Evaluation of Services for Orphans and Vulnerable Youth in Botswana 3 ABSTRACT This evaluation—conducted by MEASURE Evaluation, a project funded by the United States Agency for International Development and the United States President’s Emergency Plan for AIDS Relief (PEPFAR)—aimed to understand how orphans and vulnerable children (OVC) programming by the Government of Botswana (GOB) and the PEPFAR-funded Botswana Comprehensive Care and Support for Orphans and Vulnerable Children (BCCOVC) project prepares older youth to be healthy, productive young adults. It examined the effect of services on the educational, economic, and health outcomes of older youth graduating from the programs. This mixed-methods evaluation was a one-time quasi-experimental study, with the intervention group receiving services from the BCCOVC project and the GOB and a comparison group receiving services from the GOB only. The primary outcomes were as follows: • Youth who sat for and passed the Botswana General Certificate of Secondary Education exam (i.e., received a score of 36 points or higher) in 2018 • Youth who had basic financial literacy • Youth who had an HIV test in the past 12 months and knew their test results The BCCOVC project had mixed success in improving HIV and health, economic strengthening, and education outcomes. It had some effect on HIV/health and economic strengthening outcomes but none on education outcomes. Qualitative data revealed youth perspectives around accessing HIV testing and treatment, awareness of gender-based violence, the importance of education, and economic challenges and aspirations. HIV-positive respondents reported that teen clubs provided support and improved adherence. Adolescent OVC are an important population to support as they transition to adulthood, and additional research is needed to understand how services reach them. 4 Evaluation of Services for Orphans and Vulnerable Youth in Botswana ACKNOWLEDGMENTS The evaluation team thanks several people and organizations for their support of and involvement in this study. We greatly appreciate the effort of the study participants: orphans and vulnerable youth and their caregivers; Project Concern International (PCI) staff and volunteers; local partner staff; and Department of Social Protection (DSP) employees. At the organizational level, we received support from the DSP in the Ministry of Local Government and Rural Development; the United States Agency for International Development (USAID) in Botswana and Washington, DC; the United States President’s Emergency Plan for AIDS Relief (PEPFAR); and PCI. This evaluation would not have been possible without the support of Ellen Kgatleng and Ookame Mokabathebe (local principal investigators, DSP); Malebogo Modiakgotla (DSP); Mosarwa Segwabe and Segametsi Dugs (local principal investigators, USAID/Botswana), Lily Asrat and Joshua Volle (USAID/Washington, DC); and Tsige Teferi, Mathabo Pule, and Watipa Gaogane (PCI). 5 AM Consultancy collected the quantitative data under a subcontract led by Gabriel Pachawo and local principal investigator, Nnunu Tsheko. The qualitative data were collected under a subcontract to Research 4 Results, led by one of the local principal investigators, Iris Halldorsdottir. We appreciate the tireless efforts of the 5 AM Consultancy and Research 4 Results teams, including the field managers, data collection supervisors, interviewers, and data managers. Styn Jamu, consultant on this evaluation, provided in-country logistical and administrative support throughout the evaluation. Grace Mulholland (a doctoral student at the Gillings School of Global Public Health, University of North Carolina, Chapel Hill) programmed the tablets for household survey data collection and, along with Milissa Markiewicz (MEASURE Evaluation), helped train the quantitative data collectors and provided study management support for the household survey. Mathew Mainwaring (MEASURE Evaluation) assisted with cleaning and management of the survey data and Emily Weaver (MEASURE Evaluation) analyzed the survey data. We thank members of the local Technical Working Group for reviewing and providing technical assistance to the study design, and helping to interpret the results of the evaluation. We would also like to thank Sonja Niederhumer from Graphic Harvest for the illustrations of the Ripple Effects Mapping. Finally, we thank MEASURE Evaluation’s knowledge management team for editorial, design, and production services. Suggested citation Mandal, M., Cannon, A., Parker, L., Halldorsdottir, I., & Millar, E. (2019). Evaluation of Services for Orphans and Vulnerable Youth in Botswana: Final Report. Chapel Hill, NC, USA: MEASURE Evaluation, University of North Carolina. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 5 CONTENTS Abstract..........................................................................................................................................................................3 Acknowledgments........................................................................................................................................................4 Contents.........................................................................................................................................................................5 Figures............................................................................................................................................................................8 Tables.............................................................................................................................................................................9 Abbreviations..............................................................................................................................................................10 Executive Summary....................................................................................................................................................11 Background ............................................................................................................................................................ 11 Evaluation Aim and Objectives........................................................................................................................... 11 Main Exposures and Outcomes.......................................................................................................................... 11 Methods.................................................................................................................................................................. 12 Results..................................................................................................................................................................... 12 HIV and Health..................................................................................................................................................12 Economic Strengthening.........................................................................................................................................13 Education .............................................................................................................................................................13 Discussion and Conclusions................................................................................................................................ 13 Introduction ................................................................................................................................................................15 Background ............................................................................................................................................................ 15 PEPFAR-Funded and GOB OVC Services in Botswana ...................................................................................16 Evaluation Aim and Objectives........................................................................................................................... 19 Evaluation Aim ...................................................................................................................................................19 Evaluation Objectives............................................................................................................................................19 Methods.......................................................................................................................................................................20 Evaluation Design ................................................................................................................................................. 20 Ethics....................................................................................................................................................................... 20 Quantitative Component...................................................................................................................................... 20 Quantitative Sampling and Sample Size................................................................................................................20 Quantitative Data Collection.................................................................................................................................22 Quantitative Analysis ...........................................................................................................................................22 Qualitative Component ........................................................................................................................................ 22 Results..........................................................................................................................................................................24 Quantitative Response Rates............................................................................................................................... 24 Characteristics of Youth Respondents............................................................................................................... 24 Exposure to OVC Services.................................................................................................................................. 25 HIV and Health..................................................................................................................................................... 26 6 Evaluation of Services for Orphans and Vulnerable Youth in Botswana BCCOVC HIV and Health-Related Services......................................................................................................26 HIV Testing........................................................................................................................................................28 HIV Prevention ...................................................................................................................................................32 GBV Experience, Knowledge, and Services............................................................................................................35 ART Initiation and Adherence.............................................................................................................................36 Summary of HIV and Health-Related Results......................................................................................................42 Economic Stability ................................................................................................................................................ 43 BCCOVC Economic Stability-Related Services ....................................................................................................43 GOB Economic Stability-Related Services .............................................................................................................44 Financial Literacy and Saving...............................................................................................................................44 Work and Work-Related Education.....................................................................................................................46 Income Generation.................................................................................................................................................48 Summary of Economic Stability-Related Results ....................................................................................................49 Education................................................................................................................................................................ 50 BCCOVC Education-Related Services.................................................................................................................50 GOB Education-Related Services..........................................................................................................................50 Exposure to BCCOVC Education-Related Services .............................................................................................50 School Completion.................................................................................................................................................51 Project-Related Influences on School Completion .......................................................................................... 51 School Enrollment and Attendance........................................................................................................................51 School Progression and Performance .......................................................................................................................53 Dropping Out and Reenrollment............................................................................................................................55 Summary of Education-Related Results .................................................................................................................57 Crosscutting issues: Project Implementation .................................................................................................... 58 Discussion....................................................................................................................................................................59 Limitations.............................................................................................................................................................. 61 Recommendations......................................................................................................................................................63 Conclusions.................................................................................................................................................................64 References....................................................................................................................................................................65 Appendix A. Quantitative Tables.............................................................................................................................67 Appendix B. Qualitative Matrix of Key Results.....................................................................................................73 Appendix C. Youth Household Survey...................................................................................................................79 Appendix D. Caregiver Household Survey ..........................................................................................................123 Appendix E. Youth Mobile Survey........................................................................................................................142 Appendix F. Qualitative Guide for Community Service Provider Interviews ................................................144 Appendix G. Qualitative Guide for Implementing Partner Interviews............................................................147 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 7 Appendix H. Qualitative Guide for REM Focus Group Discussion ...............................................................150 Appendix I. Qualitative Guide for Social Worker Interviews............................................................................153 Appendix J. Qualitative Guide for Social and Community Development Office Interviews.......................156 Appendix K. Qualitative Guide for Youth Interviews .......................................................................................159 Appendix L. Qualitative Guide for Caregiver Interviews...................................................................................175 Appendix M. Ripple Effect Mapping xMind Maps.............................................................................................188 Appendix N. Ripple Effect Mapping Illustrations of the Two Groups...........................................................192 Appendix O. Study Protocol and Evaluation Team Members..........................................................................204 Appendix P. Conflict of Interest Statements........................................................................................................229 8 Evaluation of Services for Orphans and Vulnerable Youth in Botswana FIGURES Figure 1. Map of Botswana .......................................................................................................................................15 Figure 2. BCCOVC + GOB OVC project theory of change ..............................................................................18 Figure 3. Exposure to BCCOVC project HIV-related services among the qualitative HIV-positive subsample (n=16).......................................................................................................................................................27 Figure 4. Exposure to BCCOVC project HIV-related services among the qualitative HIV-negative or unknown status subsample (n=23)..........................................................................................................................27 Figure 5. Exposure to BCCOVC project GBV and/or child abuse-related services among the qualitative subsample (n=39).......................................................................................................................................................28 Figure 6. Percentage of youth who had had an HIV test and knew their results, previous 12 months**.....28 Figure 7. Percentage of female youth who had had an HIV test and knew their results, previous 12 months.........................................................................................................................................................................29 Figure 8. Percentage of male youth who had had an HIV test and knew their results, previous 12 months....................................................................................................................................................................29 Figure 9. Percentage of youth who had accessed services in the past 12 months ............................................30 Figure 10. Percentage of youth who had reported using a condom every time in the past three months....32 Figure 11. Percentage of youth who reported high-risk sexual behavior...........................................................33 Figure 12. Percentage of youth who had received medical care or psychological services in the past 12 months due to GBV+........................................................................................................................35 Figure 13. Percentage of HIV-positive youth who reported being on ART.....................................................37 Figure 14. Percentage of HIV-positive youth who reported adherence to ART..............................................37 Figure 15. Influence of accepting one’s HIV status on ART initiation and adherence, health and well-being, and education outcomes........................................................................................................................38 Figure 16. Exposure to BCCOVC project economic stability-related services among the qualitative subsample (n=39).......................................................................................................................................................43 Figure 17. Basic financial literacy of youth, mean score* .....................................................................................44 Figure 18. Percentage of youth who reported various economic stability-related outcomes..........................45 Figure 19. Exposure to BCCOVC project education-related services among the qualitative subsample (n=39) ..........................................................................................................................................................................50 Figure 20. Percentage of youth in 2017 and 2018 who sat for and received 36 points or higher on the BGCSE exam..............................................................................................................................................................51 Figure 21. Percentage of youth enrolled in any school, and tertiary or vocational school ..............................52 Figure 22. Percentage of youth who missed any days of school in the past week............................................52 Figure 23. Percentage of youth who progressed to each secondary school level..............................................53 Figure 24. Percentage of beneficiaries who had dropped out of school, and reenrolled or repeated a grade.............................................................................................................................................................................56 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 9 TABLES Table 1. BCCOVC project districts of operation and implementing partners.................................................17 Table 2. Sampling goals for primary evaluation outcomes...................................................................................21 Table 3. Response rates for youth participants in the household survey ...........................................................24 Table 4. Response rates for Form 5 youth participants in the follow-up mobile survey.................................24 Table 5. Demographic characteristics of youth......................................................................................................25 Table 6. Percentage distribution of youth’s reported exposure to BCCOVC and/or GOB OVC services in the past 12 months, by study arm.........................................................................................................26 Table 7. Percentage of youth who had ever had sex reporting one or more sex partners in the past three and twelve months, by study arm ............................................................................................................................32 Table 8. Significance and direction of logistic regression coefficients assessing the differences in HIV and health behaviors and services between the intervention and comparison groups...........................42 Table 9. Significance and direction of logistic regression coefficients assessing differences in economic stability between intervention and comparison groups........................................................................................49 Table 10. Significance and direction of logistic regression coefficients assessing differences in education￾related factors between intervention and comparison groups.............................................................................57 10 Evaluation of Services for Orphans and Vulnerable Youth in Botswana ABBREVIATIONS ART antiretroviral therapy BCCOVC Botswana Comprehensive Care and Support for Orphans and Vulnerable Children BGCSE Botswana General Certificate of Secondary Education CSP community service provider DSP Department of Social Protection GBV gender-based violence GOB Government of Botswana LP local partner N/A not applicable NS not significant OVC orphans and vulnerable children P pula PCI Project Concern International PEPFAR United States President’s Emergency Plan for AIDS Relief REM Ripple Effects Mapping RH reproductive health SSI Stepping Stones International SW social worker USAID United States Agency for International Development Evaluation of Services for Orphans and Vulnerable Youth in Botswana 11 EXECUTIVE SUMMARY Background The HIV epidemic has left many children orphaned and vulnerable, especially in Botswana, where HIV prevalence is 18 percent. Twenty-four percent of youth ages 15–17 years were orphans in Botswana in 2013 (Republic of Botswana, 2013). Orphanhood puts children at risk for poor health, including increased risk of acquiring HIV and AIDS, having low education levels, and experiencing poor economic outcomes. Since 2016, the Botswana Comprehensive Care and Support for Orphans and Vulnerable Children (BCCOVC) project, which is funded by the United States President’s Emergency Plan for AIDS Relief (PEPFAR), has supported the Government of Botswana (GOB) to deliver social services in seven PEPFAR priority sites. The GOB’s core package of OVC services includes the provision of food, school uniforms, clothes, shoes, and toiletry items; and psychosocial support. BCCOVC services supplemented this core package of services with the goals of increasing the uptake of HIV prevention, care, and treatment and other reproductive health (RH) services; strengthening youth economic opportunities; and improving school completion. The lack of evidence around the status of adolescent orphans and vulnerable children (OVC) as well as evaluations of adolescent-focused OVC interventions, especially in Botswana, pointed to the need to better understand how OVC programs affect adolescent outcomes. To provide the evidence required to plan and implement services for the unique needs of adolescent OVC, the United States Agency for International Development (USAID) and the GOB requested that the USAID- and PEPFAR-funded MEASURE Evaluation project, with support from PEPFAR, evaluate how PEPFAR-supported BCCOVC- and GOB￾supported OVC interventions in Botswana affected the educational, economic, and health outcomes of adolescent OVC. Evaluation Aim and Objectives The aim of this evaluation was to understand how OVC programming provided by the GOB and the BCCOVC project prepares older youth to be healthy, productive young adults. The study specifically examined the effect of OVC services on the educational, economic, and health trajectories and related outcomes of older youth graduating from the programs. This evaluation had two objectives: Objective 1: To examine qualitatively how factors at the personal, family, school, community, and service delivery levels, including OVC services, influenced the educational, economic, and health trajectories and related outcomes of orphaned and vulnerable youth beneficiaries Objective 2: To determine quantitatively whether orphaned and vulnerable youth beneficiaries who participated in one to two years of OVC services provided both by the United States Government and the GOB had better educational, economic, and health outcomes than did orphaned and vulnerable beneficiaries of GOB-only services Main Exposures and Outcomes PEPFAR-funded OVC services delivered by the BCCOVC project have been designed to include linkages to HIV services, such as counseling, testing, and antiretroviral therapy (ART); referrals for other health problems and life skills education; financial education, work readiness training, and training to start a small business; literacy courses and tutoring; and individual and group psychosocial support. 