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      Effect of a Prize-Linked Savings Intervention on Savings and Healthy Behaviors Among Men in Kenya : A Randomized Clinical Trial

      , ScD , 1 , 2 , , PhD 3 , , PhD 1 , 2

      JAMA Network Open

      American Medical Association

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          Key Points

          Question

          Do prize-linked savings accounts lead to increased savings and reduced spending on alcohol, gambling, and transactional sex among men in Kenya?

          Findings

          In this randomized clinical trial of 300 men, 37.3% who received a prize-linked savings intervention saved money in a bank account compared with 27.2% in the control group, although the difference was not significant. There were no significant differences in expenditures on alcohol, gambling, and transactional sex.

          Meaning

          Prize-linked savings interventions can increase savings among men but did not significantly differ from standard-interest savings accounts; more evidence is needed on their potential for reducing spending on risk behaviors.

          Abstract

          This randomized clinical trial evaluates the effect of prize-linked savings accounts, compared with standard-interest savings accounts, on savings behavior and expenditures on alcohol, gambling, and transactional sex among men in Kenya.

          Abstract

          Importance

          Interventions to reduce men’s alcohol use and risky sexual behaviors are essential for reducing new HIV infections in high-prevalence settings in sub-Saharan Africa. Prize-linked savings accounts can motivate savings and may decrease expenditures on risky behaviors, but few studies have examined the HIV prevention potential of such savings interventions among men.

          Objective

          To evaluate the effect of prize-linked savings accounts on savings behavior and expenditures on alcohol, gambling, and transactional sex among men in Kenya.

          Design, Setting, and Participants

          Randomized clinical trial among communities in Siaya County, Kenya. Participants were men 21 years or older who owned a mobile phone, were engaged in fishing or transportation sector work, and were willing to open an account with a local bank; they were screened for eligibility between September 3 and October 5, 2018.

          Interventions

          Eligible participants were offered savings accounts endowed with 1000 Kenya shillings (US $10) and randomized (1:1) to receive weekly lottery-based rewards contingent on growth in savings balance or to a control group that received standard interest.

          Main Outcomes and Measures

          The primary outcome was an indicator of whether a participant saved any money in the bank account (intent-to-treat analysis) during the study period. Secondary outcomes included total amount saved in the bank account, total amount saved in all sources, and expenditures on alcohol, gambling, and transactional sex.

          Results

          A total of 425 men were screened, 329 (77.4%) met eligibility criteria, 300 (70.6%) were enrolled (with 152 randomized to the intervention group and 148 to the control group), and 270 of 300 (90.0%) opened bank accounts. Participants’ mean age was 33.7 years (interquartile range, 13.5 years), 84.3% (253 of 300) were married, and the mean weekly earnings were US $30 (interquartile range, US $23). During a mean (SD) follow-up of 9 (2) weeks, 37.3% (50 of 134) in the intervention group saved money in a bank account vs 27.2% (37 of 136) in the control group, although the difference was not statistically significant (odds ratio, 1.62; 95% CI, 0.96-2.74). The intervention group had higher growth in bank savings balances (US $10.26; 95% CI, US $5.00-US $58.20 vs US $4.87; 95% CI, US $0.67-US $9.00) and higher total savings from all sources (US $201; 95% CI, US $133-US $269 vs US $145; 95% CI, US $88-US $202), but neither difference was statistically significant. The intervention did not have a significant effect on alcohol, gambling, and transactional sex expenditures.

          Conclusions and Relevance

          Prize-linked savings accounts modestly increased savings among high-risk men in Kenya over a 9-week period, but the difference compared with standard-interest savings accounts was not significant. Testing of more powerful savings products is needed to assess whether such savings-led interventions can reduce men’s expenditures on alcohol, gambling, and transactional sex.

          Trial Registration

          Social Science Registry identifier: AEARCTR-0003224, and ClinicalTrials.gov identifier: NCT04013295

          Related collections

          Most cited references 11

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          HIV/AIDS in fishing communities: challenges to delivering antiretroviral therapy to vulnerable groups.

          Fishing communities have been identified as among the highest-risk groups for HIV infection in countries with high overall rates of HIV/AIDS prevalence. Vulnerability to HIV/AIDS stems from, the time fishers and fish traders spend away from home, their access to cash income, their demographic profile, the ready availability of commercial sex in fishing ports and the sub-cultures of risk taking and hyper-masculinity in fishermen. The subordinate economic and social position of women in many fishing communities makes them even more vulnerable to infection. In this paper we review the available literature to assess the social, economic and cultural factors that shape many fisherfolks' life-styles and that make them both vulnerable to infection and difficult to reach with anti-retroviral therapy and continued prevention efforts. We conclude from the available evidence that fisherfolk will be among those untouched by planned initiatives to increase access to anti-retroviral therapies in the coming years; a conclusion that might apply to other groups with similar socio-economic and sub-cultural attributes, such as other seafarers, and migrant-workers including small-scale miners, and construction workers.
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            Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions.

            Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.
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              The treatment effect, the cross difference, and the interaction term in nonlinear “difference-in-differences” models

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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                13 September 2019
                September 2019
                13 September 2019
                : 2
                : 9
                Affiliations
                [1 ]Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
                [2 ]Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
                [3 ]Impact Research and Development Organization, Kisumu, Kenya
                Author notes
                Article Information
                Accepted for Publication:
                Published:10.1001/jamanetworkopen.2019.11162
                Open Access: CC-BY License JAMA Network Open
                Corresponding Author: Ellen Moscoe, ScD, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, 1123 Blockley Hall, Philadelphia, PA 19104 ( ellen.moscoe@ 123456pennmedicine.upenn.edu ).
                Author Contributions:
                Concept and design:
                Acquisition, analysis, or interpretation of data:
                Drafting of the manuscript:
                Critical revision of the manuscript for important intellectual content:
                Statistical analysis:
                Obtained funding:
                Administrative, technical, or material support:
                Supervision:
                Conflict of Interest Disclosures:
                Funding/Support:
                Role of the Funder/Sponsor:
                Disclaimer:
                Data Sharing Statement: Supplement 3
                Article
                zoi190439
                10.1001/jamanetworkopen.2019.11162
                6745050
                31517964
                Copyright 2019 Moscoe E et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                Categories
                Research
                Original Investigation
                Online Only
                Global Health

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