is possible that some meaning was lost in this process. The sample was limited to school-going women, which limits generalisability. The sample was also limited to people with sufficient documentation to open a bank account. While some women in the study mentioned being able to obtain an identity card through the study, it is possible that poorer participants or those experiencing migration or housing instability may have been unable to enrol. Similarly, young women who did not have a present caregiver may have been excluded. Finally, young women may have felt the cash transfer programme encouraged education through its conditionality on school attendance, and thus they may have emphasised it more during interviews than they would have otherwise. Interviewer positionality may have influenced responses or even feelings of hopefulness, although interviewers did not interview participants they knew, in an attempt to limit this influence. Atkins et al. Page 12 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript Conclusion Study findings reveal how receiving cash transfers influenced hope among young women in rural South Africa by alleviating daily stressors, allowing aspirations for saving toward higher education, and increasing confidence and the desire for independence. Hope was highly reliant on contextual factors, especially family support and financial situation. Cash transfers may have varying impacts on girls and young women in different social and environmental contexts, which should be explored through additional research. Acknowledgements We are grateful to the young women who took part in this study, to the HPTN 068 team whose time and efforts made this work possible, and to Amanda Selin for her support to the study. Funding Overall support for the HIV Prevention Trials Network (HPTN) was provided by the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute of Mental Health, and the National Institute on Drug Abuse of the US National Institutes of Health (NIH) under Award Numbers UM1AI068619 (HPTN Leadership and Operations Center), UM1AI068617 (HPTN Statistical and Data Management Center), and UM1AI068613 (HPTN Laboratory Center). Additional funding was provided by the Division of Intramural Research at NIAID, and by the Carolina Population Center (Award Number 5R01MH087118). 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Pseudonym Times interviewed First year interviewed Last year interviewed Blessing 5 2012 2014 Mia 5 2012 2014 Ruth 5 2012 2014 Sarah 5 2012 2014 Grace 4 2012 2013 Precious 4 2012 2013 Amahle 4 2012 2014 Iminathi 4 2012 2014 Angel 3 2012 2013 Faith 3 2012 2013 Lesedi 3 2012 2013 Margaret 3 2012 2013 Ayanda 3 2013 2014 Liyani 3 2013 2014 Cult Health Sex. Author manuscript; available in PMC 2023 August 01. A uthor M anuscript A uthor M anuscript A uthor M anuscript A uthor M anuscript Atkins et al. Page 17 Table 2. Participant Characteristics at Baseline (n = 14) N or Median % or IQR Age 16 (15, 16) School Grade 9 1 7% 10 5 36% 11 8 57% 12 0 0% Household Size 1 to 5 6 43% 6 to 10 7 50% 10+ 1 7% Parents at Home Neither 3 21% Mother Only 9 64% Father Only 0 0% Both 2 14% Primary Caregiver Mother 11 79% Older Brother or Sister 1 7% Grandparents 1 7% Food Insecurity Yes 6 43% No 8 57% Cult Health Sex. Author manuscript; available in PMC 2023 August 01. Abstract Introduction Methods Study Setting and Sample Data Collection Analysis Ethics Findings Anticipation of a Positive Future Independence: Reliance on Self Interdependence: Value of Community Swa Koteka: A “Sky is the Limit” Mentality Personal Motivation to Achieve Goals Influence of Others on Hope Discussion Limitations Conclusion References Table 1. Table 2.