12 Evaluation of Services for Orphans and Vulnerable Youth in Botswana OVC services for youth delivered by the GOB program have been designed to include monthly food baskets, coupons, or vouchers; monthly toiletries; school supplies and school-related services, such as school uniforms and transportation for school trips; and casual clothing, shoes, and blankets, as needed. Caregivers of orphaned and vulnerable youth who are in the BCCOVC plus GOB OVC project receive parenting skills building sessions focused on improving parent-child communications. Methods This mixed-methods evaluation was designed as a one-time quasi-experimental study, with an intervention group of youth beneficiaries who received services from both the PEPFAR-funded BCCOVC project and the GOB, and a comparison group of youth beneficiaries who received services from the GOB only. The primary outcomes were: • Youth who sat for and passed the Botswana General Certificate of Secondary Education exam (i.e., received a score of 36 points or higher) in 2018. • Youth who had basic financial literacy. • Youth who had an HIV test in the past 12 months and knew their test results. Quantitative data were collected from BCCOVC project and GOB program beneficiaries ages 16 to 18 and their primary caregivers via an interviewer-administered, tablet-based survey. Qualitative data collection focusing on BCCOVC project beneficiaries included in-depth interviews with beneficiaries and their caregivers (n=39 dyads), local partners (LPs) (n=11), community service providers (n=10), social and community development officers (n=4), and social workers (n=4). In addition, the Ripple Effects Mapping (REM) method was used to describe multiple waves of project effects from the beneficiary perspective. Youth REM participants were selected from the qualitative and quantitative sample frame and from LP beneficiary lists and from teen club participants. Four REM groups were held in different locations. Results HIV and Health Quantitative results showed that a higher percentage of PEPFAR-funded BCCOVC project youth beneficiaries reported using a condom every time they had sex in the previous three months, although multivariate analysis revealed that the differences were not statistically significant. High-risk behavior (multiple sexual partners, inconsistent condom use, or transactional sex) was about the same between the study arms. In bivariate and multivariate analyses, BCCOVC project beneficiaries were significantly more likely to have had an HIV test in the past 12 months and to know their results compared with GOB-only beneficiaries (p<.01). BCCOVC beneficiaries were also significantly more likely to have accessed any HIV service (HIV prevention, testing, and treatment advice) than the GOB program’s youth beneficiaries. BCCOVC beneficiaries were marginally significantly more likely to receive medical care or psychological services because of gender-based violence (GBV) in the previous 12 months (p<.1). BCCOVC and GOB youth beneficiaries who were HIV-positive were equally likely to report being on ART and to report adherence to ART. Qualitative results revealed that the PEPFAR-funded BCCOVC project helped HIV-positive youth accept their status and improved their confidence, self-esteem, and outlook. Consequently, youth became more resilient to stigma and discrimination, more committed to ART adherence, more engaged at school, more Evaluation of Services for Orphans and Vulnerable Youth in Botswana 13 willing to participate in social activities, and more willing to disclose their status. Youth also reported an increased understanding of the consequences of not adhering to treatment and realized that without treatment for HIV, one will die sooner than otherwise. This motivated HIV testing and ART adherence. BCCOVC’s education activities on how medications work to combat HIV and the importance of taking them on time also motivated youth to adhere. The results indicate that challenges remain around access to condoms due to social norms and stigma, lack of knowledge of GBV and associated services, and barriers to HIV testing, including fear of judgement from caregivers or clinicians. Economic Strengthening BCCOVC project beneficiaries were significantly more likely than GOB youth beneficiaries to report starting a small business for an income generating activity in the past 12 months (p<.05), working for cash in the past three months (p<.05), and saving money in the past 12 months (p<.001). BCCOVC youth beneficiaries were significantly more likely to be financially literate (p<.05) than GOB youth, although the difference in the value of the mean financial literary score between the two groups was small and not programmatically meaningful. Based on the qualitative data, PEPFAR-funded local partners (LPs) have helped youth reflect on their spending patterns and the value of using money wisely to meet short-term needs and to achieve long-term goals through saving, prioritization, budgeting, and cost-cutting. LPs have provided youth with education on entrepreneurship skills and motivated them to plan or start their own businesses. The most commonly cited barrier was the lack of start-up capital. Moreover, relatively few respondents reported being exposed to work skills, and many requested access to skills to find work or job placements. Education Quantitative data revealed no differences between the PEPFAR-funded BCCOVC project and GOB youth beneficiaries in school enrollment or graduating from senior secondary school. Qualitative data indicated that many youth did not consistently receive material support, such as food vouchers, school fees, school uniforms, or transport money, which can negatively affect school attendance. PEPFAR-funded LPs have helped youth take responsibility for their education by building their confidence to ask questions, enabling access to tutoring services, and encouraging youth to set up study groups for peer support. Viewing education as a pathway out of poverty, which was promoted by caregivers and PEPFAR-funded LP staff, motivated youth to attend school, perform well, and complete school. Discussion and Conclusions This evaluation study is the only we identified that examines the effects of a multi-component intervention for orphans and vulnerable youth in Botswana transitioning to adulthood. Study results indicate that the PEPFAR-funded BCCOVC project has had mixed success in improving HIV and health, economic strengthening, and education outcomes among orphans and vulnerable youth. Of the three main outcome areas of the evaluation, the project has had some effect on HIV and health and economic strengthening outcomes. However, there are no observed effects of the PEPFAR-funded intervention on education outcomes. The BCCOVC project had a positive, significant effect on numerous HIV-related indicators including youth getting an HIV test and knowing their results; receiving HIV prevention, testing, or treatment advice; receiving RH services in the past 12 months; and receiving GBV-related care in the past 12 months. However, more education is needed about what constitutes GBV, existing GBV and child abuse laws, and resources available for those experiencing GBV and child abuse. 14 Evaluation of Services for Orphans and Vulnerable Youth in Botswana The evaluation did not find that the BCCOVC project had a quantitative, measurable effect on HIV￾positive youth being on or adhering to ART. While from its inception the project has focused on the first “90” of the global 90-90-90 goals, it only recently began to place more emphasis on efforts to increase the second and third “90”, which may explain this finding. The BCCOVC project positively impacted HIV-positive youth accepting their status; and improved their self-esteem, resilience, and attitudes. Teen clubs helped youth improve adherence to ART, school performance, coping skills, and outlook on life. These improvements in skills and adherence are critical in supporting youth in their positive and healthy transition to adulthood, and in the prevention of HIV for future partners. The teen clubs reach a relatively small number of HIV-positive youth in the study area and, therefore, have not yet been able to increase ART adherence (or other outcomes) among a large enough number of youth to impact the quantitative results. As Botswana begins to shift focus to the second 90 of adherence, support for promising practices, such as teen clubs, becomes critical. Economic strengthening indicators indicate that the BCCOVC project is effective in providing adolescent OVC with the skills needed to gain economic stability as they transition to adulthood. This may be especially important in light of the high percentage number of youth who drop out of school. The BCCOVC project had no impact on measured education outcomes among youth. Data on project exposure reveal that coverage of services may play a role in the lack of effect, with fewer than expected youth receiving GOB material support and/or BCCOVC education support. Among youth who received educational support, it helped improve their attendance, performance, and returning to and completing school. We note that differences between study arms may be underestimated due to many respondents reporting that they did not receiving OVC-related services in the past 12 months. Although the intervention arm was designed to include respondents who received both BCCOVC and GOB services, and the comparison arm designed to include respondents who received only GOB services, there was sometimes overlap in receipt of services between the study arms. The BCCOVC project effects may have therefore been diluted. In sum, the evaluation showed that the PEPFAR-funded BCCOVC project had some positive effects on HIV testing, treatment, and access to services, and on strengthening economic prospects for youth beneficiaries. OVC adolescents continue to be an important population to support as they transition to adulthood. Additional research is needed to understand how service delivery and support services are reaching youth. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 15 INTRODUCTION Background Botswana is a landlocked country in Southern Africa (Figure 1) with just over 2 million people. About 10 percent of the population lives in the capital and largest city, Gaborone. Botswana has the third highest HIV prevalence of the world, at 18 percent. Females ages 35–39 have the highest HIV prevalence in the country, at 50.5 percent, and girls ages 15–19 are twice as likely to be HIV-positive as boys the same age (Republic of Botswana, 2013). The HIV epidemic has left many children orphaned and vulnerable. In 2007, the National Situation Analysis on Orphans and Vulnerable Children in Botswana estimated the number of orphans at 137,805, constituting 17.2 percent of the number of children below age 18 (Ministry of Local Government, Department of Social Services, 2008a). Botswana’s 2008 National Guidelines on the Care of Orphans and Vulnerable Children define a vulnerable child as any child under the age of 18 years who lives in an abusive environment, in a poverty-stricken family unable to access basic services, or in a child-headed household; a child who lives with sick parents or outside family care; or a child who is HIV￾positive (Ministry of Local Government, Department of Social Services, 2008b). There are no available estimates of the number of vulnerable children because of HIV, poverty, or other causes in Botswana. Among youth ages 15–17 years, 23.8 percent are orphans, compared with 11.9 percent among children younger than 15 years (Republic of Botswana, 2013). Limited research focusing on adolescent orphans and vulnerable children (OVC) revealed that vulnerabilities faced by adolescent OVC are different, and magnified, when compared with those of other youth. This is particularly true for adolescent OVC girls and their mental health and HIV/sexually transmitted infection risk behaviors in Kenya (Chhabra, 2018). Focus group discussions identified added psychological stressors for girls, as compared with boys, concerning financial challenges (at times leading to transactional sex), additional adult responsibilities, and lack of appropriate socialization and respect; quantitative survey results also showed girls being more likely to feel lonely and unable to sleep due to worries (Chhabra, Teitelman, Silver, Raufman, & Bauman, 2018). Several studies examining youth OVC aging out of institutional care in Zimbabwe, Nigeria, and Ethiopia have revealed many challenges on leaving care, including difficulty finding and keeping employment, lack of basic life skills and support networks, financial and housing challenges, and stigma due to their institutional care (Gwenzi, 2018; Pryce, et al., 2016; Sekibo, 2019). Several evaluation studies also found mixed results for interventions focusing on improving outcomes for adolescent OVC. One study evaluated a poverty-targeted OVC cash transfer program’s impact on adolescent pregnancy and early marriage during transition to adulthood in Kenya (Handa, et al.,, 2015). This same study showed a decrease in pregnancy but not in early marriage. Several studies examined school-based support or subsidies as part of HIV prevention for adolescent orphans, finding improvements in HIV risk behaviors in Kenya (Cho, et al., 2011) and improved school and socioeconomic status, but no biological evidence of HIV prevention in Zimbabwe (Hallfors, et al., 2015). No such studies or evaluations were identified for OVC youth in Botswana. Figure 1. Map of Botswana 16 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A recent literature review found that older HIV orphans are underrepresented in the literature. Moreover, lack of support, financial disadvantages, and psychosocial stressors for youth can make them vulnerable to exploitation and abuse (Popoola & Mchunu, 2016). The lack of evidence around the status of adolescent OVC and the lack of evaluations of adolescent-focused OVC interventions, especially in Botswana, illustrates the need to better understand how OVC programs impact adolescent outcomes. To provide the evidence needed to plan and implement services for the unique needs of adolescent OVC, the United States Agency for International Development (USAID) and the Government of Botswana (GOB) asked the USAID- and United States President’s Emergency Plan for AIDS Relief (PEPFAR)-funded MEASURE Evaluation project, with support from PEPFAR, to evaluate how PEPFAR- and GOB￾supported OVC interventions in Botswana affect the education, economic, and health outcomes of adolescent OVC. PEPFAR-Funded and GOB OVC Services in Botswana In June 2009, the GOB approved the Children’s Act (GOB, 2009), which is the current legal framework guiding Botswana’s OVC program. Under the Act, social workers were assigned a variety of responsibilities, including supporting parents and caregivers in the community, investigating cases of abuse or neglect, and arranging alternative care for children, where needed. The core of the GOB’s OVC services is food baskets, vouchers, or coupons, along with school uniforms and school supplies, other clothing and shoes, and toiletries, which are provided to every OVC beneficiary served by the GOB. Transportation for school trips, casual clothing, shoes, and blankets are also given, as needed. Household and psychosocial support is provided to some OVC, but this varies by district and subdistrict. Psychosocial support includes a variety of individual and group counseling sessions, such as bereavement counseling, life skills counseling, and social skills counseling. Some districts also provide workshops for caregivers to improve parenting skills. From 2011 to 2015, the United States Government supported OVC service provision in Botswana through a project called the Tsela Kgopo OVC and Gender Project. It currently supports OVC services through the Botswana Comprehensive Care for Orphans and Vulnerable Children (BCCOVC) project. BCCOVC was awarded to Project Concern International (PCI) in 2016. The project has two objectives: (1) strengthen households and community structures to support OVC; and (2) improve policy implementation for the delivery of coordinated quality social services. Although it serves male and female OVC ages 0 to 17, one area of focus is the subpopulations of vulnerable adolescent girls and young women at high risk of HIV acquisition. The project builds on the work already undertaken by the Tsela Kgopo project in the seven PEPFAR priority sites of Mahalapye, Goodhope, Southern, and greater Gaborone (Kweneng East, Gaborone, Kgatleng, and South East). PCI has partnered with seven local and international organizations to implement the BCCOVC project (Table 1). Evaluation of Services for Orphans and Vulnerable Youth in Botswana 17 Table 1. BCCOVC project districts of operation and implementing partners PEPFAR Scale-Up District Health District(s) Administrative Division(s) Partner Greater Gaborone cluster Gaborone Gaborone City Council Botswana-Baylor Children’s Clinical Centre of Excellence (Baylor) Hope Worldwide Stepping Stones International (SSI) Mothers’ Union Kweneng East Kweneng East Subdistrict Hope Worldwide Baylor Kgatleng Kgatleng District SSI, Bakgatla Bolokang Matshelo South East South East Subdistrict SSI Hope Worldwide Baylor Mahalapye District Mahalapye Central – Mahalapye Subdistrict Mothers’ Union Baylor Southern District Southern Kanye Subdistrict Mothers’ Union Hope Worldwide Baylor Moshupa Subdistrict Mothers’ Union Goodhope District Goodhope Goodhope/Borolong Subdistrict SSI, Baylor Hope Worldwide The core package of services for OVC of varying ages offered by BCCOVC consists of the following: • Provision of and linkages to pediatric HIV testing/treatment and sexual and reproductive health (RH), family planning, tuberculosis, and gender-based violence (GBV) services • Home-based and facility-based case management • Peer-to-peer approaches: teen clubs, Young Mothers Clubs, Kids Clubs, and Literacy Clubs • Household economic strengthening and empowerment • Parenting skills development and parent-child communication skills development Services focused on adolescents are increasing the uptake of HIV prevention, care, and treatment services by increasing the linkages to services through community- and school-based interventions; developing and using a social and behavior change communication strategy to motivate youth and those who influence youth to choose positive behaviors; life skills education; and delivering post-violence care services to adolescent girls and young women. The BCCOVC project also works to improve financial literacy and strengthen the economic opportunities of youth by continuing and expanding the Aflateen program from the Tsela Kgopo project; supporting youth savings and loans groups that foster social and economic empowerment through access to financial 18 Evaluation of Services for Orphans and Vulnerable Youth in Botswana services and training in leadership and collective action; building the skills of youth to help them enter the workforce; and linking youth to business and entrepreneurial skills training and vocational opportunities. Finally, services for the BCCOVC youth beneficiaries focus on improving school completion and building social assets among adolescents to reduce their risk of HIV. Activities are mentoring, role modeling, and follow-up for OVC enrolled in school; literacy courses and tutoring; and collaborating with guidance and counseling teachers and career guidance teachers to facilitate parent-student-teacher consultations for comprehensive support and positive role modeling. Caregivers of orphaned and vulnerable youth who are in the BCCSOVC and GOB OVC project receive parenting skills building sessions focused on improving parent-child communication. Adolescent and caregiver services are theorized to lead to: increased access to counseling and testing and antiretroviral therapy (ART) and adherence to treatment; increased HIV, economic, and education-related knowledge, skills, and behaviors; and increased coping skills, resilience, and self-efficacy. Achieving these intermediary factors depend on a broader supportive environment in the community. Figure 2 presents the project’s theory of change. Figure 2. BCCOVC + GOB OVC project theory of change Evaluation of Services for Orphans and Vulnerable Youth in Botswana 19 Evaluation Aim and Objectives Evaluation Aim The aim of this evaluation was to understand how OVC programming provided by the GOB and the PEPFAR-funded BCCOVC project prepares older youth to be healthy, productive young adults. The study specifically examined the effect that OVC services have on the education, economic, and health trajectories and related outcomes of older youth graduating from the services. Evaluation Objectives The evaluation had two objectives: Objective 1: To qualitatively examine how factors at the personal, family, school, community, and service delivery levels, including OVC services, have influenced the educational, economic, and health trajectories and related outcomes of orphaned and vulnerable youth beneficiaries. Objective 2: To quantitatively determine whether orphaned and vulnerable youth beneficiaries who participated in one to two years of OVC services provided by both the United States Government and the GOB have better education, economic, and health outcomes compared with orphaned and vulnerable beneficiaries of GOB-only services. 20 Evaluation of Services for Orphans and Vulnerable Youth in Botswana METHODS Evaluation Design This mixed-methods evaluation was designed as a one-time quasi-experimental study with an intervention group of youth beneficiaries who received services from both the BCCOVC project and the GOB, and a comparison group of youth beneficiaries who received services from the GOB only. Youth in the intervention arm were selected from seven PEPFAR districts/subdistricts: Gaborone, Kweneng East, Kgatleng, South East, Mahalapye, Southern, and Goodhope. Youth in the comparison arm were selected from 10 non-PEPFAR sites (subdistricts): Ditshegwane, Kumakwane, Letlhakeng, Sesung, and Takatokwane (Kweneng West District); Molapowagojang and Mmanyana (Southern District); and Radiselse, Serowe, and Topisi (Central District). The primary outcomes for HIV and health, economic stability, and education were as follows: • Youth who had had an HIV test in the past 12 months and knew their test results • Youth who had had basic financial literacy, as measured by a financial literacy index • Youth who had sat for and passed the Botswana General Certificate of Secondary Education (BGCSE) exam (i.e., received a score of 36 points or higher) in 2018 The evaluation also examined numerous secondary outcomes in each focal area. Ethics This study adhered to the three Belmont principles of ethics that guide researchers in conducting safe research: respect for persons, beneficence, and justice. Ethical clearance was obtained from the Ministry of Health, Health Research and Development Council Ethics Committee (Ref no. HDPME 13/18/1) and the University of North Carolina at Chapel Hill Institutional Review Board (IRB no. 18-0605). Quantitative Component The study population for the quantitative sample consisted of BCCOVC and GOB beneficiaries ages 16 to 18 and their primary caregivers. Quantitative Sampling and Sample Size Two sampling frames were created, one for the intervention sample and the other for the comparison sample. The intervention sampling frame was created by collating two OVC beneficiary lists: the active GOB OVC beneficiary list in all study sites and the active BCCOVC beneficiary list in the intervention sites. Using the active BCCOVC beneficiary list, we identified beneficiaries that also appeared on the active GOB beneficiary list and created a third list of common beneficiaries. The intervention group was to be sampled from this third combined beneficiary list; however, only six beneficiaries were identified on both lists. Therefore, the intervention group was randomly sampled from the BCCOVC project beneficiary list and the comparison group was randomly sampled from the active GOB program beneficiary list. The sample size was calculated to detect potential differences in population values for the three primary outcomes: 7 percent difference for the primary HIV and health outcomes; 7 percent difference for the economic stability outcome; and 8 percent difference for the education outcome. The sampling goals for each primary outcome are shown in Table 2. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 21 Table 2. Sampling goals for primary evaluation outcomes Study Population Primary Health Indicator Primary Economic Stability Indicator Primary Education Indicator BCCOVC + GOB beneficiaries 30% 50%1 33%2 GOB-only beneficiaries 23%3 43% 25% We used Fleiss’ “two-proportion” formula for sample size estimation: N = deff ∗ [Z1−α/2 √2 ∗ p (1 − p) + Z1−β √p1 (1 − p1 ) + p2 (1 − p2)] 2 (p2 − p1) 2 Where, N = Estimated sample size Z1−α/2 = Value of Z for level of significance alpha (at 0.05 level of significance, value of Z is 1.96) Z1−β = Value of Z for power 1-β (at .80 power, level of Z1−β is 0.84 p1 = Value of study outcome at Time 1 (Baseline) p2 = Value of study outcome at Time 2 (End line) p = (p1 + p2)/2 We made the following additional assumptions to calculate the estimated sample sizes: Parameters/Assumptions Power 80% Two-tailed alpha 0.05 for 2-arm study Non-response due to inability to locate eligible sample from compiled beneficiary lists 0.10 Response rate among eligible and located sample 0.90 Proportion of eligible 18-year-old youth (Indicator 1) 0.50 Based on the above, the target sample size was 796 in each study arm, with oversampling of 622 Form 5 students in each arm. 1 Figure chosen as most conservative estimate of indicator. 2 Figure based on Botswana General Certification of Secondary Education 2016 Provisional Summary of Results, available here: http://www.bec.co.bw/results/results-summary-psle-jce-bgcse/bgcse-results-summary/2016-bgcse￾provisionanal-report/view 3 Figure based on Bodia SM, Lekone P, Loeto P, et al. (2016). Prevalence of HIV testing and counseling and associated factors among secondary school students in Botswana. Journal of International Adolescent Medicine and Health, 8(2). 