# Using a cash transfer plus SMS nudge package to improve the wellbeing among caregivers of adolescents living with HIV during the COVID-19 epidemic in South Africa: A pilot randomised controlled trial

## TL;DR

A pilot study in South Africa tested cash transfers and SMS messages to improve wellbeing of caregivers of HIV-positive adolescents during the pandemic.

## Contribution

This study is the first to pilot a combined cash transfer and SMS nudge intervention for caregivers of HIV-positive adolescents in sub-Saharan Africa.

## Key findings

- The intervention showed a reduction in caregiver burden and depressive symptoms, though changes in psychological wellbeing were not statistically significant.
- High retention and uptake rates suggest the intervention is feasible and acceptable to participants.
- The total societal cost of the intervention was US$13,549 with an incremental cost per wellbeing score increase of US$1,080.

## Abstract

Caregivers of adolescents living with HIV encounter multiple economic and psycho-social challenges which impair their wellbeing and provision of optimal care. Cash transfers combined with short message service (SMS) nudges may address the financial and mental barriers to caregiver wellbeing in sub-Saharan Africa. We examined the preliminary effectiveness and feasibility outcomes of this multipronged approach for improving caregiver wellbeing. We piloted the Caregiver Wellbeing intervention in the eThekwini municipality, KwaZulu-Natal, South Africa. Participants were randomly assigned to one of the following groups: (i) the intervention arm (n = 50) received three cash payments (of ZAR 350, approximately 21 USD), coupled with behaviourally-informed mobile SMS nudges over a 3-month period; (ii) the control arm (n = 50) received a standard SMS encouraging linkage to health services. The primary outcome was change in psychological wellbeing at four-months follow-up. Secondary outcomes were changes in depressive symptoms and caregiver burden scores, recruitment pace, retention, uptake, acceptability and costs. Trial Registraion Number: PACTR202203585402090. The n = 100 caregivers (mean age = 42.3 years, 87% female) enrolled at baseline were recruited within six weeks. Compared to controls, there was a non-significant increase in psychological wellbeing (β = 3.14, p = 0.319). There was a 1.32 unit (p = 0.085) decrease in depressive symptoms and a reduction in caregiver burden (β = -1.28, p = 0.020) in the intervention arm. Participant retention was 85%, with high intervention uptake (95%). Caregivers expressed appreciation for the intervention as the cash component allowed them to fulfil their carer responsibilities and the SMS brought a sense of belonging and self-acceptance. Total societal cost of the intervention was US$13,549, and the incremental cost per increase in wellbeing score was US$1,080. Results suggest a cash transfer plus SMS nudge package, whilst feasible and acceptable, may require longer duration and an economic empowerment component to enhance caregiver wellbeing as part of post-pandemic recovery efforts.