22 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Quantitative Data Collection The first round of data was collected from September through December 2018 during household visits using an interviewer-administered, tablet-based survey of primary caregivers of 16- to 18-year-old youth, and a combined interviewer- and self-administered tablet-based survey of 16- to 18-year-old youth. In February 2019, interviewers conducted a follow-up mobile call with youth who reported at the time of the interview that they were attending Form 5 and were planning to sit for the BGCSE exam. Quantitative Analysis Quantitative data were analyzed using STATA statistical software version 15.1 (Stata Corps LP, College Station, Texas). First, we explored characteristics of the sample, calculating frequency distributions of all variables. Then, we used chi-square tests and analysis of variance to examine the bivariate associations between the study arm and each primary and secondary outcome. Last, we used multivariable logistics and linear regressions to examine the relation between the study arm and each outcome. We included the following control variables in each regression model: age, sex, school status, orphanhood, and primary caregiver. Qualitative Component Four PEPFAR districts were included in the qualitative study: Gaborone, Kweneng East (Molepolole and Lentsweletau), Kgatleng (Mochudi), and Central District (Mahalapye). The beneficiary qualitative sample frame included all those interviewed in the quantitative survey in the intervention group and who resided in the qualitative sample sites at the time of the survey and were screened and determined to have received at least one BCCOVC service. Households were located either from contact information collected by the quantitative survey team or from community service providers (CSPs) who knew the location of the beneficiaries’ residence. Data were collected from October 2018 through March 2019. In-depth interviews were conducted with beneficiaries ages 16 to 18 and their caregivers (n=39 dyads), local partners (LP) (n=11) and their CSPs (n=10), social and community development officers (n=4), and social workers (SWs) (n=4). The interviews were conducted in English or Setswana, according to participant preference. Interviews were translated and transcribed directly into English. A coding framework was created pertaining to each of the three outcome evaluation areas (education, economic strengthening, and health), with a focus on attitude or behavior change and barriers to change, project management issues, and recommendations for future improvements. This framework was used to code excerpts in Dedoose qualitative analysis software. Excerpts were then organized into matrices by participant type, location, and LP to facilitate thematic analysis. A qualitative method called Ripple Effects Mapping (REM) was also used to further describe project effects from the beneficiary perspective. REM is a qualitative participatory group method used to engage stakeholders to retrospectively and visually map intended and unintended consequences of a program, using elements of mind mapping, appreciative inquiry, and group interviewing (Kollcok, Flage, Chazdon, Paine, & Higgins, 2012). REM was used to better understand the lived experiences of adolescents who were part of the project, and the pathway between their exposure to the project and their outcomes. REM groups were held in four locations: Mochudi (n=11), Mahalapye (n=5), Thamaga (n=5), and Lentsweletau (n=7). REM participants were selected from the qualitative and quantitative sampling frame, from LP beneficiary lists, and current members of teen club. Because of the limited pool of potential participants with availability and willingness to participate, the age range of participants was expanded for this component. All five groups included more female participants (n=22) than males (n=6). The groups consisted mostly of youth ages 16-18 years (n=25), with a smaller number of youth age 19 (n=3). Two group discussions with beneficiaries living with HIV (n=16) and two group discussions with HIV-negative beneficiaries (n=12) were conducted. Waves of project effects were analyzed and visualized using Xmind Evaluation of Services for Orphans and Vulnerable Youth in Botswana 23 mind-mapping software. In addition, two of the REM group mind maps (one HIV- and one HIV+ group) were graphically illustrated to more effectively show project outcomes in an easily digestible format. See Appendixes C-L for data collection tools and interview guides. The four REM Xmind maps developed based on the original hand-written REM map and the digital transcript can be found in Appendix M. The illustrations of the two REM groups can be found in Appendix N. 24 Evaluation of Services for Orphans and Vulnerable Youth in Botswana RESULTS Quantitative Response Rates A total of 2,358 orphans and vulnerable youth were sampled for the household surveys, with 798 sampled for the intervention group and 1,560 sampled for the comparison group. A portion of the sampled youth were not eligible because they were either outside the age range (16–18 years) or other youth in the household had already been surveyed. After dropping these beneficiaries, 745 youth were eligible in the intervention group and 1,417 youth in the comparison group. Of these, 305 households were not found; 39 respondents refused to participate; 191 youth were not at home; 22 youth were incapacitated; and 221 households were inaccessible. Ultimately, 507 youth in the intervention group and 900 youth in the comparison group were surveyed (68% and 64% response rates, respectively). Table 3 shows the response rates for the youth surveys, and Table 4 presents the response rates for Form 5 youth participants in the follow-up mobile surveys. Table 3. Response rates for youth participants in the household survey Intervention Comparison Individuals sampled 798 1,560 Individuals eligible (youth eligibility was those ages 16‒18 years, and no other youth in the household selected) 745 1,417 Individuals surveyed 507 900 Response rate (%) of eligible individuals 68.0 64.0 Table 4. Response rates for Form 5 youth participants in the follow-up mobile survey Intervention Comparison Individuals sampled 63 143 Individuals surveyed 43 93 Eligible youth response rate (%) 68.3 65.0 Characteristics of Youth Respondents Approximately one-third each of the youth were 16, 17, and 18 years old and one-half were female. Youth in the intervention and comparison groups were similar with respect to age and sex. Youth in the intervention group were significantly less likely to be single (p<.01) and double orphans (p<.001); and were significantly more likely to have a mother as their primary caretaker (p<.001). Table 5 shows the demographic characteristics of the youth. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 25 Table 5. Demographic characteristics of youth Intervention Comparison Total Age (%) 16 years 28.6 32.3 31.0 17 years 35.3 41.8 39.5 18 years 36.1 25.9 29.6 Sex (%) Females 48.3 51.0 50.0 Males 51.7 49.0 50.0 School status (%) Not in school 32.9 25.0 27.9 In primary school (Standard 1‒7) 1.4 1.8 1.6 In junior secondary school (Forms 1‒3) 36.7 37.1 37.0 In senior secondary school (Forms 4‒6) 26.6 34.2 31.5 In university/college/vocational school 1.2 1.2 1.2 Missing 1.2 0.7 0.9 Orphanhood (%) Single orphan** 35.7 43.4 40.7 Double orphan*** 7.5 32.6 23.5 Primary caregiver (%) Mother** 62.3 32.7 43.4 Aunt 9.9 21.3 17.2 Grandmother 16.4 26.4 22.8 Other 11.1 19.6 16.5 Missing 0.4 0.0 0.1 **p<.01 ***p<.001 Exposure to OVC Services Quantitative survey results revealed that the youth’s reports of the services they received from the BCCOVC project and/or the GOB were often not in line with the study arm they were in. All youth in the intervention group should have received both BCCOVC and GOB OVC services; however, only about 28 percent reported receiving them, and almost one-quarter reported not receiving any services in the past 12 months. In the comparison group, where all youth should have received GOB OVC services, only about 71 percent of youth reported receiving them, and only about 15 percent reported receiving both BCCOVC and GOB services. Tables 6 shows the percentage of youth who reported receiving BCCOVC and/or GOB services, by study arm. See Appendix A for additional tables on exposure. 26 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Table 6. Percentage distribution of youth’s reported exposure to BCCOVC and/or GOB OVC services in the past 12 months, by study arm Intervention Comparison Total Reported no services 24.3 3.1 10.7 Reported BCCOVC services only 16.4 0.6 6.3 Reported GOB services only 26.2 70.9 54.8 Reported BCCOVC + GOB services 28.4 14.8 19.7 The caregiver reports of services received was highly correlated with the youth’s reports of services received (Cronbach’s alpha = 0.92)). The qualitative reports of the receipt of services for the qualitative subsample are presented below by each outcome area. HIV and Health Below are results on HIV and health services provided to OVC youth, as described by key informants; services reported to have been received by the youth; and the effect of services on youth HIV and health outcomes. Additional outcomes by study arm can be found in Appendix A; please see Appendix B for a matrix of key qualitative results by outcome. BCCOVC HIV and Health-Related Services The BCCOVC LP staff reported promoting HIV testing, HIV prevention, and ART adherence. At the household level, CSPs reported recommending that all household members be tested for HIV and provided referrals to health facilities for testing. For HIV-negative youth, CSPs advised them to be tested twice per year and provided HIV prevention education. In households where a member had HIV, CSPs advised on ways that HIV can be transmitted. For HIV-positive youth, CSPs checked their health cards to ensure that they were attending appointments and that their viral load was suppressed. Psychosocial support and adherence support were provided in the homes, at LP centers, at teen clubs, and through referrals to SWs. LPs also provided HIV education during life skills sessions at schools where youth learned about how HIV operates in the body, living with HIV, and HIV prevention. LPs also counselled youth on how to accept their status and to manage stigma, discrimination, and disclosure. For GBV and child abuse, LPs reported educating youth and their caregivers at their homes, during life skills sessions for youth at schools and LP centers, and in the communities during parent-teacher association meetings and at public meetings. Education included how to recognize GBV and child abuse, laws prohibiting each, how and where to report abuse, and that it was an offence to not report witnessed abuse. One LP reported providing free legal counseling. GBV education was also inserted in other project activities, such as GROW; Young Mothers, Safe Spaces (a component of the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe [DREAMS] programs); and Caregiver-Child Communication workshops. Qualitative Subsample Exposure to BCCOVC HIV and Health-Related Services Figures 3 and 4 show the BCCOVC project HIV-related services that youth in the qualitative subsample reported being exposed to. All HIV-positive youth in the quaitative sample report receiving ART adherence counseling, with the majority of youth reporting that they received support on accepting their status, stigma, discrimination or disclosure. About half reported exposure to HIV prevention education or sexual and reproductive health counseling. Sixteen of 23 HIV-negative youth reported exposure to HIV Evaluation of Services for Orphans and Vulnerable Youth in Botswana 27 prevention education, with about half reporting receiving HIV testing support or sexual and reproductive health counseling. Figure 3. Exposure to BCCOVC project HIV-related services among the qualitative HIV-positive subsample (n=16) Figure 4. Exposure to BCCOVC project HIV-related services among the qualitative HIV￾negative or unknown status subsample (n=23) 12 16 12 4 1 2 7 4 9 0% 20% 40% 60% 80% 100% HIV testing support HIV prevention education Sexual and reproductive health Education on ART adherence Education on accepting status Education on HIV stigma, discrimination or disclosure Yes No No data 7 6 16 11 11 6 7 3 2 0% 20% 40% 60% 80% 100% HIV testing support HIV prevention education Sexual and reproductive health ART adherence counseling Counseling on accepting status Counseling on stigma, discrimination or disclosure Yes No No data 28 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Figure 5 shows the BCCOVC project GBV and child abuse-related services that youth in the qualitative subsample reported being exposed to. Among youth who reported that they had learned about GBV, it was often described as either verbal or physical abuse of children, and sexual abuse or defilement (having sex with a minor). Figure 5. Exposure to BCCOVC project GBV and/or child abuse-related services among the qualitative subsample (n=39) HIV Testing In both bivariate and multivariate analyses, BCCOVC youth beneficiaries were significantly more likely to have had an HIV test in the 12 months preceding the survey and to know their test results compared with the GOB youth beneficiaries (Figure 6). About 40 percent of females and 31 percent of males in the intervention group and 26 percent of females and males each in the comparison group had had an HIV test in the past 12 months and knew the results (Figures 7 and 8). (The statistical significance of sex￾disaggregated data was not examined due to an inadequate sample size.) In addition, BCCOVC youth were significantly more likely to have accessed any HIV service (HIV prevention, testing, and treatment advice) than GOB youth. BCCOVC youth beneficiaries were also marginally more likely to have accessed RH services than GOB youth (Figure 9). Figure 6. Percentage of youth who had had an HIV test and knew their results, previous 12 months** 34.9 25.9 7.7 5.0 0 20 40 60 80 100 Intervention (n=507) Comparison (n=900) Yes Missing **p<.01 19 9 15 0% 20% 40% 60% 80% 100% GBV and/or child abuse counseling or education GBV counseling or education Child abuse counseling or education Yes No No data Evaluation of Services for Orphans and Vulnerable Youth in Botswana 29 Figure 7. Percentage of female youth who had had an HIV test and knew their results, previous 12 months Figure 8. Percentage of male youth who had had an HIV test and knew their results, previous 12 months 39.7 26.4 12.0 10.6 0 20 40 60 80 100 Intervention (n=262) Comparison (n=441) Yes Missing 31.4 26 23.6 28.7 0 20 40 60 80 100 Intervention (n=245) Comparison (n=459) Yes Missing 30 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Figure 9. Percentage of youth who had accessed services in the past 12 months BCCOVC Project-Related Influences on HIV Testing Beneficiaries attributed several positive influences on HIV testing to the BCCOVC project. During household visits, BCCOVC LP staff and their CSPs said that they advised all household members to test for HIV. If beneficiaries had not tested recently, they were given referral forms and encouraged to go to clinics or centers to be tested. If youth tested HIV-negative, follow-up visits were done to encourage them to test again and to maintain their negative status. Both CSPs and youth-caregiver dyads reported that CSPs taught household members about the importance of HIV testing. Several youth beneficiaries and caregivers credited LPs with motivating youth to test and/or motivating the caregiver to encourage youth to test. For example, during a household visit, one CSP recommended that everyone in the home be tested for HIV, which then prompted the caregiver to take the children for testing. Caregivers also helped youth overcome personal barriers that they faced to testing. One youth who had learned about testing from a CSP was not comfortable going alone. When her caregiver offered to accompany her, she then got tested. In some cases, the participants reported that they got tested themselves and even encouraged other youth to get tested. LPs were able to combat fears of testing by communicating that having HIV is not a death sentence. As one youth participant said, the LP “taught us that living with HIV is not the end of life. They are the ones that motivated me. At first I was afraid to test, but after hearing [what they said], I felt like I really needed to know my status.” Barriers to HIV Testing Knowing one’s status was a prerequisite for receiving other project services. If a youth tested positive for HIV, his/her appointment attendance and viral load were then tracked, and s/he was provided counseling (either directly or through a teen club) on adherence. If youth tested negative, they was advised on HIV prevention methods and encouraged to stay negative. If the HIV status was unknown, then they were encouraged to get tested. However, LPs faced significant barriers to obtaining HIV test results. 56.2 11.1 45.7 6.6 0 20 40 60 80 100 HIV prevention/testing/treatment advice** Reproductive health services+ Intervention (n=507) Comparison (n=900) +p<.1 **p<.01 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 31 One LP reported that relying on clinics or testing facilities to provide HIV testing services made it difficult to determine whether a beneficiary youth had reached the referral point and had been tested. Another LP said that sometimes the results could take two to three months to be received and that by that point, a client’s health could have deteriorated. Home-based or center-based testing were both suggested as ways to remedy these problems. Participants suggested that LPs offer testing services themselves. One LP suggested that it be able to administer tests to get the test results more quickly. One youth also suggested that the LP offer the test at its center. Despite understanding the importance of testing, youth described several barriers to getting tested, including not knowing where to get tested and confusion around the process for getting testing. Youth who did get tested reported that being offered home-based testing was pivotal for them, suggested that home-based testing be provided more widely, and that LPs open their own clinics for testing. A belief that youth are not at risk posed a barrier to HIV testing. Some caregivers said that they did not know the child’s status, and several were not aware about whether the child had been tested. For caregivers, the belief that a child is not at risk resulted in a lack of urgency or unwillingness to test at all. For example, both a 16-year-old girl who had never been tested and her caregiver thought that it could be done later. The caregiver planned to take the youth after her Form 3 exams, whereas the youth wanted to take the test when she was 18. On the other hand, being too old was also a barrier for caregivers to encourage testing. One caregiver said of her 18-year-old granddaughter, “I can’t boss a child around as old as her. The younger ones I can take to get tested at the clinic. I take it that she’s old so she should go by herself.” One CSP found a testing center that would not test minors because they believed such youth to be low risk, but the CSP persuaded them that testing minors was also necessary. Another significant barrier to testing was beliefs about what testing implied about youth’s behavior. As a 16-year-old said, “I’m scared to ask them to take me for testing. They would wonder why I want to test, as young as I am.” Interviews revealed that youth also felt uncomfortable talking about sexual relationships with their caregivers. During a household assessment, an LP found a 14-year-old was categorized as high risk due to having multiple sexual partners. The LP wanted to refer her for HIV testing; however, she was unwilling to ask her caregiver to take her for an HIV test because she did not want her caregiver to find out. Given the barriers to open discussion about sexual relationships, talking about testing for HIV was also challenging, and youth feared discussing or asking for an HIV test because of the expected judgement from their caregivers. LPs lamented that without parental support, there was nothing that they could do. However, the caregivers did feel that testing was needed to determine why a youth was not recovering from an illness. Conversely, this association between illness and HIV led caregivers to believe that if the child was not ill, there was no need for an HIV test. In most cases, children are taken there when they’re sick and not getting healed and showing signs. That is when you can take a child to go for a test and ask them to test the child because you see certain things. Nothing that prompts has ever happened. —Caregiver Although youth reported that LPs emphasized the importance of testing, they did not always explain why it was important. Witnessing the effects of being HIV-positive and the benefits of treatment had a positive impact on a youth’s desire to test. One youth recommended that LPs help youth understand the importance of knowing their status and the consequences of not knowing their status. 32 Evaluation of Services for Orphans and Vulnerable Youth in Botswana They can talk to them about the importance of getting tested and that if the virus is detected early it can be controlled well than when the CD4 count is very high. If the person tests very late, it will be difficult to treat them and that will end up causing unnecessary deaths. —Male, 17 years old HIV Prevention The mean age of sexual debut among youth who had ever had sexual intercourse was 15.6 years and 15.5 years, among youth in the intervention and comparison groups, respectively. Sexual risk behaviors, including the number of sex partners, use of condoms, and transactional sex, did not significantly differ between the study arms. Table 7 shows youth’s reported number of sexual partners in the past three and twelve months. Table 7. Percentage of youth who had ever had sex reporting one or more sex partners in the past three and twelve months, by study arm Intervention (n=107) Comparison (n=115) Total (n=222) 1+ sex partners in the past 12 months Yes 77.6 76.6 77.0 Missing 8.4 8.7 8.6 1+ sex partners in the past three months Yes 61.7 61.7 61.7 Missing 25.2 21.7 23.5 2+ sex partners in the past three months Yes 14.0 13.9 14.0 Missing 25.2 21.7 23.4 Although descriptively, a higher percentage of intervention youth beneficiaries reported using a condom every time they had had sex in the previous three months, there was not a significant difference in the multivariate results (Figure 10). Figure 10. Percentage of youth who had reported using a condom every time in the past three months 61.7 55.7 30.8 35.7 0 20 40 60 80 100 Intervention (n=107) Comparison (n=115) Used condom every time Missing Evaluation of Services for Orphans and Vulnerable Youth in Botswana 33 High-risk sexual behavior was about the same between the intervention and comparison youth. Note the high percentages of missing data due to non-response in both groups (Figure 11). Figure 11. Percentage of youth who reported high-risk sexual behavior Project-Related Influences on HIV Prevention Caregivers and youth reported being exposed to HIV prevention education provided by LPs and other nongovernmental organizations. CSPs educated families during household visits or during LP sessions held at schools. Both CSPs and the beneficiaries said that youth learned about HIV transmission and precautions that could be taken to avoid infection. Beneficiaries reported learning about sexual and non-sexual means of HIV transmission. Prevention methods discussed in relation to sexual modes of transmission included the ABC message (i.e., abstinence, be faithful to one partner, and condom use) and male circumcision. The beneficiaries living with HIV learned about the possibility of being reinfected by another HIV-positive person and that transmission can be prevented by having an undetectable viral load. During interactions in the homes and in life skills sessions at schools, LPs emphasized that abstinence was the best way to prevent HIV and pregnancy. These messages were also reinforced in schools during sessions hosted by clinic staff and former students. [If one abstains] You can’t be infected with the virus, you can’t fall pregnant and also won’t get abused like the way some people get abused in relationships.—Female, 16 years old, in-depth interview Because if I abstain, no risk of pregnancy, no risk of contracting HIV and…if I abstain, it can help me be focused and not think of a baby I left at home, who is mine, while I go to school. It helps me be focused on my schoolwork.—Female, 17 years old, in-depth interview The lecture taught us that we should not engage in relationships while we are still schooling because if we do that, your partner will be always on your mind while in class and you would lose concentration. I also learned that if you are in a relationship, you could fall pregnant and drop out and when you come back you would be older than those in the same class as you and they would start verbally abusing you, saying they don’t want to school with an elder.— Female, REM group discussion In one case, the caregiver was educated by a CSP on different “protective measures against HIV/AIDS, like how he can protect himself by abstaining and using a condom. But they mostly focused on that they are still growing and should abstain.” The youth was not at home when the CSP visited, but he said that 18.7 18.3 14.95 13.9 17.8 17.4 21.5 23.5 0 20 40 60 80 100 Intervention (n=107) Comparison (n=115) Intervention (n=107) Comparison (n=115) Multiple sex partners or inconsistent condom use, past 3 months Transactional sex in past 6 months Yes Missing 34 Evaluation of Services for Orphans and Vulnerable Youth in Botswana his mother had scared him about HIV/AIDS, saying that it was “so bad and you won't be well if you have it,” and had used fear to motivate him to protect himself. Therefore, positioning HIV prevention as a way to avoid suffering and missed opportunities was persuasive for some. One LP advised youth to stick to one partner and choose wisely. They advised me that I should choose a good life partner, not the one who thinks about sex only, not caring about my schoolwork and that I have to read.—Female, REM group discussion I had many boyfriends, I was so naughty, but since I joined [LP] and was taught that we have to stick to one partner, I stopped things that I was doing.—Female, REM group discussion Messages that aim to help HIV-positive youth accept that living with HIV is possible were also appreciated by those who did not have HIV. For example, one youth learned that if she became HIV-positive, she should accept her status and “not just throw myself under the bus waiting to die.” Others learned that medication should be taken for life, and that if the medications were not taken consistently, the virus would multiply. They taught us that if you are living with HIV, then you are supposed to take your pills at the time that you were told, exercise, and eat nutritious food that has been recommended by the doctor. You are also supposed to protect yourself from people in your household so that you don’t infect them with the virus. —Female, 18 years old These lessons helped HIV-negative youth appreciate the situation of others who were living with HIV, helping to destigmatize HIV. It also preconditioned those who had not acquired HIV to be able to cope better should they acquire the virus in the future. Knowing that treatment was available helped one youth who was engaged in high-risk behavior cope with the prospect of acquiring HIV. One HIV-positive youth was persuaded to use adherence as a way of preventing transmission. Anticipating being in a relationship and having sex, a youth asked the teen club leader if her partner was at risk. She was advised that “it won’t spread if I take my pills,” which motivated her to adhere. “If you stop taking them, there is a possibility that you can pass the virus to another person, but because I don’t want to do that, I just have to keep taking them so that I don’t infect him.” She disclosed her status to her partner, but thereafter became concerned about pregnancy. Although she did encourage him to use condoms, he asked her to have sex without them. She said, “I was afraid, but he told me nothing will happen… He told me that he can control his sperms, so no mistake will happen,” and she trusted him. Last, the caregivers and youth alike admitted that talking to each other about sexual relationships was difficult. For caregivers, knowing that youth were getting the information elsewhere provided relief. One caregiver suggested that LPs talk about sexual relationships and risks because their children did not want to share with them. Talk to these children, because if we try and talk to these children and give them advice, they get angry at us at home. So please do talk to these children about sexual activities, because these children engage in sexual activities without protecting themselves.—Caregiver On the other hand, LP staff said that youth were, in fact, willing to share their experiences with them. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 35 Barriers to HIV Prevention Although LPs taught youth about condoms and, in one case, correct condom use, there were notable barriers to their use, especially access to condoms. Youth feared judgement from staff at clinics and also that someone from the community would see them obtaining condoms at the clinic and would tell others, especially their caregivers. LPs accompanied some fearful youth to clinics to access condom; however, they said that this is not always possible due to time constraints. Although one youth recommended that LPs tell them where they could access condoms, a CSP went one step further and suggested that LPs should also be distributing condoms, saying, “teaching about condoms is not enough.” Moreover, LPs suggested that condoms be distributed at schools, especially at boarding schools, although they had encountered resistance. LPs said that the schools cited the education policy as the barrier. One LP said that there were no policy barriers, but the schools were still unwilling. As with HIV testing, some youth feared that their caregivers would find out that they were accessing methods of HIV prevention because they did not want their caregiver to know that they were sexually active. For example, one boy got circumcised as a method of HIV prevention, but never told his caregiver. Engendering a belief that one can live like anyone else helped youth cope with the prospect of being HIV￾positive and facilitated HIV testing. GBV Experience, Knowledge, and Services Approximately 1.6 percent each of youth in the intervention and comparison groups reported having experienced sexual violence in that past 12 months. Receipt of medical care and psychological services for GBV in the past 12 months was asked of all youth, regardless of whether they reported having experienced sexual violence in the past 12 months. BCCOVC youth beneficiaries were marginally significantly more likely to have received medical care or psychological services due to GBV (p<.1). Note the large percentage of missing data because of non-response (Figure 12). Figure 12. Percentage of youth who had received medical care or psychological services in the past 12 months due to GBV+ 8.7 5.9 35.5 33.0 0 20 40 60 80 100 Intervention (n=507) Comparison (n=900) Received GBV services Missing + p<.1 36 Evaluation of Services for Orphans and Vulnerable Youth in Botswana BCCOVC Project-Related Influences on GBV Knowledge and Services Participants’ definitions of GBV varied. A minority of youth and caregivers accurately defined GBV as physical, emotional, or sexual violence related to gender. Some youth reported GBV occurring between parents or gave examples of sexual harassment. However, most defined GBV as violence, such as verbal, emotional, physical, and sexual abuse perpetrated by an adult toward a child. One youth said that GBV was “to abuse a child. Maybe wanting to have sex with her or maybe the child refuses and he will beat that kid or even chase her, chase her away from home.” LPs reported that after learning about what constituted abuse, survivors were more likely to recognize that they were experiencing abuse. In particular, after life skills sessions at schools or in safe spaces, some youth approached the facilitator and revealed in private that they had experienced abuse. LPs said that GBV was normalized and only recognized as abuse following education. One youth reported that the LP helped him cope with GBV between his parents at home. …the situation was still burdening me because it was always happening. [After the LP’s advice] I was able to see what I can do and if the situation is like that I shouldn’t harbor them too much in my heart. I should just focus on my life and my education.—Female 17 years old The LP also informed the youth where she could seek help, (i.e., SW office, hospital, church, or police), although she had not done so. One youth reported learning that such abuse can affect children academically because they would be distracted by what would happen when they went home. Some caregivers found the education enlightening because they had not realized calling their child names was abusive; one respondent said that she stopped using such language when speaking with her child. When GBV was identified in homes, LPs conducted family conferences to address the problem, referred to the Families Matter! Program, and referred to SWs for support. One LP reported offering psychosocial services, helping survivors find alternate accommodations, providing legal counsel, accompanying survivors to the police, and monitoring and prompting the progression of reported cases through the legal system. Barriers to GBV Knowledge and Services Two CSPs reported that they could not educate beneficiaries about GBV unless they had reason to believe that the beneficiary was experiencing violence. Abuse may be identified through administration of a household assessment tool or merely by chance. CSPs reported that not being able to educate households about the nature of abuse led to underreporting because many youth did not realize that what they were experiencing was abuse and that it can be reported. One CSP said that GBV was only discovered when visiting a home and finding the victim upset and then finding out that she had been beaten by her partner. ART Initiation and Adherence BCCOVC project and GOB youth beneficiaries who were HIV- positive were equally likely to report being on ART and to report adherence to ART (Figures 13 and 14). Evaluation of Services for Orphans and Vulnerable Youth in Botswana 37 Figure 13. Percentage of HIV-positive youth who reported being on ART Figure 14. Percentage of HIV-positive youth who reported adherence to ART BCCOVC Project-Related Influences on ART Initiation and Adherence Encouraging Caregivers to Inform Youth about Their Status CSPs encouraged the caregivers to inform youth that they were HIV-positive because adherence would be difficult if they did not know why they were taking the medications. Some youth reported not adhering when they were younger because they had been deceived about the purpose of the medications. The children found out only later from someone else and, in one case, the respondent learned of her positive status when the doctor discovered, through a treatment monitoring test, that the youth was not adhering. The doctor realized that the reason why I was not adhering to the medication was because my mother never talked to me… I learned that I’m going to take these pills for the rest of my life and if I don’t take them I will die… If it wasn’t for that doctor explaining things to me, I would have been dead by now.—Female, 17 years old Another youth’s caregiver said the youth asked the SW about the medication and when she learned why she was taking them, her adherence improved. “She is different than she was before she knew she has HIV. Back then, she would refuse to take the pills, but after talking to the SW, she started adhering.” 92.2 88.2 2.0 0 20 40 60 80 100 Intervention (n=51) Comparison (n=51) On ART Missing 76.6 75.6 2.1 4.4 0 20 40 60 80 100 Intervention (n=47) Comparison (n=45) On ART Missing 38 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Helping Youth Accept Their Status Learning to accept one’s status engendered the most positive and far-reaching changes in youth’s lives. This attitude shift affected youth in different and overlapping ways, including improved confidence, self￾esteem, outlook on the future, and resilience; reduced fear of stigma and discrimination; and acceptance of and adherence to treatment requirements. Youth reported that these changes, in turn, led to positive effects on their school performance, willingness to participate in social activities, and disclosure of their status to others (Figure 15). Figure 15. Influence of accepting one’s HIV status on ART initiation and adherence, health and well-being, and education outcomes Youth and caregivers credited the education, counseling, and peer support provided by teen clubs for helping youth accept their status. The messages that had the greatest impact were that being HIV-positive did not mean the end of their lives, that they could live like anyone else without HIV, and that they were not alone. I am living well since I accepted my status… So, I feel like I live just like everybody else. I feel the challenges I would face as an HIV-positive person are the same that an HIV-negative person would face.—Female, 18 years old I found so many people who were going through what I was going through…So that’s when my eyes started opening and I also started becoming wise.—Female, 17 years old Sometimes I would want to stop taking the pills so that I can die… They helped me accept the situation that I’m in… I am becoming better.—Female, 17 years old BCCOVC Teen Clubs Other influences Supportive home environment Peer-group support counseling Evaluation of Services for Orphans and Vulnerable Youth in Botswana 39 Understanding the Purpose of Medications LPs’ efforts to educate youth on the purpose of their medications, the nature of the virus, and how the medications combat its effect were successful at encouraging proper adherence. One youth said that she was not taking her pills correctly; however, once she learned from the teen club about how the pills worked, this helped her understand the importance of taking them as prescribed. Like if my scheduled pill intake time passes, and I had forgotten to take them, I would let it go and not take them at all. When I have to go to hospital and I didn’t want my father to notice, I would throw them away so he doesn’t notice how many days I missed.—Female, 16 years old I learned that the pills increase our CD4 count and that I have to make sure I take them all the time and not miss any day, because if I don’t, I might end up killing my remaining cells… Because they are the ones that fight small diseases like flu.—Female, 16 years old Even her caregiver noticed a big improvement since the youth started attending the teen club and said that she now took the pills on time and on her own without needing to be reminded. In another case, a caregiver said that the youth improved greatly after reading books provided by the LP. She used to forget to take her medications on time, but now, the caregiver said, she knows that “if she doesn’t take her pills, the virus will attack her immune system and she will become sick.” Some youth also said that they were motivated to adhere because they knew that if they did, they would live longer. This message was often reinforced by blunt messages that if they did not take their medications, they would die. For one youth, the most significant change achieved by the LP was the realization that if she stopped taking her pills, she could die. As another youth said, “If you don’t drink these pills, you are literally digging your own grave.” His caregiver said that this message had made a big difference in the youth’s commitment to taking his medications on time. They are beneficial. Before he received the lessons, he took medication for granted. Even when it is 7 p.m., because he takes his medication at 7 p.m., he would just play. But today when it’s time, he comes running and takes his medication. —Caregiver Another caregiver said “Even when the river is full and he has to walk far to the hospital, he still goes for treatment.” For his part, the youth also found the lessons useful. “It is beneficial, because if you have been told that you have HIV and you don’t take medication, you may lose your life.” Other youth struggled to remember to take their medications on time when they were busy or distracted, for example, by studying for school exams. During one home visit, a CSP advised a girl that she could set an alarm. This was a good reminder strategy and she recommended that LPs help others by providing watches to do the same. The caregivers also reported helping youth remember to take their medications and, in one case, both the caregiver and the youth had the virus and would remind each other. Youth reported that adhering to their medications had had a significant impact on their health, for example, by gaining weight, feeling better, and looking better. Combatting Stigma and Discrimination Teen clubs helped youth cope with and manage stigma and discrimination, which had a positive impact on adherence. Youth reported facing multiple barriers to proper adherence. Exhibiting behavior associated with HIV treatment, like regularly taking medication or queuing at clinics, was often cited as a reason for nonadherence. Youth admitted that they often did not take their medications when around those who were unaware of their status for fear that others would suspect that they were HIV-positive. I feel that if I have to go take my pills, they are going to want to ask me too many questions, so that is the thing that can make me not take my pills.—Female, 16 years old 40 Evaluation of Services for Orphans and Vulnerable Youth in Botswana I used to forbid her from visiting other people because she would not adhere to her medications. When you tell her to take the medication, she will just pretend as if she is taking it. [Since the teen club, she has changed and now] she is taking them consistently. —Caregiver Teen clubs provided support and encouragement to youth who feared that their status was obvious or would be discovered. For those who did not want everyone to know, they were reassured that HIV is not visible and that they did not need to be afraid. Initially, some thought that just being at a clinic was an obvious sign of being HIV-positive or that others could just plainly see it from their appearance. This led some youth to assume that others knew, and it resulted in their withdrawal from social situations and fear of being the object of attention at school, for example, in class discussions (particularly on HIV) and when making presentations. With the support of the teen clubs, they overcame their fears, built confidence, and engaged more socially, both in the community and inside the classroom. “It’s not like it’s written on my forehead or any part of my body that I’m HIV-positive.” This was reinforced by participation in the teen clubs, where youth were exposed to many others with HIV and could see for themselves that they looked like anyone else. LPs also helped youth realize that disclosure was a choice and one to make carefully, (i.e., they should consider the trustworthiness of the person, the regard the person has for them, and how the person might use the information). At the same time, some youth found the courage to be open about their status to people outside their inner circles of trusted friends and said that they were able to cope with others’ negative reactions. Disclosure to school staff also helped the staff be more understanding about absences. The thing is with accepting yourself comes a lot of things. If you accept yourself, even if you hear someone saying something negative about HIV, just be content that you’ve accepted yourself. And what he’s saying isn’t true, so long as you’ve accepted your status, everything is fine. —Female, 18 years old Teen clubs also gave youth advice on how to disclose to their partners. They said, if you have a lover and you want to tell him/her about your status, you shouldn’t be direct with him/her. You start by asking him/her questions that will eventually have you arrive to your point where you then tell him/her, ’I’m HIV-positive.’ Like it should be a joint agreement and full knowledge that you are HIV-positive… You have to know that he might go or he might stay and support you.—Female, 18 years old Creating a Supportive Environment LPs also reported being able to improve the health of HIV-positive youth by compensating for barriers in communication with their caregivers. For example, the caregivers and youth both reported feeling awkward talking about sexual matters or partners, and LP was able to provide information and advice when the caregivers could not. Likewise, youth said that they felt more open talking to people at the teen club (and to siblings and friends) than with their caregivers. LPs’ efforts also helped some youth let go of their anger about being infected. One caregiver said that a youth had struggled to accept her status and “would break down crying, blaming me for infecting her with the virus.”The caregiver explained that she had not known and that it was her father who had brought the virus home from outside relationships. At the teen club, youth learned that “living with HIV is possible and that I just need to take care of myself... They educated me on how to live with HIV… I told myself that it is life and there is nothing I can do.” Some youth also said that the teen club helped them put their problems in perspective. One youth came to appreciate that “there are people with bigger problems than mine, so I shouldn’t stress myself about this.” A positive, caring, and supportive environment at home helped youth accept their status. As a caregiver said, “Love, we give him love. We do not discriminate against him. Even the young ones, they just share Evaluation of Services for Orphans and Vulnerable Youth in Botswana 41 things with him. We do not show him that he is different from anyone, he just does anything freely.” The youth said that his ability to accept his status was influenced by how his caregiver treated him. Household Monitoring and Interventions The qualitative data revealed examples of support from the BCCOVC project that encouraged and enabled youth to adhere, who otherwise might not have continued to take their medications. For example, one CSP found a youth who had not had an ART monitoring test since 2016 and had stopped taking her medications. Through intensive monitoring and support, the CSP was able to ensure that the youth attended medical appointments and was taking her medications. Her viral load decreased and the CSP believed that their interventions may have saved the youth’s life. Problems with HIV care and treatment were detected through the review of health cards (a medical history card carried by clients to each health facility visit on which the health professional records information, such as services provided and test results) to determine whether youth were attending medical appointments and whether their viral load was suppressed. CSPs reported investigating issues with health facility visits or treatment through one-on-one counseling and/or by referring youth for counseling and support at the teen club or from SWs. One LP taught a caregiver how to support her child by monitoring the pill bottles. “They taught us to take care of the children and ensure that they take the medications well. And to further look at their health to confirm whether they are taking their pills or throwing them away.” However, some youth tried to cover up their failure to take their pills by throwing out the ones that they had neglected to take. In one of these cases, the CSP reported being able to detect such instances with treatment monitoring tests. Barriers to ART Initiation and Adherence A barrier to adherence cited by LPs and youth is the need for food to take the medications. CSPs assessed household food security and the quality of food available, with cases of nutritional deficits being referred to SWs for support. However, not all beneficiaries were assessed at the household level and some participants requested and recommended that the CSP facilitate access to food. One youth recommended that the LP provide food to those who did not have enough because the medications need to be taken with food and some only have enough for one meal a day. One caregiver recommended that the LP provide financial support to buy nutritious food for those whose parents were not able to provide it. Yet another caregiver complained that the government was only focused on antiretrovirals and not on looking at the family’s problems holistically, including food insecurity. Overwhelmingly, youth were empowered by the teen clubs; however, one youth did not want to attend the teen club any longer because her neighbors were curious about the purpose of the meetings. “Then I explained to them that we are taught some activities, then they accused me of lying… I felt like everyone knew… I felt like I was discriminated against and exposed among others.” The caregiver later noticed that the youth had not been going to the club and wondered whether there was another place she could go farther from home, where no one could see her. One youth recommended that the BCCOVC project focus more on self-acceptance for HIV-positive youth: They [BCCOVC project] should also educate them [HIV-positive youth] on issues of discrimination… They should teach them how to be firm in their decision making. It is not easy to accept your situation, but if someone doesn’t want to stay in your life, it can only mean that they don’t love you, and it is okay. Whoever stays will stay and whoever goes will go.—Female, 18 years old LPs reported that caregiver care and support or neglect had a significant impact on ART adherence. LPs found that when youth were at home, their adherence was better than when they left home. However, LPs 42 Evaluation of Services for Orphans and Vulnerable Youth in Botswana reported that some parents neglected their children and that they lacked care on many levels, including nutrition and support for ART adherence. One LP reported wishing that they could relocate the children to more caring environments, but found that there was no alternative living situation for the children. Summary of HIV and Health-Related Results Table 8 summarizes the multivariable results for the HIV and health indicators, comparing youth in the intervention and comparison groups. Statistically significant differences in a positive direction indicated that youth in the intervention group fared better for these indicators than youth in the comparison group. Table 8. Significance and direction of logistic regression coefficients assessing the differences in HIV and health behaviors and services between the intervention and comparison groups¥ HIV/Health Indicator Significant Difference? Direction of Association % youth who had an HIV test in the past 12 months and know their results ** Positive % youth who received HIV prevention/testing/treatment advice ** Positive % youth who received RH services in the past 12 months + Positive % sexually active youth who used a condom every time during sex in the past three months NS N/A % sexually active youth who reported multiple sex partners OR inconsistent condom use in the past three months NS N/A % sexually active youth who engaged in transactional sex in the past six months NS N/A % youth who received care in the past 12 months due to GBV NS N/A % HIV-positive youth who are on ART NS N/A % HIV-positive youth who report adhering to ART + Positive ¥Models adjusted for age, sex, school status, orphanhood, and primary caregiver. NS = Not significant +p<.01 **p<.01 N/A = Not applicable • The BCCOVC project helped HIV-positive youth accept their status and improved their confidence, self-esteem, and outlook. Consequently, the youth became more resilient to stigma and discrimination, more committed to ART/treatment adherence, more engaged at school, more willing to participate in social activities, and more willing to disclose their status. • From the PEPFAR-funded education activities and from personally witnessing those with HIV, the youth understood the consequences of not adhering and realized that without treatment for HIV, one will die. This motivated HIV testing and ART adherence. • The PEPFAR-funded education on how medications work to combat HIV and the importance of taking them on time motivated the youth to adhere. • Fear of moral judgement was a barrier for the youth to ask for an HIV test or to access HIV/pregnancy prevention methods. HIV and Health: Key Findings on BCCOVC Project and GOB Program Effects and Challenges On Evaluation of Services for Orphans and Vulnerable Youth in Botswana 43 Economic Stability In this section, we share the results on the economic stability-related services provided to OVC youth, as described by key informants; services reported to have been received by youth; and the effect of services on youths’ economic stability outcomes. Additional outcomes by study arm can be found in Appendix A; please see Appendix B for a matrix of key qualitative results by outcome. BCCOVC Economic Stability-Related Services LP staff reported using tools and activities to improve financial literacy, build entrepreneurial capacity, and prepare youth for the workplace. Ready to Work, the Aflateen program, and life skills sessions taught entrepreneurship skills (market research, positioning, and financial management), work skills (finding work and working with people), and money management (budgeting and saving), and facilitated internships and job placements. These sessions were for secondary school students and were held at their schools or at LP centers. The leadership program helped out-of-school youth learn new skills or find employment. The GROW (formerly called We Legacy) initiative provides education on entrepreneurship and invited people to form a group savings scheme. Members made weekly contributions to a shared fund that could be borrowed by members with interest or used as start-up capital for members to launch new businesses. LPs monitored the progress of the group in their ability to generate income from their activities. The Young Mothers program had an economic strengthening component. LPs helped youth access vocational training schools by providing information on courses offered and helping youth with applications. LPs helped access government programs such as Poverty Eradication, Young Farmers Fund and Youth Empowerment. For those youth and households who did not receive GOB food support, LPs referred them to SWs. Qualitative Subsample Exposure to BCCOVC Economic Stability-Related Services Participants reported that LP facilitators or CSPs provided education on a wide range of topics for improving economic stability, including understanding the differences between needs and wants, the idea that savings can be used when problems arise, becoming more financially independent at present and financially secure in the future, looking at income against expenditures, and adjusting spending if expenditures were greater than income. Figure 16 shows the BCCOVC project economic stability-related services that youth in the qualitative subsample reported being exposed to. Out of 37 youth in the qualitative subsample, 26 reported receiving financial literacy services, 13 reported receving work readiness skills, and 14 reported receiving income generation services. Figure 16. Exposure to BCCOVC project economic stability-related services among the qualitative subsample (n=39) 26 13 14 0% 20% 40% 60% 80% 100% Financial literacy Work readiness Income generation Yes No No data 44 Evaluation of Services for Orphans and Vulnerable Youth in Botswana GOB Economic Stability-Related Services The GOB was tasked with providing households with monthly food assistance in the form of food baskets, vouchers, or coupons. The GOB was also tasked with providing financial support to orphans in the form of an allowance of pula (P)600 for the first orphan in a household, P850 for two orphans, and P1500 for three or more orphans. Toiletries were reported to have been provided every three months. When a youth turned 18 or failed Form 3, SWs would counsel youth about possible income generating activities and facilitate access to GOB grants to start small businesses by explaining that youth was an orphan and recommending that s/he be given assistance. Financial Literacy and Saving Youth scored, on average, 6.4 out of 10 points on a financial literacy index that asked respondents questions about hypothetical scenarios to capture how well youth understood various concepts of saving and spending money. Females scored 6.5 and males scored 6.3 on this index (data not shown). Youth in the intervention group were .10 points more likely to be financially literate than those in the comparison group. Although this difference was statistically significant (<.05) it is not programmatically meaningful (Figure 17). Figure 17. Percentage of youth who reported various economic stability outcomes * p<.05 ** p<.001 BCCOVC youth beneficiaries were significantly more likely than the GOB youth beneficiaries to report starting a small business or conducting an income generating activity in the past 12 months (p<.05), working for cash in the past three months (p<.05), and saving money in the past 12 months (p<.001) (Figure 18). 25.6 17.4 11.4 7.9 4.3 22.0 15.0 7.8 4.9 3.2 Perceive they have the skills necessary for employment or starting a business Saved money in the past 12 months** Report having worked for cash in the past three months* Report having started a small business or other income-generating activities in the past 12 months* In an internship or job training program Comparison (n=900) Intervention (n=507) Evaluation of Services for Orphans and Vulnerable Youth in Botswana 45 Figure 18. Basic financial literacy of youth, mean score* *p<.05 Project-Related Influences on Financial Literacy and Saving Beneficiaries reported that the BCCOVC financial literacy sessions enabled them to reflect on the ways that they were spending money and the benefits of prioritization, budgeting, and cost cutting to help them now and in the future. Lessons from the BCCOVC project led youth to reflect that the purchases they were making were often wasteful or unnecessary. Two female youth said that when they had money, “I would spend it all within a day.”A male youth said that he would just “buy whatever it is that excites me.” Some said that they used to spend their money on sweets or junk food at the tuck shop (small retail food shop). For example, one girl who received P1,600 (US$150) in monthly compensation for her father’s death said that she used to immediately call her friends, spend the money recklessly, and save none of it. She learned from the project how to use money, and now attends weekly meetings and makes contributions to a joint savings fund. She said she now spends the money wisely, saving P600 each month, buying clothes, and giving her mother money or food for the house. Youth said that they used their money to buy things that were needed, for example, food, toiletries, or school supplies. Others were saving for things that they wanted for themselves, such as clothes or a phone. After the BCCOVC lessons, some participants came to the realization that money saved could be used to generate income. One participant wanted to save to start a business if school did not work out, a few to sell sweets and chips, one to open a tuck shop, and another for the equipment he needed to run a design and technology business. In another case, one girl who had failed Form 3 learned how budgeting and saving could help her build up capital to start a business. She learned that first one budgets to see if “the things you budgeted for can be covered by the money you have for the things you need.” Although the girl had not yet started her business, she realized its potential. The financial education was “useful to me because I can help my family with anything they need. Like when the food is finished, the money I would have made from the business, I would be able to take something from it and help them.” Caregivers also noted a difference in financial literacy and behavior following youths’ participation in the BCCOVC project. In one case, the caregiver noticed a big change in the youth’s attitude and behavior. “Last year, before attending the lessons, he lived a hand-to-mouth life…[Now he knows] when you have money, you don’t have to use all of it. You should save part of it and use some. And continue saving until you can open a business with the money.” The youth said he wanted to use his saved money to open a tuck shop (i.e., a kiosk or shop selling snacks, airtime, or drinks). Another youth said that LP had taught 6.45 6.35 0 2 4 6 8 10 Intervention (n=507) Comparison (n=900) 46 Evaluation of Services for Orphans and Vulnerable Youth in Botswana her to achieve a realistic balance, “It’s not like I should use all of it for important things. I am a kid and I should spoil myself occasionally.” Others found ways to save when buying goods, for example, by choosing cost-saving grocery specials like “combos,”walking to school instead of using transport money, and cooking instead of eating out. Youth also learned where money could be saved, like using a money box or purse, saving in an Orange Money account (bank account linked to an Orange cell company phone number), or storing their money in a bank with the assistance of their caregivers. One girl saved in an Orange Money account, and her friends trusted her and asked her to keep their money for them. Barriers to Financial Literacy and Saving Youth participating in the BCCOVC project reported that saving and having money at hand had its pitfalls. Two reported siblings siphoning it off, either by borrowing and not repaying it or by accessing their Orange savings account and spending it. Friends also pressured some youth to spend their money on things they wanted, like junk food at the tuck shop or going to places that cost money. However, learning about money management did provide a frame of reference that helped the youth recognize the negative influences. After learning how to manage his money better and to stop spending recklessly, “I then realized that pleasing my friends doesn’t allow me to budget my money properly.” Although many beneficiaries reported learning about the importance of saving and having money when needs arise in the future, most said that they were never in a position to save because their needs were always immediate and they drained whatever money they had at hand. One youth said that he tried to save, but “then I would hear that there is no salt and I would give them [money] to go and buy [it].” In another case, the caregiver said that the child would not save because whatever money he had, he gave to the family to buy what they needed. “So, if people give him P100, he can’t just say he is going to save P50 for himself. He is going to say, ‘Let me go give Ma P50 so she can buy sugar.’” Even with the desire to save and apply what they had learned, one youth reported that s/he was struggling to meet basic needs, and all income was used toward this end. Although this could be said to be good money management in terms of prioritization, the practice and benefits of saving were never realized. Some beneficiaries said that what they learned was already known and practiced, oftentimes because the need to be careful with money was reinforced by family members, especially in households that were struggling to meet basic necessities. Work and Work-Related Education BCCOVC project youth beneficiaries were significantly more likely than the GOB youth beneficiaries to report having worked for cash in the past three months (p<.05) (Figure 18). BCCOVC Project-Related Influences on Work and Work-Related Education Around one-third of the BCCOVC beneficiaries reported having been exposed to work-related education or guidance. Those who reported this said that they had learned about the educational requirements to qualify for different jobs; how their interests and skills related to jobs in the marketplace (and were provided with informational pamphlets); how to write a CV; and how to use a computer. One youth who reported participating in a workshop on career planning said that they mapped career interests using magazine cuttings and discussed their collage and their thoughts about career choices. LPs said that the Leadership Program was mostly offered to out-of-school youth to find jobs. One CSP reported that some youth were applying for or had secured employment. For example, one youth had secured a short-term task-related job at an organization. Another CSP said that the program “has changed a lot of lives.” One beneficiary was told that if she didn’t do well in school, she could sign up for this Evaluation of Services for Orphans and Vulnerable Youth in Botswana 47 program and learn “handiworks,” such as sewing or cooking. However, one beneficiary felt that she was missing out because the LP offered business skills only to youth who had poor grades. They were taught such skills as handiwork, sewing, or cooking, which could be used to generate income. Despite her interest, she did not feel that those services were accessible to her and suggested that they be offered to all youth. From a program perspective, one LP thought that the Ready to Work program, which helped youth find work placements suited to their skills and qualifications, was more effective than Aflateen, which focused on education. LPs provided skills training at their centers, which prompted a caregiver’s suggestion that LPs provide certificates demonstrating that youth had been trained in a particular skill as supporting documentation for job applications. Realizing the consequences of not being financially independent was cited as a motivating factor to find work. One female youth said that becoming a parent made her think more seriously about finding work so that she and the baby could “survive.” One CSP advised a girl who had failed Form 3 that she should not stay home and be idle, because then “I will soon get used to depending on my parents to say, they are the ones that will do things for me. Because if I worked, I could be earning something and be able to do things for myself.” Taking this advice to heart, she reflected that her parents could pass away, and “who is going to do things for me then?” Thereafter, she was inspired to take action and applied to go to a vocational school as a means of later finding employment. One youth was motivated to not give up on her dream of playing netball professionally by succumbing to the setback of an injury. She watched a movie at the teen club, which inspired her to continue training. Barriers to Work and Work-Related Education One barrier to advancing in work was how the options were perceived. One youth believed that the LP only assisted people with disabilities. Another thought that Brigades (government vocational training) was only for children who had failed. One youth did not have hope that he would find work. Although he learned job application skills from a nongovernmental organization, he did not feel optimistic. “We are looking for jobs, but there aren’t any.” Participants also found the lack of money a barrier to finding work, for example, not having money for transport or for printing and copying CVs. Many caregivers and youth reported that there was a general sentiment that in-school youth should not be working while they were in school. As one caregiver said, “I told him that school comes first and work second. You learn, you pass, then you work.” One youth started selling sweets at school to make money, but the teachers disallowed it because they thought it would distract him from his studies. One caregiver noticed that after the income generation sessions, the youth was motivated to start a business, but the caregiver felt that this exposure was inspiring interest too soon. “Yes, I think there has been a change. It’s only that he likes being clever. He likes things that have to do with business, [but] I tell him that he is still too young.” The BCCOVC beneficiaries’ recommendations about work were in line with the types of activities that LPs already offered. A few said that LPs should help youth find work, such as by facilitating enrollment in the Tirelo Sechaba Program (government national service program for secondary school leavers). One respondent suggested that LPs should help those who struggle with traditional academic education to advance at the vocational schools at which handiwork was taught. Another wanted the LP to “provide extra support and advice relevant to specific careers.” Last, one beneficiary thought that youth should be exposed to career fairs that give practical demonstrations of what the work would entail, so that they could make more informed choices, because verbal descriptions were not always easy for youth to grasp. 48 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Income Generation BCCOVC youth beneficiaries were significantly more likely than the GOB youth beneficiaries to report starting a small business or an income generating activity in the past 12 months (p<.05) (Figure 18). BCCOVC Project-Related Influences on Income Generation The BCCOVC project’s efforts were successful in educating and motivating beneficiaries (both caregivers and youth) to plan, start, and continue income generating activities. Most participants who reported learning the skills required to run a business had not yet applied them, but some had started making plans and others had acted on them. LPs educated youth in a practical way. One LP reported that in one area, the LP helped students set up a carwash at school. They washed teachers’ cars and the proceeds were used to buy school uniforms for students who needed them. Others learned how to grow a vegetable garden and how to sell the vegetables. One LP showed youth how to make things to sell, for example, bracelets from newspapers dyed with paint. One LP reported success with the GROW program under BCCOVC; however, it was mostly used by older people rather than youth. Some members started businesses using loans from GROW, such as a poultry farm, selling second-hand clothing, and selling health and beauty products. One LP reported that one group started a catering business that did well. Although some businesses had folded, the LP said, others were thriving. GOB sponsorships also facilitated access to funds to start income generating activities, which one SW reported have been successful in enabling youth to start their own businesses. Barriers to Income Generation All participant types most often mentioned the lack of start-up capital as a barrier to youth income generation. LPs/CSPs said that the focus on skills building was not enough to make a lasting difference. Offering skills to start a business or advice on saving could not be acted on when basic needs like food, school supplies, or electricity were not being met. As a CSP remarked, when education was offered, beneficiaries (caregivers or youth) felt you were “wasting their time” given that they did not even have enough to feed their children. When basic necessities were not met, education “was not enough.” For example, one out-of-school youth had an “inspiring conversation” about how she could open a business, such as selling poultry. The girl was confident that she could save with a savings account and start the business, but she lacked start-up capital. The money she received from her father was used for household needs, and she used the money she received from her boyfriend for necessities for herself and her baby. “All my money is used to buy food, and when there is no food, there is nowhere we can get the money from.” She recommended that the LP work with SWs to facilitate access to government initiatives that provided grants to start new businesses. Other participants reported that LPs sparked interest in ways to generate income but failed to follow through by setting up and facilitating the GROW entrepreneurship savings scheme. In other situations, CSPs were successful at alleviating poverty by facilitating access to material support and government programs, such as the Poverty Eradication Scheme. One CSP said that there were people who were so poor that they had given up on life. They were depressed and did not believe that their lives could improve. Facilitating access to GOB services changed their lives immensely, improving their standard of living and enabling them to be more economically stable. This helped youth overcome the hopelessness or helplessness that had consumed them. They were advancing in life both academically and eventually finding work. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 49 In the GOB program, there were also barriers related to start-up capital. A few caregivers and youth tried, and failed, to access assistance, such as the Youth Development Fund, with one respondent saying, “They should improve their accessibility to funds. They should give all youth money so that they can make businesses for themselves if they want to make businesses.” Although the GOB prioritizes OVC for government grants to start small businesses, success is limited by their capacity to handle business management, (e.g., being able to write or do bookkeeping), and therefore, the businesses have failed. SWs recognized the need for OVC to learn money management and business skills so that income generation activity support can be successful. Summary of Economic Stability-Related Results Table 9 provides a summary of the multivariable results for the economic stability indicators, comparing youth in the intervention and comparison groups. Statistically significant differences in a positive direction indicated that youth in the intervention group fared better for these indicators than did youth in the comparison group. Table 9. Significance and direction of logistic regression coefficients assessing differences in economic stability between intervention and comparison groups¥ Economic Stability Indicator Significant Difference Direction of Association Mean score on financial literacy index * Positive % youth in an internship or job training program NS N/A % youth who started a business/income generating activity in the past 12 month * Positive % youth who worked for cash in the past three months * Positive % youth who saved money in the past 12 months ** Positive % youth who perceive that they have the skills necessary for employment or starting a business NS N/A ¥Models adjusted for age, sex, school status, orphanhood, and primary caregiver. NS = Not significant *p<.01 **p<.01 N/A = Not applicable • The PEPFAR-funded LPs helped youth reflect on their spending patterns and the value of using money wisely to meet short-term needs and achieve long-term goals through saving, prioritization, budgeting, and cost-cutting. • The PEPFAR-funded LPs provided youth with education on entrepreneurship skills and motivated them to plan or start their own businesses. The most commonly cited barrier was start-up capital. • Relatively few respondents reported being exposed to work skills, and many requested access to skills to find work or job placements. Economic Stability: Key Findings on the BCCOVC Project and GOB Program Effects and Challenges 50 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Education In this section, we share the results on the education-related services provided to OVC youth, as described by key informants; services reported to have been received by youth; and the effect of services on youth education outcomes. Additional outcomes by study arm can be found in Appendix A; please see Appendix B for a matrix of key qualitative results by outcome. BCCOVC Education-Related Services LPs reported motivating and supporting youth, at both the household level and at the LP centers, to attend school, perform well and complete their studies. Literacy clubs, tutoring support, time management, and study skills training were provided. CSPs reported monitoring attendance, school performance, and progression. Students were encouraged to complete secondary school. Those who did not improve with tutoring assistance and failed, or those who were out of school, were guided to other options, such as vocational training or income generation opportunities. LPs reported facilitating access to vocational training, by both inspiring interest through discussions with youth about their interests and the courses that are available, and also helping them obtain and complete applications. LPs hosted community dialogues about the importance of education and their role in supporting youth to complete their studies. CSPs reported conducting household assessments to identify needed support in the form of food, school fees, uniforms, transport money, or toiletries, and making referrals or facilitating access to government services. GOB Education-Related Services The GOB staff reported providing educational support in the form of payment of school fees annually; provision of school uniforms every two years; transportation (for school trips and to school, where needed); clothes annually; school shoes, when needed; and accommodations when enrolled at the Brigades (vocational school). SWs facilitated progression from Form 3 to Form 4; and from Form 5 to tertiary school by writing a letter to the educational institution informing it that the child was an orphan and requesting that admission be taken at 31 points instead of 36, as required for other students. SWs also checked attendance when doing household visits, although these visits were limited by competing demands and a lack of transport. Exposure to BCCOVC Education-Related Services Figure 19 shows the BCCOVC project education-related services youth in the qualitative subsample reported being exposed to. Figure 19. Exposure to BCCOVC project education-related services among the qualitative subsample (n=39) 11 27 9 6 11 1 0% 20% 40% 60% 80% 100% Attendance support Academic performance support School completion support Yes No No data Evaluation of Services for Orphans and Vulnerable Youth in Botswana 51 School Completion Approximately 18 percent of youth who sat for the BGCSE exam in the year 2018 and 15 percent of youth in the year 2017 scored 36 points or higher on the exam. In the adjusted regression models, there was no statistically significant difference in either year between youth in the intervention and comparison groups in whether they scored 36 points or higher or less than 36 points (Figure 20). Figure 20. Percentage of youth in 2017 and 2018 who sat for and received 36 points or higher on the BGCSE exam BCCOVC Project- and GOB-Program Related Influences on School Completion Participants reported that GOB material support for OVC education had a significant impact on school completion. Youth acknowledged that the provision of uniforms, clothes, and transport, and the payment of school fees enabled them to complete school. School Enrollment and Attendance Approximately 66 percent of youth were enrolled in any type of school and about one percent were enrolled in tertiary or vocational school. After adjusting for covariates, there were no statistically significant differences between youth in the intervention and comparison groups in school enrollment (any type, and tertiary or vocational school), or in school attendance in the past week (Figures 21 and 22). 13.3 16.7 14.0 19.4 33.3 16.7 2.3 2.2 0 10 20 30 40 50 Intervention (n=15) Comparison (n=18) Intervention (n=43) Comparison (n=93) Year 2017 Year 2018 52 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Figure 21. Percentage of youth enrolled in any school, and tertiary or vocational school Figure 22. Percentage of youth who missed any days of school in the past week BCCOVC Project- and GOB Program-Related Influences on School Enrollment and Attendance Some CSPs reported monitoring attendance by looking at schoolbooks, to see whether work was done that day, and counseling beneficiaries on the importance of attending school. For some HIV-positive youth, fear of social stigma was a barrier to attending school regularly. Project efforts were successful at helping HIV-positive youth overcome their personal fears, accept their status, and cope with discrimination. Through the teen clubs, beneficiaries were able to accept their status and not let others deter them. One male youth said, “They said abstaining from school is useless. Even if someone laughs at you because you have HIV, it’s useless because they may have it tomorrow.” He also said he was ashamed of the condition of his uniform. Now, his caregiver says, “He attends wholeheartedly… He doesn’t focus on the condition of his pants, he just goes to school. I think it’s because of the lessons he got from [LP].” Another female youth was ashamed of being different from the other students, but after participating in LP group sessions, she realized that she was not alone. In one case, multiple factors were tackled through successful collaboration among the CSP, SW, and headmaster. The caregiver said that the youth could not adjust to the decline into poverty, and that she became rebellious, missed school, lied about her whereabouts, and was stealing. She was eventually expelled after 21 absences in Form 4. Both the CSP and SW counselled her that “life is hard” and that her education will “save her.” The CSP worked with the SW to obtain fees, uniforms, and transport money, 13.5 12.9 Intervention (n=507) Comparison (n=900) 65.9 1.2 74.3 1.2 0 20 40 60 80 100 Enrolled in any type of school Enrolled in tertiary or vocational school Intervention (n=507) Comparison (n=900) Evaluation of Services for Orphans and Vulnerable Youth in Botswana 53 and with the headmaster to secure a space at the school. She said she was now motivated to return and to study hard this time. Barriers to School Enrollment and Attendance Participants reported that without school fees and uniforms and, sometimes, transport money, youth could not attend school. However, many youth did not have access to this government support, a gap LPs have tried to remedy. CSPs recognized that access to GOB services improved when they worked as an intermediary between the family and the SW. LPs said that SWs were overloaded with referral traffic from many sources covering many different areas. Participants reported significant delays from application to receipt of services; for example, a case could be assessed in a given month but services would be received six months later. CSPs prepared referrals to SWs specifying what services the LP had provided and the gaps they were requesting that the SW fill. However, CSPs said that caregivers who went alone with the referral letter were not taken seriously. School Progression and Performance About 11 percent of youth did not progress to Form 1, which is the first class of junior secondary school (data not shown); and 83 percent of youth did not progress to Form 3, which is the first class of senior secondary school. Figure 23 shows the percentage of youth who progressed to each class in secondary school. After adjusting for covariates, there were no statistically significant differences between youth in the intervention and comparison groups. Figure 23. Percentage of youth who progressed to each secondary school level BCCOVC Project- and GOB Program-Related Influences on School Performance Participants said that the BCCOVC project helped youth build confidence and inspired self-reliance and a belief in their own ability to effect change by giving them the skills and resources they needed to take responsibility for own their education and improve their performance. We started to understand that [LP] wanted us to work out problems and find answers… that you need to study on your own, but the teacher will help you where you don’t understand, but you are responsible for your studies.—Male, 17 years old 2.9 14.9 51.5 77.7 88.1 2.0 17.6 55.6 78.2 90.2 0 10 20 30 40 50 60 70 80 90 100 Form 5 Form 4 Form 3 Form 2 Form 1 Comparison (n=900) Intervention (n=507) 54 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Through group sessions or one-on-one discussions, beneficiaries said that they were encouraged to not be afraid and to ask questions in class. One youth used to be quiet in class and would never ask questions when she was confused. “Now, I can ask questions, unlike before. I have the confidence to also ask questions in class.” Beneficiaries also learned that if they struggled to understand the lessons at school, they could access tutoring or homework assistance from the LP centers or at the school. Beneficiaries said that the tutoring sessions in Setswana, having concepts explained carefully and patiently, and not fearing corporal punishment for not understanding, were helpful. Some beneficiaries learned about time management and the importance of planning when schoolwork should be done. One youth attributed her improved results to the LP’s guidance on study skills and time management. “I managed to start revising, giving myself extra work and being able to study when an exam was approaching.” Learning about prioritization also influenced decision making more generally. [LP] taught me to have my own stand. I used to be somebody who did what I was told without thinking for myself. They helped me know what I want in life. This year they taught us about prioritizing things that are important and those that are not.—Female, 17 years old Students were also encouraged to form study groups to tackle difficult subjects together. Nearly all youth who benefited from these sessions found them useful, and many credited them for improvements in their marks. Counseling by LPs and advice from caregivers often focused on the message that education is a pathway out of hardship and into living a better life. Messages framed in this way were often successful. In one case, an LP persuaded a female youth, who used to miss classes she did not like and who would sleep in the classes she did attend, to take her education more seriously. She then began attending, focusing in class, and completing assignments. Another youth came to the realization that being an orphan was evidence that nothing can be taken for granted and that one must not assume that a caregiver would always be there for you. She was then driven by a desire for economic independence, which led her to concentrate more on her studies and resulted in improved performance. Others saw education as a pathway to a new identity and life. For example, one female youth said, “You know the reason as to why you are going… If you study hard, you can be something in life.” Understanding that education was a requirement for specific career goals was also a motivating factor. A female youth who aspired to be an actress believed that a university degree in the arts was necessary to achieve that goal. “You know, if I didn’t want to do the career I want, I could have left school. Now it’s important because I want to go and do this other course… It’s the only thing that makes me want to go to school.” Another youth, grieving for the loss of her last living parent, fell into a deep depression and refused to attend school or even leave her bed. “I would be thinking about my father and that if he was alive maybe I would be living a better life.” The teen club group sessions helped her find hope and focus on school. “Nowadays, I don’t miss school like I used to.” LPs supported this by informing youth about the specific educational requirements for different occupations. Participation in the teen club improved confidence, self-esteem, and self-initiative for many HIV-positive beneficiaries, which had a positive impact on their school performance. Before the youth participated in the teen club they said that they were shy and reluctant to speak up in class or to give presentations. Some imagined that others somehow knew or could visibly see that they were HIV-positive, which resulted in self-shaming and social withdrawal. Two youth even thought that school lessons on HIV were being directed at them. Fear of being caught taking medication also made some reluctant or unwilling to participate in school trips. Beneficiaries credited the teen club with building courage to accept their status, accept themselves, and overcome their fears and inhibitions. One female youth who did not go on school trips previously was Evaluation of Services for Orphans and Vulnerable Youth in Botswana 55 later not afraid to go, whereas another said that she had overcome her shyness and could spontaneously contribute to class discussions and speak to others about HIV. Another female youth learned to never be ashamed of herself or to let herself be discouraged when she did not do well. This advice motivated her to not give up and her grades have since improved. CSPs reported checking schoolbooks, exam papers, and school reports to see how well students were performing. Where a need was identified and services were available, CSPs referred beneficiaries to tutoring services. CSPs also encouraged caregivers to monitor their children’s performance by looking at their schoolbooks and ensuring that their homework was completed. One CSP believed that caregivers who took a sincere interest in their children’s education and actively monitored their work and performance had the potential to make the most significant improvement in performance. Beneficiaries said that their caregivers or family members motivated them to be serious about their studies and to work hard, either by showing how important it is to advance in life or because of the family’s hope that the beneficiaries’ work success would help improve the material circumstances of the family. However, as one CSP said, the caregivers were sometimes limited in the amount of support they could provide, given their own education levels and ability to understand the school work. CSPs, caregivers, and beneficiaries alike recognized that poor performance could be due to learning difficulties, some of which could stem from a lack of aptitude or interest in more formal academic learning. CSPs noticed that although most youth did improve their marks with tutoring, others did not, and they perceived that this lack of progress was linked to the student’s learning style. In such cases, both CSPs and families considered vocational schools as a more viable option. CSPs have also helped improve caregiver￾youth relationships, which helped a youth be more receptive to their caregivers’ advice to enroll in a vocational school. GOB material and psychosocial support also helped youth to perform better. One youth said that the provision of fees and uniforms helped her focus on her studies. I don’t worry about who is going to buy my uniform, who is going to provide me with food. Because I know that someone is there for me. Unlike when there was no one. I would be worried that my shoes are worn out and what I need to do. Obviously [I] am going to think of something negative, a way to get money and buy myself shoes…there is just a tendency at school, girls date combi (minibus) men to get money. So, I think [I] am lucky because I don’t need to do that to get money. The government is there to provide.—Female, 17 years old SWs also reported that psychosocial support helped build confidence and assertiveness, which enabled the youth to perform better at school. Barriers to School Performance Nearly all participants applauded the tutoring and literacy clubs as benefiting youth and improving performance. LPs also reported that schools were receptive to interventions that improved performance. However, many complained that the interventions were not frequent enough, not regular enough, or not accessible. LPs recommended that government funding for education be increased to help meet the demand. Dropping Out and Reenrollment About 10 percent of the youth had ever dropped out of school, and 38 percent had ever reenrolled or repeated a grade in both groups. In the multivariable model, there were no statistically significant differences between the intervention and comparison groups in terms of dropping out of school, or reenrolling or repeating a grade (Figure 24). 56 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Figure 24. Percentage of beneficiaries who had dropped out of school, and reenrolled or repeated a grade BCCOVC Project- and GOB-Program Related Influences on Reenrollment Among youth who had left school, LPs helped them overcome emotional and practical barriers to returning to school. Renewing hope after academic failure successfully encouraged youth to return to school. A female youth who was not interested in school and often misbehaved returned to school after failing Form 3. She said that the CSP told her that failing Form 3 “doesn’t mean it’s the end of me.” Her uncle helped her reenroll, and she looked forward to attending senior secondary school and tertiary thereafter. Another female youth who had failed Form 3 was encouraged to never give up and to “try again somewhere else” and to “learn new things.” Since then, the youth had returned to rewrite her exams, and the CSP was helping her apply to a vocational school. Her caregiver felt confident that the CSP would succeed because she had seen other students helped by the LP. Moreover, youth, caregivers, SWs, and Social and Community Development officers all reported that receiving uniforms and clothes helped youth improve their confidence and self-esteem which had an impact on their attitude toward school and motivation to attend and ultimately complete school. SW counseling also had a positive influence on attendance and completion. Barriers to Reenrollment CSPs advised the caregivers to appeal to SWs for food support, vocational training, or other government material support. In some cases, CSPs actively interacted with SWs to ensure that these services were received. However, the respondents reported challenges. For example, one female youth said that the most significant change the LP had made was persuading her to return to school after dropping out due to pregnancy. However, the process stalled. The girl thought that the next step was for her mother to request documentation from SW to apply for vocational training. She therefore asked her mother to seek help from the SW. On the other hand, the caregiver thought that the next step was for the CSP to help the girl enroll in the school. The caregiver complained that the CSP had not helped, telling her what she could do but not helping her do it. Then, frustrated by inaction, the girl asked for the CSP to act on their behalf. “[The CSP] encouraged me to go back to school,” the girl said, “That’s one thing that I liked. If I could go back to school, that is when I would say they have really changed my life.” Thus, a barrier to school reenrollment stemmed from confusion about the respective roles of CSPs, caregivers, and beneficiaries about the process required to access services. Another challenge noted by a caregiver was a misalignment between youth’s educational interests and goals and the CSP’s ambitions for the youth. For example, one youth failed school in 2016 and the caregiver said that a CSP came twice to encourage the youth to go to a vocational school. The CSP looked around for 38.1 37.3 9.9 10.0 0 20 40 60 80 100 Intervention (n=507) Comparison (n=900) Intervention (n=507) Comparison (n=900) Re-enolled in or repeating a grade Dropped out of school Evaluation of Services for Orphans and Vulnerable Youth in Botswana 57 schools, gave him information on different types of jobs to review, and asked him to collect his certificates and look into schools. After this, the CSP would help him find a place at the school. However, during neither of the two CSP visits did the youth admit to the CSP that he was not interested in returning to school; what he really wanted was to buy a carwash machine and open his own business. The caregiver recalled the conversation: “He said to me, ‘Mum, I don’t see the use of me going to school. What I really want for my life is if I can run a business.’” When asked how the LP’s services could be improved to help youth, he recommended that the LP help youth find places for them to “maybe run a business so they can make a living from it.” Having a different ambition from the one being offered may have made it difficult for the boy to be honest and the opportunity for encouraging entrepreneurship was lost. At the same time, in this case, the CSP may never have learned that their efforts had failed. Summary of Education-Related Results Quantitative data did not reveal any significant differences in educational outcomes between the intervention and comparison groups; however, the qualitative data revealed many examples of project support related to attendance, performance, and enrollment in school. Table 10 shows a summary of the multivariable results for education indicators, comparing youth in the intervention and comparison groups. Table 10. Significance and direction of logistic regression coefficients assessing differences in education-related factors between intervention and comparison groups¥ Education indicator Significant Difference Direction of Association % youth who received 36+ points on the BCCSE exam in the year 2018 NS N/A % youth who received 36+ points on the BCCSE exam in the year 2017 NS N/A % youth enrolled in any type of school NS N/A % youth in tertiary or vocational school NS N/A % youth who missed any school in the past week NS N/A % youth who progressed to each grade in secondary school NS N/A % youth who dropped out of school NS N/A % youth who reenrolled or repeated a grade NS N/A ¥Models adjusted for age, sex, school status, orphanhood, and primary caregiver. NS = Not significant N/A = Not applicable • Many youth or households did not consistently receive material support, such as food vouchers, school fees, school uniforms, or transport money, which sometimes negatively affected school attendance. • The PEPFAR-funded LPs helped the youth take responsibility for their education by building confidence to ask questions, enabling access to tutoring services, and encouraging the youth to set up study groups for peer support. • Viewing education as a pathway out of poverty, promoted by caregivers and PEPFAR-funded LP staff, motivated the youth to attend school, perform well, and complete school. Education: Key Findings on BCCOVC Project and GOB Program Effects and Challenges 58 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Crosscutting issues: BCCOVC Project Implementation LPs reported several challenges to reaching beneficiaries, delivering quality services, and meeting donor targets. Many of these challenges were reflected in the beneficiaries’ and caregivers’ complaints about the services provided and their recommendations. First, LPs reported that beneficiaries were often not at home when the CSP called and were difficult to locate. LPs said that they found beneficiaries at school or at the lands or cattle post; or their whereabouts were unknown. Caregivers/beneficiaries recommended that CSPs visit households at those times.; however, LPs reported challenges to having CSPs work at those times because some CSPs do not work overtime or on weekends. One caregiver said, “I just think that these surprise home visits are a bad idea, because they can come and find an empty yard,” and they recommended that LPs set a particular place and time so that the youth would know where and when the services would be available. Second, LPs said that pressure to meet targets sometimes threatened the quality of services and ability to meet household/beneficiary needs, given that the amount of time that could be spent at the households was limited. When asked about weaknesses in the project, one manager said, “I think with weaknesses, it’s more because of the high target that we have, we are not able to give the utmost time to our clients because now we are running in to say after every quarter, I must have served this number of people. So, if the family needs more of your time, you are not able to do that.”—Local partner LPs say said that progress and, thereby, coverage was impeded by staff turnover and donor scope changes, both of which led delays in service provision due to training or retraining. LPs and youth also reported rapid turnover of staff resulted in a lack of the project’s effectiveness (e.g., CSPs and beneficiaries/caregivers often needed to restart some processes and build confidence and trusting relationship again). A lack of depth and follow through was apparent in the caregivers’ complaints. One caregiver said, “They just come and ask questions. There is really nothing that they are doing.” One youth said the CSP left referral forms for HIV testing, and reminded the youth to go to the clinic, but no other service was provided. Another caregiver said that they did not spend a lot of time and “write whatever they will be writing and then they go.” Although the CSP told this caregiver that they “would be checking on them,” the caregiver has not seen them return. These accounts suggest that a household assessment was conducted and an expectation of receiving services was created, yet not followed through. Donor targets requiring one beneficiary contact per quarter may leave a long period of time between visits. Third, one LP said that the time available for the life skills sessions limited the number of modules that could be covered, and thereby the number of youth beneficiaries that could be reported as reached. One youth suggested that more time would be beneficial: “They should not focus on one item when teaching. They should talk about many things.” Access to services was also an issue reported by some youth. Some youth lived too far away and requested access to transport so that they could attend the LP center. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 59 DISCUSSION This evaluation study is the only we have identified that examines the effects of a multi-component intervention among orphans and vulnerable youth in Botswana transitioning to adulthood. Study results indicate that the PEPFAR-funded BCCOVC intervention has had mixed success in improving the HIV and health, economic strengthening, and education outcomes among orphans and vulnerable youth. Of the three main outcome areas of the evaluation, the project has had some impact on HIV and health and economic strengthening outcomes. There is no observed quantifiable impact of the BCCOVC intervention on education outcomes, although qualitative data indicate some positive effects. Although the youth were assigned to a study arm based on whether they were listed on BCCOVC and/or GOB beneficiary lists, there is not a high association between the study arms to which the youth were assigned and exposure to BCCOVC and/or GOB OVC services. Based on the design of the study, those in the intervention arm should have received both BCCOVC and GOB services; and those in the comparison arm should have received GOB-services only. However, less than one-third of youth in the intervention arm report receiving BCCOVC and GOB services; and 71 percent of youth in the comparison arm report receiving GOB services only. Of the primary and secondary HIV and health indicators, quantitative results showed that the BCCOVC project had a positive, significant effect on youth getting an HIV test and knowing their results; and on youth receiving HIV prevention, testing, or treatment advice. Baylor is the main LP on the project that is responsible for providing clinical services. Other LPs providing interventions, such as life skills or work readiness training, are tasked with referring their youth participants to Baylor for clinical services. The results indicate that youth are being successfully referred for clinical services, and especially for HIV testing services. The BCCOVC intervention may have also had a positive effect on youth receiving RH services in the past 12 months and receiving care in the past 12 months due to GBV. These results provide further evidence that youth participants of the BCCOVC project are more likely to access and receive clinical services compared with youth receiving only GOB services. In contrast to HIV testing and prevention services, the quantitative results did not find that the BCCOVC project affected HIV-positive youth reporting being on or adhering to ART. This may be because while the project has, from its inception, focused on the first “90” (90% of people living with HIV know their results) of the global 90-90-90 targets, it has only recently begun to place more emphasis on trying to increase the second and third “90s,” (i.e., 90% of HIV-positive people are on ART and 90% of those on ART are virally suppressed). Although qualitative data indicate that teen clubs have helped HIV-positive teens understand the need to adhere to ART, with some examples of success in adherence, the clubs may reach a relatively small number of HIV-positive youth in the study area and, therefore, have not yet been able to increase ART adherence among a large enough number of youth to impact the quantitative results. It should be noted that the study includes a small sample of HIV-positive youth and is not powered to detect differences in ART initiation and adherence between the study arms. Moreover, even though there is no observed difference between the study arms, the overall proportion of youth who report being on ART is similar to national figures for people of all ages living with HIV/AIDS: 90.2 percent of HIV￾positive youth in this study report being on ART, compared with national data from 2015 showing that 84 percent of people of all ages living with HIV/AIDS in Botswana were on ART. In addition, about 77 percent of youth in this study report adhering to ART in the past 30 days, compared with the national figure of 81 percent of people of all ages living with HIV/AIDS being virally suppressed (Gaolathe, et al., 2016). It is important to highlight the positive impacts reported by BCCOVC project beneficiaries who participated in teen clubs. Teen clubs provided an open, accepting space in which youth could discuss complex, personal issues related to living with HIV and receive the support they need. The evaluation 60 Evaluation of Services for Orphans and Vulnerable Youth in Botswana found that teen clubs helped youth accept their HIV status, and this was highly related to initiating and adhering to ART. Many of these impacts are highlighted in the REM group illustrations included in the appendixes of this report. These impacts are similar to results from another qualitative study in Gaborone, Botswana, which found that acceptance of HIV status, the ability to avoid internalizing stigmatizing attitudes, and the identification of and encouragement from confidantes, including clinicians, were key factors related to high ART adherence (Nam, Fielding, Avalos, Dickinson, Gaelathe, & Geissler, 2008). The teen-club services delivery model is promising and fills an important gap for many HIV-positive youth. Qualitative results indicate that some youth are not very concerned about engaging in risky sex and being at risk for HIV given that ART is available and effective; this message seems to have been introduced or reinforced by LPs. This finding is in line with an analysis of the Botswana AIDS Indicator Survey IV, which shows that those who are less concerned about acquiring HIV since the introduction of antiretrovirals are more likely to engage in high-risk sexual behaviors. Almost one third of youth aged 15- 24 years old (31% males; 32% females) said they were less concerned about HIV since the introduction of ARVs. And, those who were less concerned were nine times more likely to use a condom inconsistently and 1.6 times more likely to have reported multiple sexual partners than those who were more concerned (Keetile, 2015). Quantitative results also indicate that the BCCOVC project did not significantly affect the sexual behavior of youth. Based on the study’s theory of change, it was theorized the BCCOVC project would reduce risky sexual behavior through exposure to life skills curricula (which include lessons on gender roles, sexual decision making, pregnancy, and sexually transmitted infection prevention) and one-on-one or small group counseling on sexual decision making. Data on exposure show that a small number of youth were exposed to this component of the project, which could explain the lack of effect. A systematic review of programs using sexuality education curriculum to prevent pregnancy and HIV indicate specific criteria, such as curricula grounded in clear behavior change theory and a high dosage, are required to significantly change behavior (Kirby, Laris, & Rolleri, 2007). Although it is beyond the scope of this evaluation to assess the content and delivery of the life skills curricula, one reason the BCCOVC project may not have affected sexual behavior is if the curricula do not meet the minimum criteria for standards of life skills curricula (Kirby, Rolleri, & Wilson, 2007). The BCCOVC project had a statistically significant effect on the mean score for financial literacy (0.1 point difference). However, this difference, which indicates that youth in the intervention group answered, on average 0.1 points better than youth in the comparison group, is not programmatically meaningful. Several other economic strengthening indicators, including the percentage of youth who started a business or income generating activity, worked for cash in the past three months, and saved money in the past 12 months, indicate that the BCCOVC project is effective in providing adolescent OVC the skills needed to gain economic stability as they transition to adulthood. Based on the qualitative reports, a few parents felt that youth should focus solely on school and not try to find jobs or focus on job-related skills. Although it is beneficial for youth who are still enrolled in school to focus on their studies and work to pass their exams, about 25 percent to 35 percent of youth in our study were not enrolled in any type of school at the time of the survey. Taking part in economic strengthening activities helps youth who have dropped out of school plan for their livelihoods as they transition to greater financial and social independence. This is particularly important considering that 14 percent of the youth reported engaging in transactional sex in the past six months. The BCCOVC project had no quantitative effect on educational outcomes of youth. Statistically non￾significant differences were observed for a few indicators, including the percentage of youth who received 36 points or higher on the BGCSE exam, with youth in the comparison group faring slightly better than those in the intervention group. Study results on class progression in secondary school show that the largest drop in progression occurs between Form 3, the end of junior secondary school, and Form 4, the Evaluation of Services for Orphans and Vulnerable Youth in Botswana 61 beginning of senior secondary school. Analysis of national data of all youth from 2015 found similar results regarding progression and drop-outs (Statistics Botswana, 2015). Qualitative data also indicate that many youth interviewed failed the Form 3 exams and were unable to progress to Form 4, indicating that more focus and resources are needed to help students pass Form 3. A low dose of services is one reason we may have not seen a stronger positive quantifiable effect on some HIV and health and economic stability outcomes and on any education outcomes. Exposure to BCCOVC and GOB services was not ideal, with 11 percent of youth indicating that they did not receive any OVC services in the past 12 months. Specifically, receipt of GOB food assistance by OVC was lower than expected, at about 50 percent. This is unexpected because food assistance in the form of food baskets, vouchers, or coupons is a core GOB OVC service that should be provided to all OVC in the nation. The low receipt of services reported by youth from the BCCOVC project and GOB program points to implementation issues. Among youth who reported receiving BCCOVC services, many had received either no or few services beyond an initial assessment. One reason for this is that the BCCOVC project started in September 2017, and recruitment of beneficiaries took place during the first 12 to 18 months. Therefore, many evaluation study participants had not been exposed to the intervention for an adequate length of time for project effects to be observed. In addition, CSPs are required to visit households once quarterly—or only four times per year— with many visiting less than required. This is likely not adequate to substantively improve the HIV, economic, or education status of OVC. Relatedly, the wide range and spread of intervention components among the seven LPs means that the intervention lacked a cohesive and coordinated approach to service delivery, with most youth receiving only one type of service from the LP in their geographic area. With few youth being exposed to intervention components from two or all three focal areas, exposure dosage to the BCCOVC project was further compromised. Changes to project scope, staff turnover and pressure to meet targets reduced the amount of time LPs were able to spend with each beneficiary and thereby limited the number of services they were able to provide. These challenges affects service quality, effectiveness and coverage. Many of the positive results mentioned by youth and caregivers, while encouraging, came from the few beneficiaries who reported receiving consistent services. Limitations Several study limitations should be noted when interpreting the results of this evaluation. First, we used an “intention to treat” approach, meaning that we analyzed the data by treating survey respondents as they were assigned to the study arms. Given the probability of misclassification of participants in study arms, as mentioned above, this may have resulted in an underestimate of the effects of the BCCOVC project on study indicators. Second, this is a cross-sectional (i.e., one point-in-time) evaluation; therefore, we cannot make strong conclusions about changes over time. Although we asked quantitative and qualitative questions about changes in indicators over the past one to two years, the respondents may not have accurately remembered changes over time. If misremembering changes in one’s knowledge, perceptions, behaviors, or receipt of services was systematically different in one study arm compared with the other, then the results may be affected by recall bias. Third, sample sizes for several indicators were too small to determine whether there was a statistical difference between youth in the intervention and comparison groups. These include the primary education indicator, percentage of youth who received 36 or more points on the BGCSE exam; and indicators about risky sexual behavior. 62 Evaluation of Services for Orphans and Vulnerable Youth in Botswana There were also large amounts of missing data on sexual behavior, condom use, and GBV. If missingness was related to the study arm assigned to youth, then this could bias the results. Moreover, Baylor-served youth were under-represented in the overall sample due to late approval from the Baylor institutional review board (which was required by Baylor before implementation of the second round of household surveys). Because Baylor is the BCCOVC LP providing clinic-based services, including HIV testing services and provision of ART, the effect of the BCCOVC project on these indicators could be underestimated, meaning that the BCCOVC project may have had a greater effect on many of the HIV-related indicators than was observed in the data. Last, Botswana also implements DREAMS programming and pre-exposure prophylaxis programming, which are being provided by some of the same nongovernmental organizations and local partners as BCCOVC. Some youth respondents may have received DREAMS or pre-exposure prophylaxis services and, therefore, the observed effects of the BCCOVC project may be effects from the combination of two or three of the programs. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 63 RECOMMENDATIONS Based on the collaborative interpretation of results of this evaluation with local stakeholder members of the technical working group, we recommend the following to improve services for OVC youth transitioning to adulthood: • Increase the frequency of each type of service provided by the BCCOVC project to OVC youth, to ensure that beneficiaries receive the minimum dosage needed to attain positive changes in HIV and health, economic stability, and education outcomes. • Strengthen the HIV testing and counseling referral process so that the LPs receive information on whether referrals they provide to youth for HIV testing is completed and, subsequently, receive testing results more quickly. This would enable LPS to provide appropriate follow-up services based on whether the youth tested positive or negative for HIV. • Increase access to discrete and local HIV testing, including home-based test kits, to address barriers to accessing testing; thereby closing the gap between interest, intention, and action to test. • Continue focusing on increasing ART adherence among HIV-positive youth, including through an increased number of and geographic locations of teen clubs. • Increase ART adherence rates among HIV-positive OVC youth by focusing on mitigating psychosocial factors that are barriers to adherence. • Identify strategies to reduce transactional sex among youth. • Increase awareness of the GBV definition, laws, and local resources by educating OVC youth and their caregivers during home visits and in schools. Relatedly, ensure CSPs and SWs understand that they can educate youth and caregivers about GBV, regardless of whether they suspect GBV or child abuse in the household. • Increase access to tutoring for youth in junior secondary school so that they can receive the required assistance to pass their Form 3 exams. • Develop agreed-upon criteria for youth to participate in economic strengthening activities that balance current educational activities and future economic needs. • Assess the BCCOVC project to examine how services to OVC youth can be rolled out in a faster, more efficient manner; with greater uniformity across LPs, and in higher doses. • Assess GOB services to determine barriers and bottlenecks to OVC youth receiving services, especially around food assistance in the form of food baskets, coupons, and vouchers. • Implement a follow-up survey with BCCOVC and GOB OVC youth beneficiaries after two years to measure potential changes over time. Using data from this evaluation as a baseline and data from a follow-on study as an end line would provide a more rigorous estimation of the effect of the BCCOVC project on HIV and health, economic stability, and education outcomes of OVC youth. 64 Evaluation of Services for Orphans and Vulnerable Youth in Botswana CONCLUSIONS The PEPFAR-funded BCCOVC project had several positive effects on HIV testing, treatment, and access to services, and strengthening economic prospects for OVC youth beneficiaries. OVC youth continue to be an important population to support as they transition to adulthood, and additional research is needed to understand how service delivery and support mechanisms can be structured to continue improving their HIV, health, and economic status, and to make an impact on their education outcomes. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 65 REFERENCES Bodika, S.M., Lekone, P.E., Loeto, P., Alwano, M.G., Zulu, T.C., Kim, E.,…Voetsch, A.C. 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Evaluation of Services for Orphans and Vulnerable Youth in Botswana 67 APPENDIX A. QUANTITATIVE TABLES Evaluation of Services for Orphaned and Vulnerable Youth Quantitative Tables Table A1. Percent distribution of youth’s reported exposure to specific OVC services (BCCOVC or GOB) in past 12 months, by study arm Exposure Intervention Comparison Total Advice on HIV prevention, testing, or treatment 56.2 45.7 49.5 Assistance with payment of medical fees 1.6 1.1 1.28 Home-based medical care and advice 12.03 9.6 10.5 Referrals to clinics 16.0 11.4 13.1 Information on equitable relationships between men and women 27.4 22.4 24.2 Food baskets 9.3 26.0 20.0 Food coupons 13.6 47.2 35.1 Food vouchers 3.0 7.7 6.0 Food basket, coupons or vouchers 17.4 55.9 42.0 Vocational training scholarships 1.0 1.0 1.0 Information on STIs other than HIV 45.4 43.7 44.3 Out-of-school literacy training or tutoring 4.3 3.9 4.1 Youth clubs 13.4 3.7 7.2 Aflateen or financial literacy groups 3.8 2.3 2.8 Savings and loan groups 2.8 1.9 2.2 Business and entrepreneurial skills training and mentoring 6.3 6.0 6.1 School uniforms 22.7 56.7 44.4 Assistance with paying school fees 37.9 59.4 51.7 Received transportation money for school 6.7 16.6 13.0 Bereavement counseling 5.7 8.2 7.3 Other types of counseling 7.9 6.9 7.3 Assistance with housing or accommodation 1.2 1.6 1.4 Education or counseling on sexual decision-making 12.2 7.9 9.5 Information on GBV 25.1 24.9 25.1 68 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Table A2. Percent distribution of youth’s reported receipt of services by local organizations, by study arm Local Partner of PCI under BCCOVC Program Organization Intervention Comparison Total Bolokang Matshelo 6.5 4.6 5.3 Humana People to People 9.5 7.0 7.9 Mahalapye Orphan Care 5.5 6.4 6.1 Hope Worldwide Botswana 16.6 5.0 9.2 Stepping Stones International 21.9 6.4 12.0 Botswana-Baylor Children’s 12.0 7.0 8.8 Mother's Union 12.8 6.8 9.0 PCI, or Project Concern International 3.4 2.9 3.1 Peace Corps 4.3 2.7 3.3 Advancing Partners & Communities 4.1 3.9 4.0 Table A3. Demographic characteristics of caregiver Intervention Comparison Total Mean age (range) 46.5 [21, 100] 49.5 [17, 90] 48.5 [17, 100] Sex (%) Females 83.2 89.4 87.2 Males 6.3 7.4 7.0 Missing 10.5 3.1 5.8 Highest level of education (%) None 19.3 28.4 25.2 Some or completed primary school 29.4 33.3 31.9 Some or completed junior secondary school (Forms 1-3) 32.2 24.8 27.4 Some or completed senior secondary school (Form 4-6) 5.1 4.8 4.9 University/college/vocational school 3.6 5.6 4.8 Missing 10.5 3.1 5.8 Marital status (%) Married/cohabitating 18.9 21.8 20.8 Separated 0.8 1.2 1.1 Divorced 1.2 1.3 1.3 Widowed 8.3 13.7 11.7 Never been married 60.4 58.9 59.4 Missing 10.5 3.1 5.8 Work status (%) Worked in last 7 days 22.5 23.9 23.4 Missing 10.5 3.1 5.8 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 69 Worked in past 12 months 34.1 36.7 35.8 Missing 10.5 3.1 5.8 Mean number of children in the household/under caregiver’s care (range) 2.8 [0-14] 2.5 [0-19] 2.6 [0-19] Food insecurity in past 4 weeks (%) Never 45.0 48.6 47.3 Rarely 23.7 22.7 23.0 Sometimes 13.0 15.1 14.4 Often 7.9 10.6 9.6 Missing 10.5 3.1 5.8 Mean number of household items (range) 5.3 [0-16] 5.8 [0-20] 5.6 [0-20] Table A4. HIV and health outcomes of youth respondents, by study arm (%) Health outcomes of youth Intervention Comparison Total Has had an HIV test in the last 12 months and know their test results 34.9 25.9 64.9 Missing 7.7 5.0 6.0 Mean age of sexual debut (among youth who have had sexual intercourse) 15.6 [1, 18] 15.5 [0, 18] 15.5 [0, 18] Had 2+ sex partners in last 3 months 14.0 13.9 14.0 Missing 25.2 21.7 23.4 Used condom every time, last 3 months 61.7 55.7 58.6 Missing 30.8 35.7 33.3 Had 2+ sex partners or did not consistently use condoms, last 3 months 18.7 18.3 18.5 Missing 17.8 17.4 17.6 Had 2+ sex partners AND did not consistently use condoms, last 3 months 2.8 4.4 3.6 Missing 17.8 17.4 17.6 Had transactional sex in last 6 months 15.0 13.9 14.4 Missing 21.5 23.5 22.5 Had 1+ sex partners in last 3 months 61.7 61.7 61.7 Missing 25.2 21.7 23.4 Had 1+ sex partners in last 12 months 77.6 76.5 77.0 Missing 8.4 8.7 8.6 Multiple sex partners in last 12 months (out of all youth) 24.3 20.9 22.5 Missing 8.4 8.7 8.6 70 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Have accessed HIV prevention/testing/treatment advice in past 12 months 56.2 45.7 49.5 Missing 1.6 0.3 0.8 Have accessed reproductive health services in the past 12 months 11.1 6.6 8.2 Missing 2.6 1.4 1.9 Report having experienced sexual violence in past 12 months 1.6 1.6 1.6 Missing 25.1 21.0 22.5 Of all youth (regardless if they reported experiencing sexual violence), those who received medical care or psychological services ever due to GBV 11.1 7.9 9.0 Missing 34.9 32.2 33.2 Of all youth (regardless if they reported experiencing sexual violence), those who received medical care or psychological services due to GBV in the past 12 months 8.7 5.9 6.9 Missing 35.5 33.0 33.9 Have used drugs and/or alcohol in the past 12 months 23.5 14.3 17.6 Missing 0.4 0.0 0.1 HIV positive youth who report being on antiretroviral therapy 92.2 88.2 90.2 Missing 2.0 0.0 1.0 HIV positive youth who take ARVs daily 97.9 91.1 94.6 Missing 0.0 0.0 0.0 HIV positive youth who report having missed a pill in last 30 days 21.3 13.3 17.4 Missing 2.1 4.4 3.3 HIV positive youth who report adherence to ART 76.6 75.6 76.1 Missing 2.1 4.4 3.3 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 71 Table A5. Economic strengthening outcomes of youth respondents, by study arm Intervention Comparison Total Perceive they have the skills necessary for employment or starting a business (%) 25.6 22.0 23.3 Missing 0.4 0.0 0.1 Mean score for basic financial literacy [95% CI] 6.5 [6.35 - 6.64] 6.4 [6.22 - 6.47] 6.4 [6.31 - 6.49] Saved money in the last 12 months (%) 17.4 15.0 15.9 Missing 0.4 0.0 0.1 Report having worked for cash in the past three months (%) 11.4 7. 8 9.1 Missing 0.4 0.0 0.1 Report having started a small business or other income generating activities in the past 12 months (%) 7. 9 4.9 6.0 Missing 0.4 0.0 0.1 In an internship or job training program (%) 4.3 3.2 3.6 Missing 0.4 0.0 0.2 Table A6. Education outcomes of youth respondents, by study arm Intervention Comparison Total Sat for and received 36 points or of higher on the 2018 Botswana General Certificate of Secondary Education [BGCSW] (%) 14.0 19.4 17.7 Missing 2.3 2.2 2.2 Sat for and received 36 points or of higher on the 2017 Botswana General Certificate of Secondary Education [BGCSW] (%) 13.3 16.7 15.2 Missing 33.3 16.7 24.2 Enrolled in any type of school (%) 65.9 74.3 71.3 Missing 0.0 0.0 0.1 Missed any school last week (%) 13.5 12.9 13.1 Missing 0.3 0.0 0.1 Dropped out of school (%) 9.9 10.0 89.2 Missing 1.2 0.7 0.9 Re-enrolled or repeated a grade (%) 38.1 37.3 37.6 Missing 1.2 0.7 0.9 Highest school level completed (%) Less than Form 1 12.0 9.8 10.6 Form 1 9.4 11.4 10.7 Form 2 26.6 24.8 25.5 Form 3 37.1 36.4 36.6 Form 4 12.0 15.6 14.3 Form 5 3.0 2.0 2.4 Form 6 0.0 0.0 0.0 Enrolled in tertiary or vocational school (%) 1.2 1.2 1.2 Missing 0.4 0.0 0.1 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 73 APPENDIX B. QUALITATIVE MATRIX OF KEY RESULTS Summary of PEPFAR and GOB program-related and nonprogram-related effects on HIV and health, economic and education outcomes Positive changes influenced by PEPFAR and/or GOB program/services Barriers to positive change HIV and other health outcomes HIV testing PEPFAR ⚫ HH members were encouraged to test and given referral forms. Some youth report testing for HIV and some CGs were persuaded to encourage or take youth for testing. ⚫ Increased awareness of different means of transmission (sexual/non￾sexual). Learning about non-sexual means of transmission helped persuade those who perceived HIV as not necessary due to perceived low sexual transmission risks. ⚫ Youth learned that when you know your status, you can start treatment. GOB ⚫ MoH campaign facilitating access to clinics ⚫ G&CT combatted fear that HIV is a death sentence. Increased fear of the risks and consequences of not knowing, i.e. can infect others and cannot access treatment ⚫ CG perceived youth at low risk for HIV, e.g. because "still young," believe youth not engaged in sexual relationships or not showing signs of illness, so not necessary to test ⚫ Youth believes "has not done anything" to put herself at risk, so not necessary to test ⚫ CG believes youth has learned about testing and can take herself ⚫ Youth believe being positive will lead to serious negative outcomes ⚫ Youth fear CG will question why youth needs to test ⚫ Youth fear moral judgment from clinic 74 Evaluation of Services for Orphans and Vulnerable Youth in Botswana HIV prevention PEPFAR and GOB ⚫ Learned about risks of infection and reinfection ⚫ Learned HIV Prevention Methods: abstinence, monogamy, condoms, male circumcision ⚫ HIV+ learned having an undetectable viral load will prevent transmission to one's partner ⚫ Encouraged to choose partners wisely, e.g. who do not pressure girl for sex or distract from school work ⚫ Youth encouraged to delay relationships until after schooling or abstain from sex ⚫ Youth awareness and reflection on negative consequences discouraged sexual relationships: (e.g. HIV infection, pregnancy, dropping out) ⚫ LPs are not distributing condoms themselves ⚫ Norms inhibiting open communication about relationships. CG and youth both experience discomfort talking about relationships, sex or prevention ⚫ CGs believe that youth is young and not in a relationship or sexually active ⚫ Youth fear moral judgement if access prevention methods at clinics GBV knowledge and services PEPFAR ⚫ Education prompts youth to reveal abuse to facilitators in Life Skills sessions at schools or in Safe Spaces (component of the DREAMS program) ⚫ When abuse identified, LPs report holding family conferences PEPFAR and GOB ⚫ Youth learned what constitutes abuse (GBV and child abuse) and were able to "see" it in their own lives ⚫ Youth learned where to report ⚫ Some CSPs report being unable to teach without evidence of abuse ⚫ LP discover GBV by chance ⚫ Youth and CG understanding of GBV includes both GBV and child physical, emotional and sexual abuse. ⚫ LPs believe that without education, CG and youth will not recognize abuse and not report ⚫ LPs struggle to help victims of GBV because CG doesn't want to leave partner Summary of PEPFAR and GOB program- related and nonprogram-related effects on HIV and health, economic and education outcomes Positive changes influenced by PEPFAR and/or GOB program/services Barriers to positive change Evaluation of Services for Orphans and Vulnerable Youth in Botswana 75 ART imitation and adherence PEPFAR ⚫ Encouraged CGs to inform youth of youth’s status; helped youth deal with anger and resentment ⚫ Educated youth about how HIV works in the body and how ARVs combat it promoted adherence ⚫ Helped youth accept status and realization that one can live well if one looks after oneself promoted adherence ⚫ CGs encouraged to help youth adhere, remind them to take medications, and confirm they are taking their medication by checking pill bottles, observing ingestion and looking for signs that pills are not being taken, e.g. illness ⚫ Youth don’t know status, nor the purpose of medications, not taken seriously ⚫ Youth don’t understand HIV or how medications work ⚫ Youth fear non-adherence will be discovered. Pills thrown out. ART initiation and adherence: psychosocial factors PEPFAR ⚫ Improved confidence, self-esteem, outlook ⚫ Peer groups promoted social solidarity and emotional support ⚫ Helped youth realize that living with HIV doesn't mean one can't live like anyone else. ⚫ Helped youth manage and copse with stigma and discrimination ⚫ Built courage and skills to disclose status ⚫ Learned HIV is not visible and disclosure is a choice, and one that must consider the trustworthiness of those who know ⚫ Helped youth accept status and cope with stigma and discrimination which reduced fear of being discovered taking medications ⚫ Youth fear status will be discovered ⚫ Youth fear reactions from friends or partner Economic outcomes Financial literacy and saving PEPFAR ⚫ Youth reflected on spending, what was useful and what was wasteful, and threats to spending, e.g. pressure from friends ⚫ Learned how to prioritize and budget ⚫ Learned the importance of saving ⚫ Inspired cost-cutting practices ⚫ Saving: youth have no money to save or, after needs met, nothing left to save 76 Evaluation of Services for Orphans and Vulnerable Youth in Botswana ⚫ Learned where savings can be kept, e.g. money box, savings account Work and work-related education PEPFAR ⚫ Learned the skills or education required for different jobs ⚫ Learned how to write a CV ⚫ Learned computer skills ⚫ Discouraged idleness and dependency on others, encouraged independence ⚫ Youth prompted to reflect on the consequences of not being financially stable, e.g. being poor or being responsible for the care of their child ⚫ Youth pessimistic about availability of jobs ⚫ Finding work requires money, e.g. transport, printing ⚫ Belief among CGs and youth that one should not work while in school ⚫ Youth request assistance with access to vocational training, securing work placements and career advice Evaluation of Services for Orphans and Vulnerable Youth in Botswana 77 Summary of PEPFAR and GOB program-related and nonprogram-related effects on HIV and health, economic and education outcomes Positive changes influenced by PEPFAR and/or GOB program/services Barriers to positive change Income generation PEPFAR ⚫ Youth learned skills to plan, start and continue IGAs ⚫ Learned skills in a practical way, e.g. car wash, how to make things to sell ⚫ Some success at current IGAs ⚫ Referrals to GoB Poverty Eradication Scheme ⚫ Youth motivated by the financial possibilities of IGA, what can be done with the money, e.g. meeting needs or obtaining wants that family cannot provide ⚫ Youth and CGs do not have money and need for capital to buy stock ⚫ Potential participants for GROW savings scheme lack money to make contributions Education outcomes School enrollment, attendance, and performance PEPFAR ⚫ Referrals for tutoring ⚫ Learned to assume responsibility for education ⚫ Built confidence to ask questions ⚫ Tutoring improved performance: patience, focus on student needs, e.g. difficult subjects, and learning abilities ⚫ Learned study skills, planning & time management ⚫ Encouraging the formation of study groups for peer support ⚫ Learned educational requirements for different jobs PEPFAR HIV+ ⚫ Accepting status improved attitude towards education and built confidence resulting in more active participation which then improved school performance ⚫ Coping with stigma reduced fear of judgment and desire to not attend ⚫ Youth and CG request easier access and frequency of tutoring ⚫ Gaps in supply of uniforms, fees, transport, food ⚫ Youth negatively influenced by peers ⚫ Youth distracted by dating ⚫ Youth miss school because fear punishment for not doing work ⚫ Youth find economic deprivation demoralizing ⚫ CG lack of interest and involvement in youths' education 78 Evaluation of Services for Orphans and Vulnerable Youth in Botswana GOB ⚫ Financial and material support for education helped youth to attend, changed their attitude towards schooling and improved self￾esteem School continuation PEPFAR ⚫ Encouraged youth who have failed secondary school to not lose hope and return to school ⚫ Encouraged youth who failed secondary school to consider different educational pathways, e.g. vocational training ⚫ Youth motivated by understanding education is a pathway to overcome hardship ⚫ CGs experience confusion about LP role in returning to school, i.e. who is responsible for what aspect Evaluation of Services for Orphans and Vulnerable Youth in Botswana 79 APPENDIX C. YOUTH HOUSEHOLD SURVEY Youth Questionnaire NO. QUESTION RESPONSE OPTIONS device_id (automatically computed) Atime_for mloaded (automatically computed) Atime_for mfirstloaded (automatically computed) Enumerator, welcome to the YOUTH questionnaire. Instructions and questions for the enumerator appear in UPPERCASE TEXT. Questions to read to the respondent appear in black text. (NOTE: THIS IS FORM VERSION 76.) A001 COMPLETE THIS INTRODUCTORY SECTION BEFORE APPROACHING THE TARGETED RESPONDENT. HOUSEHOLD IDENTIFICATION NUMBER: 1-9999 A002 DISTRICT: 1 2 3 4 5 6 7 8 66 Central Gaborone Goodhope Kgatleng Kweneng Mahalapye South East Southern Other district A002b If district is not listed: SPECIFY DISTRICT: A003 If A002 is a listed district: SUB-DISTRICT: *Subdistrict list populated based on selection in A002 A003b If district or sub-district are not listed: SPECIFY SUB-DISTRICT: A004 If A003 is a listed sub-district: VILLAGE: *Village list populated based on selection in A003 A004b If district, sub-district, or village are not listed: SPECIFY VILLAGE: A005 WARD: A008a ENUMERATOR NAME ENTER FIRST AND LAST NAMES. A008b ENUMERATOR CODE #: 1-99 ############ ENUMERATOR, UPDATE THE RESPONSE ON THE NEXT SCREEN EVERY TIME YOU VISIT THIS HOUSEHOLD. ############ vnum IS THIS THE FIRST, SECOND, OR THIRD TIME VISITING TO TRY AND INTERVIEW THIS YOUTH? 1 2 3 THIS IS THE FIRST VISIT (VISIT 1) THIS IS THE SECOND VISIT (VISIT 2) THIS IS THE THIRD VISIT (VISIT 3) If ((vnum)=2 or (vnum)=3): ############ ENUMERATOR, UPDATE THE RESPONSE ON THE NEXT SCREEN EVERY TIME YOU VISIT THIS HOUSEHOLD. ############ 80 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Aavail YOU HAVE INDICATED THAT THIS IS VISIT #(vnum) TO TRY AND INTERVIEW THE YOUTH AT HOUSEHOLD (A001). IF THAT IS INCORRECT, GO BACK AND CORRECT THE HOUSEHOLD NUMBER IN A001 OR THE VISIT NUMBER IN VNUM. ON THIS VISIT (VISIT (vnum)), ARE YOU ABLE TO BEGIN THE 1 2 3 4 5 YES NO, RESPONDENT NOT AVAILABLE NO, RESPONDENT REFUSED NO, RESPONDENT INCAPACITATED NO, COULD NOT FIND OR REACH HOUSEHOLD NO. QUESTION RESPONSE OPTIONS INTERVIEW WITH THE TARGETED YOUTH? IF YOU LEARN THAT THE TARGETED YOUTH IS NOT 16-18 YEARS OLD, TAP YES. YOU WILL THEN INDICATE AGE IN A205, SKIP THE SURVEY, AND MARK INELIGIBLE AGE AS THE OUTCOME. c_textAava il Text for AAVAIL (automatically calculated): If (Aavail)=1: 'YOU ARE ABLE TO BEGIN THE INTERVIEW WITH THE YOUTH'; If (Aavail)=2, 'THE YOUTH RESPONDENT IS NOT AVAILABLE'; If (Aavail)=3, 'THE RESPONDENT REFUSED TO PARTICIPATE'; If (Aavail)=4, 'THE RESPONDENT IS INCAPACITATED'; If (Aavail)=5, 'YOU COULD NOT FIND THE HOUSEHOLD OR YOU COULD NOT REACH IT' confirm_Aa vail CONFIRM: YOU HAVE INDICATED THAT THIS IS VISIT #(vnum) TO HH (A001), AND FOR THIS VISIT #(vnum), (c_textAavail). IS THAT CORRECT? 1 Yes 2 No *Cannot select 2 If (Aavail)=1: Begin interview. A205 ENUMERATOR: APPROACH THE YOUTH AND INTRODUCE YOURSELF. READ INFORMATION ABOUT THE STUDY FROM THE CONSENT/ASSENT FORM. THEN ASK: How old were you at your last birthday? 16 17 18 88 Sixteen Seventeen Eighteen NOT 16, 17, OR 18 YEARS OLD A205confir m If (A205)=88: ENUMERATOR: ENUMERATOR: ASK AGE AGAIN TO CONFIRM IF RESPONDENT IS ELIGIBLE FOR THE INTERVIEW (ELIGIBLE AGES ARE AGE 16, 17, OR 18 YEARS OLD). ENTER AGE OF RESPONDENT: 1-98 If (A205confirm)=16,17,18: ERROR: YOU HAVE INDICATED THAT THE RESPONDENT IS WITHIN THE RANGE OF 16 TO 18 YEARS OLD. THEREFORE, THE RESPONDENT IS ELIGIBLE FOR THE SURVEY. GO BACK 2 SCREENS TO A205 AND SELECT THE CORRECT AGE. If (A205)=88 and (A205confirm) is not 16,17,18: ENUMERATOR: THIS RESPONDENT IS INELIGIBLE DUE TO AGE OUTSIDE 16-18 YEARS. THANK THE YOUTH AND END THE INTERVIEW. THEN CONTINUE FORWARD TO COMPLETE THIS FORM. THIS FORM MUST BE SUBMITTED EVEN THOUGH THE RESPONDENT WAS NOT 16-18 YEARS OLD. Aconfirm_c onsent If (A205)=18: ENUMERATOR: THIS YOUTH IS 18, SO YOU WILL USE THE CONSENT FORM. SEEK AND DOCUMENT CONSENT FROM THE YOUTH. WERE YOU ABLE TO OBTAIN CONSENT FROM THE YOUTH? 1 2 Yes No Evaluation of Services for Orphans and Vulnerable Youth in Botswana 81 Aconfirm_a ssent If (A205)=16,17: THIS YOUTH IS UNDER 18, SO YOU WILL SEEK AND DOCUMENT: 1. CONSENT FROM THE CAREGIVER, AND 2. ASSENT FROM THIS YOUTH. WERE YOU ABLE TO OBTAIN THE CAREGIVER'S CONSENT (FOR THE YOUTH TO PARTICIPATE) AND THE YOUTH'S ASSENT? 1 2 Yes No If (Aconfirm_assent)=2 or (Aconfirm_consent)=2: ENUMERATOR: YOU HAVE INDICATED THAT CONSENT/ASSENT HAS NOT BEEN GIVEN. THANK THE YOUTH AND END THE INTERVIEW. THEN CONTINUE FORWARD TO COMPLETE THIS FORM. THIS FORM MUST BE SUBMITTED EVEN THOUGH THE RESPONDENT (OR CAREGIVER, IF UNDER 18) REFUSED. If (Aconfirm_consent)=1 or (Aconfirm_assent)=1, continue interview. Let's start out with you telling me a little about yourself and your family. A201 What are your initials? A203 To confirm, what is your sex? 1 2 Female Male NO. QUESTION RESPONSE OPTIONS A204m In what month and year were you born? Month: 1 2 3 4 5 6 7 8 9 10 11 12 JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER A204y Year: 1999-2002 If (A204y)=1999,2000 and (A205)=16; or (A204y)=1999,2002 and (A205)=17; or (A204y)=2001,2002 and (A205)=18: ERROR: AGE OF (A205) IS NOT POSSIBLE WITH A BIRTH YEAR OF (A204y). GO BACK AND CORRECT THE ERROR IN A204y OR A205 TO PROCEED. A206 Is your biological mother still living? 1 2 8 Yes No Don't know A207 If (A206)=2: How old were you when your biological mother died? RECORD IN YEARS. CANNOT EXCEED RESPONDENT'S AGE, (A205). IF UNKNOWN, ENTER 88. 0-(A205), 88 A208 If (A206)=1: Is your biological mother currently living in the same household as you, or living elsewhere? 1 2 Same household Elsewhere A209 If (A206)=1: Does your biological mother work to earn cash to help support the family? 1 2 Yes No 82 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A210 If (A209)=1: What types of activities/work does your biological mother do to earn cash to support the family? MARK ALL THAT APPLY. 1 2 3 4 5 6 7 8 9 10 66 Subsistence farming Commercial farming Livestock farming Mine labor Skilled artisan Business/Self-employment Market vendor/Seller Domestic/Cook/Gardening Formal/Salaried employment Piecework/Ipelegeng Other A210b If (A210) includes 66: Specify other type of work: A211 Is your biological father still living? 1 2 8 Yes No Don't know A212 If (A211)=2: How old were you when your biological father died? 0-(A205), 88 A213 If (A211)=1: Is your biological father currently living in the same household as you, or living elsewhere? 1 2 Same household Elsewhere NO. QUESTION RESPONSE OPTIONS A214 If (A211)=1: Does your biological father work to earn cash to help support the family? 1 Yes 2 No A215 If (A214)=1: What types of activities/work does your biological father do to earn cash to support the family? MARK ALL THAT APPLY. 1 Subsistence farming 2 Commercial farming 3 Livestock farming 4 Mine labor 5 Skilled artisan 6 Business/Self-employment 7 Market vendor/Seller 8 Domestic/Cook/Gardening 9 Formal/Salaried employment 10 Piecework/Ipelegeng 66 Other A215b If (A215) includes 66: Specify other type of work: Evaluation of Services for Orphans and Vulnerable Youth in Botswana 83 A216 Who is your primary caregiver? (i.e., who takes care of you?) A primary caregiver is defined as the person who is responsible for feeding, clothing, and caring for you. IT SHOULD NOT BE THE PERSON WHO SOLELY PROVIDES FINANCIAL SUPPORT, UNLESS THAT PERSON IS ALSO THE ONE RESPONSIBLE AS THE CAREGIVER (DEFINED ABOVE). THE PRIMARY CAREGIVER CAN BE, BUT DOES NOT NEED TO BE, THE MOTHER OR FATHER OR HEAD OF HOUSEHOLD. DO NOT READ THE RESPONSES. SCROLL TO SEE ALL CHOICES. 1 Mother (biological) 2 Father (biological) 3 Step-mother and/or foster mother 4 Step-father and/or foster father 5 Sister 6 Brother 7 Aunt 8 Uncle 9 Grandmother 10 Grandfather 11 Non-family member (female) 12 Non-family member (male) 13 Youth cares for self 66 Other *Cannot select 1 if biological mother is not living (A206=2); cannot select 2 if biological father is not living (A211=2) If (A216)=13: You have told me that you are your own caregiver. Please note that in this survey, we will ask several questions about a caregiver, including your relationship and communication with that person. When answering these questions, please answer about the last (most recent) caregiver you had before you started taking care of yourself. For the remainder of this questionnaire, (*selfCGmod) indicates questions where question text is modified for children who care for themselves. Modifications include: (*selfCGmod1): References "most recent caregiver" in place of "caregiver" alone. (*selfCGmod2): Specifies time period "before you started taking care of yourself." (*selfCGmod3): Adds note: "BECAUSE YOUTH CARES FOR SELF, ASK HOW LONG YOUTH HAS BEEN HIS/HER OWN CAREGIVER." A216b If (A216)=66: Specify other caregiver: A216c ENUMERATOR: CHECK YOUR CONTROL SHEET TO GET THE NAME OF THE CAREGIVER FROM THE BENEFICIARY LIST. CONFIRM WITH YOUTH: IS THE NAME ON THE LIST THE SAME PERSON THE YOUTH IDENTIFIED AS HIS/HER CAREGIVER? 1 YES, YOUTH IDENTIFIED THE NAMED PERSON AS HIS/HER CAREGIVER. 2 NO, YOUTH IDENTIFIED A DIFFERENT PERSON AS HIS/HER CAREGIVER. NO. QUESTION RESPONSE OPTIONS 88 DON'T KNOW (E.G., NO CAREGIVER NAME LISTED OR YOUTH DOESN'T KNOW NAME) A217 How many months has this person been your primary caregiver? (*selfCGmod3) 1 Less than 6 months 2 6 to less than 12 months 3 12 months or more A301a Have you ever attended school? 1 Yes 2 No If (A301a)=1, ask A301b-A321 as applicable. A301b Are you currently enrolled in any of the following: 1 School 2 Vocational training 3 College 4 University 5 None of these If (A301b)=1,2,3,4, ask A302-A305 as applicable. 84 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A302 During the last school week, did you miss any school days for any reason? 1 Yes 2 No 8 Don't know A303 If (A302)=1: What is the primary reason that you missed any school days during the last school week? 1 No money for materials 2 I was too sick to attend 3 Pregnancy 4 Got married 5 It is too far away 6 I had to work 7 I had to care for household members 8 Peer pressure 9 Parent/Guardian did not want me to go to school 10 I don’t like school 11 School was not in session 12 No money for transport 66 Other A303b If (A303)=66: Specify other reason: If (A301b)=1, ask A304-A305. A304 What standard or form are you in now? 1 Standard 1 2 Standard 2 3 Standard 3 4 Standard 4 5 Standard 5 6 Standard 6 7 Standard 7 8 Form 1 9 Form 2 10 Form 3 11 Form 4 12 Form 5 13 Form 6 A305 Do you expect to complete (A304)? 1 Yes 2 No NO. QUESTION RESPONSE OPTIONS A307 Were you enrolled in school (any standard or form) during the previous school year? 1 Yes 2 No A308 If (A307)=1: What standard or form were you in during the previous school year? 0 None 1 Standard 1 2 Standard 2 3 Standard 3 4 Standard 4 5 Standard 5 6 Standard 6 7 Standard 7 8 Form 1 9 Form 2 10 Form 3 11 Form 4 12 Form 5 13 Form 6 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 85 A309 Have you ever repeated a standard or form? 1 Yes 2 No A310 If (A309)=1: How many times have you repeated a standard or form? ENTER THE NUMBER OF TIMES ANY STANDARD OR FORM WAS REPEATED (1-10). 1-10 A311 What is the highest standard or form that you have completed? 0 None 1 Standard 1 2 Standard 2 3 Standard 3 4 Standard 4 5 Standard 5 6 Standard 6 7 Standard 7 8 Form 1 9 Form 2 10 Form 3 11 Form 4 12 Form 5 13 Form 6 If (A311)≥(A304): ERROR: IN A304, YOU INDICATED THAT THE RESPONDENT IS NOW IN (A304). IN A311, YOU INDICATED THAT THE HIGHEST LEVEL THE RESPONDENT COMPLETED WAS (A311). THE HIGHEST FORM COMPLETED MUST BE LESS THAN THE CURRENT FORM. GO BACK AND CORRECT THE ERROR IN A304 OR A311. A312a Do you expect to enroll in any level of education in the next school year? 1 Yes 2 No A312b If (A312a)=1: What level do you expect to enroll in next school year? 1 Standard 1 2 Standard 2 3 Standard 3 4 Standard 4 5 Standard 5 6 Standard 6 7 Standard 7 8 Form 1 9 Form 2 NO. QUESTION RESPONSE OPTIONS 10 Form 3 11 Form 4 12 Form 5 13 Form 6 14 Vocational training 15 College 16 University If (A311)=12,13, ask A314m-A317b as applicable. 86 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A314m When did you complete Form 5? Month: 1 JANUARY 2 FEBRUARY 3 MARCH 4 APRIL 5 MAY 6 JUNE 7 JULY 8 AUGUST 9 SEPTEMBER 10 OCTOBER 11 NOVEMBER 12 DECEMBER A314y Year: ((A204y)+10)-2018 A315 Did you sit for the Botswana General Certificate of Secondary Education Examination? 1 Yes 2 No A317 If (A315)=1: How many points did you have on the Exam? I am asking about the total points across your best 6 subjects. ENTER POINTS (0-48). IF UNKNOWN, ENTER -8 (NEGATIVE 8). IF REFUSED, ENTER - 9 (NEGATIVE 9). 0-48, -8, -9 A317b If ((A315)=1 and (A317)>=0): ENUMERATOR: WERE YOU ABLE TO CONFIRM THIS RESULT ON THE STUDENT'S CERTIFICATE/RESULTS SLIP? 1 Yes 2 No If (A317)=-8,-9: ENUMERATOR: YOU HAVE RECORDED 'DON'T KNOW' OR 'REFUSED' AS THE EXAM SCORE. THIS IS AN IMPORTANT QUESTION. PLEASE ASK THE RESPONDENT ONE MORE TIME HOW MANY POINTS HE OR SHE RECEIVED ON THE EXAM. IF THE NUMBER OF POINTS IS GIVEN, GO BACK AND ENTER THIS IN A317. A319 Have you ever dropped out of school? 1 Yes 2 No A320 If (A319)=1: What was the primary reason for dropping out of school the most recent time you dropped out? SCROLL TO SEE ALL CHOICES. 1 You fell pregnant 2 You became sick or disabled 3 You acquired all the education you wanted 4 No money for fees or uniform 5 You were attending initiation 6 You don't like or are not interested in school 7 You were not doing well in school/failed too many times 8 You were expelled 9 You thought you were too old to continue NO. QUESTION RESPONSE OPTIONS 10 Your parents told you to stop going to school 11 Your friend or boyfriend/girlfriend told you to stop going to school 12 You had to help at home 13 You got married 14 You had to care for someone else’s child 66 Other Evaluation of Services for Orphans and Vulnerable Youth in Botswana 87 A320b If (A320)=66: Specify other reason: A321 If ((A319)=1 and (A301b)=5): Did you re-enroll in school 1 Yes since the most recent time you dropped out? 2 No A313 What is the highest level of education that you hope to complete in your lifetime? 0 None 1 Standard 1 2 Standard 2 3 Standard 3 4 Standard 4 5 Standard 5 6 Standard 6 7 Standard 7 8 Form 1 9 Form 2 10 Form 3 11 Form 4 12 Form 5 13 Form 6 14 Vocational training 15 College 16 University 77 Not interested in further education If (A313)<(A311): ERROR: IN A311, YOU INDICATED THAT THE HIGHEST STANDARD/FORM THE RESPONDENT COMPLETED WAS (A311). IN A313, YOU INDICATED THAT THE HIGHEST STANDARD/FORM THE RESPONDENT HOPES TO COMPLETE IS (A313) THE HIGHEST STANDARD/FORM THE RESPONDENT HOPES TO COMPLETE CANNOT BE LESS THAN THE HIGHEST COMPLETED. GO BACK AND CORRECT THE ERROR IN A311 OR A313. A306 If (A301b)=5 or (A301a)=2: 1 No money for materials What is the primary reason why you do NOT go to school, 2 I am too sick to attend vocational training center, college or university? 3 Pregnancy 4 Got married 5 It is too far away 6 I have to work 7 I have to care for household members 8 Peer pressure 9 Parent/Guardian does not want me to go 10 I don’t like school, training center, college or university 11 No money for transport 12 Enrolled in non-formal schooling 66 Other NO. QUESTION RESPONSE OPTIONS A306b If (A306)=66: Specify other reason: Now I would like to ask you some questions about life skills knowledge. A401 Have you ever heard of sexually transmitted infections (STIs)? 1 2 Yes No If (A401)=1, ask A402a-403g. For each of the following, please tell me if it is a sexually transmitted infection. READ EACH. MARK YES, NO, OR DK (DON'T KNOW). Yes No DK 88 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A402a Gonorrhea 1 2 8 A402b Syphilis 1 2 8 A402c Genital herpes 1 2 8 A402d Trichomoniasis 1 2 8 A402e Tuberculosis 1 2 8 A402f Asthma 1 2 8 A402g HIV/AIDS 1 2 8 A402h Chlamydia 1 2 8 A402i Hepatitis B 1 2 8 A402j Hepatitis C 1 2 8 For each of the following, please tell me if it is a route of transmission of STIs. READ EACH. MARK YES, NO, OR DK (DON'T KNOW). Yes No DK A403a Sexual intercourse 1 2 8 A403b Blood transfusion 1 2 8 A403c Sharing injection needles 1 2 8 A403d Sharing food/drinks 1 2 8 A403e Sharing clothes 1 2 8 A403f Infected mother to child 1 2 8 A403g Kissing 1 2 8 Please tell me if the following statements are true or false. A404 Using contraceptive pills can reduce risk of being infected with STIs or HIV: 1 2 88 True False Don't know A405 Using contraceptive pills can reduce risk of getting pregnant: 1 2 88 True False Don't know A407 Using condoms can reduce the risk of being infected with an STIs or HIV: 1 2 88 True False Don't know A408 Using condoms can decrease the risk of getting pregnant: 1 2 88 True False Don't know A409 Being monogamous can reduce one’s chance of infection of STIs or HIV: 1 2 88 True False Don't know A410 Having multiple sexual partners can increase chances of being infected with STIs or HIV: 1 2 88 True False Don't know A411 Abstaining from sex is the most effective means of avoiding STIs or HIV: 1 2 88 True False Don't know NO. QUESTION RESPONSE OPTIONS A420a The next series of questions asks you about substance use (alcohol, tobacco, and other drugs). Have you ever smoked a cigarette or smoking tobacco (kwae), even one or two puffs? 1 2 Yes No A420b If (A420a)=1: Have you smoked cigarettes or tobacco (kwae) in the past 12 months? 1 2 Yes No A420c If (A420b)=1: Have you smoked cigarettes or tobacco (kwae) in the past 30 days? 1 2 Yes No Evaluation of Services for Orphans and Vulnerable Youth in Botswana 89 A421a Have you ever had more than a few sips of alcohol? 1 2 Yes No A421b If (A421a)=1: Have you had more than a few sips of alcohol in the past 12 months? 1 2 Yes No A421c If (A421b)=1: Have you had more than a few sips of alcohol in the past 30 days? 1 2 Yes No A422a Have you ever used any other substances such as: marijuana, cocaine, inhalants (glue, petrol, paint, correction fluid, markers, or paint thinner)? 1 2 Yes No A422b If (A422a)=1: Have you used any of those other substances in the past 12 months? 1 2 Yes No A422c If (A422b)=1: Have you used any of those other substances in the past 30 days? 1 2 Yes No A423a Have you ever used a needle to inject any illegal drug into your body? 1 2 Yes No A423b If (A423a)=1: Have you used a needle to inject any illegal drug into your body in the past 12 months? 1 2 Yes No A423c If (A423b)=1: Have you used a needle to inject any illegal drug into your body in the past 30 days? 1 2 Yes No Next, please tell me if the following statements are true or false: A412 A substance is anything we put in our bodies which affects the way we feel, think and behave: 1 2 88 True False Don't know A413 Only students from rich families abuse substance: 1 2 88 True False Don't know A414 Tobacco is addictive: 1 2 88 True False Don't know A415 Substance abuse is taking substances for their intended purpose: 1 2 88 True False Don't know A416 Substance abuse lowers an individual’s inhibitions and therefore can contribute to an individual making poor judgments such as driving under the influence and causing road traffic accidents: 1 2 88 True False Don't know A417 Risks associated with smoking tobacco are developing lung cancer, cancers of the mouth and lips: 1 2 88 True False Don't know A418 Assertiveness is an important skill for young people to have to ensure they stay away from substance abuse: 1 2 88 True False Don't know NO. QUESTION RESPONSE OPTIONS A419 Substances, especially alcohol, affect all areas of the body, 1 True which can lead to other diseases: 2 False 88 Don't know As you know, some people take up jobs for which they are paid in cash or in kind. Others sell things, have a small business or work on the family farm or in the family business. A501 In the last 3 months, did you do any type of work - work where you got money (pula), were paid in kind, or were not paid? 1 Did work, paid in money (pula) only 2 Did work, paid in money (pula) AND in kind 90 Evaluation of Services for Orphans and Vulnerable Youth in Botswana By 'in kind' I mean payment in goods, commodities or services, instead of cash. 3 Did work, paid in kind only 4 Did work, NOT paid 5 DID NOT do these things nor any other work A502 If (A501)=1,2: Averaging over the past 3 months, about how many pula did you earn on average per month? ADD THE TOTAL AMOUNT EARNED OVER THE LAST 3 MONTHS AND DIVIDE BY 3. ENTER THIS AVERAGE AMOUNT OF PULA (1-999999). FOR EXAMPLE, IF ZERO (0) PULA WERE EARNED LAST MONTH AND 300 PULA WERE EARNED IN EACH OF THE 2 MONTHS BEFORE THAT, YOU WOULD ENTER 200 PULA, AS (0 + 300 + 300 = 600)/3 MONTHS = 200 PULA PER MONTH. IF UNKNOWN, ENTER -8 (NEGATIVE EIGHT). 1-999999, -8 A503 If (A501)=1,2,3,4: What types of work do you do? MARK ALL THAT APPLY. 1 Subsistence farming 2 Commercial farming 3 Livestock farming 4 Mine labor 5 Skilled artisan 6 Business/Self-employment 7 Market vendor/Seller 8 Domestic/Cook/Gardening 9 Formal/Salaried employment 10 Piecework/Ipelegeng 66 Other A503b If (A503) includes 66: Specify other work: A504 Are you currently looking for work? 1 Yes 2 No A505 Do you feel you have the skills you need to have a job? 1 Yes 2 No A506 In the past 12 months have you started a small business 1 Yes (i.e., an income generating activity)? 2 No A507 Do you feel you have the skills you need to start a business? 1 Yes 2 No A508 In the past twelve months have you participated in an 1 Yes internship? 2 No A509 In the past twelve months have you participated in a job 1 Yes training program? 2 No Now I am going to ask you several questions about different issues related to your use of any money you earned or money you were given, spending money, and savings. We know that some youth have money to spend and save and others don’t. So, there are no right or wrong answers, just answer as honestly as you can. NO. QUESTION RESPONSE OPTIONS A510 In the past 12 months, have you saved or put money aside 1 Yes to use at a later time? 2 No If (A510)=1, ask A511-A512p. A511 In the past 12 months, what is the most amount of money you had saved? PROBE FOR THE MAXIMUM AMOUNT IN SAVINGS AT ANY TIME IN THE LAST 12 MONTHS. IF NONE, ENTER 0. IF UNKNOWN, ENTER -8 (NEGATIVE EIGHT). 0-999999, -8 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 91 In the past 12 months, what did you save money for? Did you save for: READ EACH ITEM. MARK YES OR NO. Yes No A512a Emergencies 1 2 A512b Personal items 1 2 A512c Household expenses 1 2 A512d Own school fees 1 2 A512e School fees for others 1 2 A512f School materials 1 2 A512g Own business 1 2 A512h Family business 1 2 A512i Future use 1 2 A512j Agricultural inputs 1 2 A512k Medical expenses for self 1 2 A512l Medical expenses for other 1 2 A512m Transport/Trips 1 2 A512n Other 1 2 A512p If (A512n)=1: Specify other thing(s) you saved money for in the past 12 months: A513 Where have you saved your money in the last 12 months? MARK ALL THAT APPLY. 1 Bank/Bank account 2 Savings account 3 Money box/Under mattress/Hole/Box/Wardrobe 4 With a friend 5 With a parent or guardian 6 In a savings group 7 Orange Money/My Zaka 88 Don't know *Cannot select don't know with other choices. I want to talk about the items that a person might own. Do you personally own or have these items? READ EACH ITEM. MARK YES OR NO. Yes No A514a A blanket 1 2 A514b A pair of shoes (other than school shoes) 1 2 A514c Two sets of clothing (other than uniform) 1 2 A514d A school bag 1 2 A514e Some jewelry 1 2 A514f A mobile telephone 1 2 A514g A clock or a wrist watch 1 2 A514h A bicycle 1 2 A514i If (A203)=1: Perfume 1 2 A514j If (A203)=1: Make-up 1 2 A514k Sports equipment 1 2 NO. QUESTION RESPONSE OPTIONS Now I have a short story to read. After I read it, I will ask you some questions about it. "Each week, Anna sits down and plans what she will earn and spend in the next week. She writes down all the places where she will get money and all the things she will spend it on. Then she is able to see if she has enough money for all of what she wants to buy." A519 What would you call that kind of plan? 1 Budget 2 Savings plan 3 Financial goal 92 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 88 Don't know/Other A516 Do you have such a plan? 1 Yes 2 No A517 If (A516)=1: 1 Yes Is your plan written down? 2 No A518 If (A516)=1: 1 All of the time Would you say that you follow your plan all of the time, 2 Some of the time some of the time, rarely, or never? 3 Rarely 4 Never Here is another story. I will ask you some questions about it after I have read it. "Imani is 17 and lives with her mother and her younger sister. Her older sister Mary is married and lives in another town, three hours away. Mary just had a baby boy, and Imani is eager to visit her sister. Imani will need to save money for transport and a small gift for the baby. A cute little hat would be perfect! But she can’t take money from her savings because she is saving that money to start her own business. Imani’s dream is to start a small catering business. Hopefully, her neighbor will employ her to work extra days in her hotel so she can get the money she needs for her trip." A521 What is one of Imani's short term financial goals? IF RESPONDENT GIVES MULTIPLE RESPONSES, ASK RESPONDENT TO CHOOSE ONLY ONE. 1 Transport to visit her sister 2 Buy a gift for her nephew 3 Start a business 66 Other 88 Don't know A522 What is Imani's long term financial goal? IF RESPONDENT GIVES MULTIPLE RESPONSES, ASK RESPONDENT TO CHOOSE ONLY ONE. 1 Transport to visit her sister 2 Buy a gift for her nephew 3 Start a business 66 Other 88 Don't know A523 What is one formal way of saving money? IF RESPONDENT GIVES MULTIPLE RESPONSES, ASK RESPONDENT TO CHOOSE ONLY ONE. 1 Bank/Bank account 2 Savings account 3 Money box/Under mattress/Hole/Box/Wardrobe 4 With a friend 5 With a parent or guardian 6 In a savings group 7 Orange Money/My Zaka 88 Don't know A524 What is one informal way of saving money? IF RESPONDENT GIVES MULTIPLE RESPONSES, ASK RESPONDENT TO CHOOSE ONLY ONE. 1 Bank/Bank account 2 Savings account 3 Money box/Under mattress/Hole/Box/Wardrobe 4 With a friend 5 With a parent or guardian 6 In a savings group 7 Orange Money/My Zaka 88 Don't know NO. QUESTION RESPONSE OPTIONS A525 Grace would like to buy a new notebook for the next school term which starts in eight weeks. If the notebook costs 10 pula and she can save 1 pula each week, will she reach her goal? 1 Yes 2 No Evaluation of Services for Orphans and Vulnerable Youth in Botswana 93 A526 In the situation described in the previous question, if Grace figured out how much she needed to save each week, and for how many weeks she needed to save in order to reach her goal, what would that be called? 1 Budget 2 Savings plan 3 Financial goal 88 Don't know/Other A527 If Grace discovered that she couldn’t reach her goal with that plan, what changes could she make so she would still reach her goal? DO NOT READ THE CHOICES. MARK 'OTHER' IF THE RESPONDENT GIVES A RESPONSE BESIDES THOSE LISTED. 1 Buy a cheaper notebook 2 Save more each week 3 Give herself longer time to reach her goal 66 Other 88 Don't know *Cannot select 88 with other choices. A527b If (A527) includes 66: Specify other: A528 Do you agree or disagree with the following statement: "Only people with a lot of money can save"? 1 Agree 2 Disagree A529 When there are weeks, for example, when you have met all your basic needs and at the end of the week you still have 5 pula remaining, what do you usually do with that money? MARK ALL THAT APPLY. 1 Save/Put aside for future use 2 Buy something extra 88 Don't know *Cannot select 88 with other choices. Now I will read some statements. For each one, please tell me if you agreeor disagree. READ EACH. MARK AGREE OR DISAGREE. Agree Disagree A701 I have people I look up to: 1 2 A702 Getting an education is important to me: 1 2 A703 My parent(s)/caregiver(s) know a lot about me: (*selfCGmod1) 1 2 A704 I try to finish what I start: 1 2 A705 I am able to solve problems without harming myself or others (for example by using drugs and/or being violent): 1 2 A706 I know where to go in my community to get help: 1 2 A707 I feel I belong at my school: 1 2 A708 My family stands by me during difficult times: 1 2 A709 My friends stand by me during difficult times: 1 2 A710 I am treated fairly in my community: 1 2 A711 I have opportunities to develop skills that will be useful later in life (like job skills and skills to care for others): 1 2 A712 I enjoy my community's traditions: 1 2 Now I will ask you about your communication with your caregiver. Remember, your responses will be kept confidential. Has your caregiver ever shared information with you about: READ EACH. (*selfCGmod1) MARK YES OR NO. Yes No A801 Contraception/preventing pregnancy? 1 2 A802 Sexually-transmitted diseases (STIs)? 1 2 A803 HIV/AIDS? 1 2 A804 Ways to protect yourself against STIs and HIV/AIDS? 1 2 A805 Condoms specifically? 1 2 A806 Postponing or not having sex? 1 2 NO. QUESTION RESPONSE OPTIONS A807 Peer pressure and sexual pressure from dating partners? 1 2 A808 How to resist sexual pressure from peers and dating partners? 1 2 94 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A901 Now I have some questions about your relationship with your caregiver. I will read some statements. For each, I would like you to tell me how often it is true. You can tell me 'Never', 'Rarely', 'Sometimes', 'Often' or 'Very often'. If I am going to be home late I am expected to tell my caregiver to let them know where I am: (*selfCGmod1, selfCGmod2) 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very often A902 My caregiver knows who my friends are: (*selfCGmod1) 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very often A903 My caregiver comes to events at my school like parent meetings, prize givings, sports day, etc.: (*selfCGmod1) 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very often A904 My caregiver asks me what I learned in school: (*selfCGmod1) 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very often A905 If I have a problem I can talk to my caregiver: (*selfCGmod1) 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very often Thank you very much for your participation so far. Now I will ask about some items or services you may have received or accessed. A1801a Have you received or accessed any advice on HIV prevention, testing, or treatment? 1 Yes 2 No 8 Don't know If (A1801a)=1, ask A1801b-A1801c. A1801b When was the first time you received/accessed any advice on HIV prevention, testing, or treatment? 1 More than 1 year ago 2 Between 6 months and 1 year ago 3 Within the last 6 months A1801c Please tell me how often you have received/accessed any such advice in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1801b)=2,3 A1802a Have you received/accessed any assistance with payment of medical fees? 1 Yes 2 No 8 Don't know If (A1802a)=1, ask A1802b-A1802c. A1802b When was the first time you received/accessed any assistance with payment of medical fees? 1 More than 1 year ago 2 Between 6 months and 1 year ago 3 Within the last 6 months NO. QUESTION RESPONSE OPTIONS Evaluation of Services for Orphans and Vulnerable Youth in Botswana 95 A1802c Please tell me how often you have received/accessed assistance with payment of medical fees in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1802b)=2,3 A1803a Have you received/accessed any home-based medical care and advice? 1 2 8 Yes No Don't know If (A1803a)=1, ask A1803b-A1803c. A1803b When was the first time you received/accessed any home- based medical care and advice? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1803c Please tell me how often you have received/accessed such home-based medical care and advice in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1803b)=2,3 A1804a Have you received/accessed any referrals to clinics? 1 2 8 Yes No Don't know If (A1804a)=1, ask A1804b-A1804c. A1804b When was the first time you received/accessed any referrals to clinics? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1804c Please tell me how often you have received/accessed such referrals in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1804b)=2,3 A1805a Have you received/accessed any information on equitable relationships between men and women? 1 2 8 Yes No Don't know If (A1805a)=1, ask A1805b-A1805c. A1805b When was the first time you received/accessed any information on equitable relationships between men and women? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1805c Please tell me how often you have received/accessed such information in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1805b)=2,3 A1806a Have you received/accessed any food baskets? By food baskets, we mean actual food items received (not coupons/vouchers). 1 2 8 Yes No Don't know If (A1806a)=1, ask A1806b-A1806c. A1806b When was the first time you received/accessed any food baskets? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months 96 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A1806c Please tell me how often you have received/accessed food baskets in the last 12 months. 1 2 Rarely (a few times a year) Sometimes (once a month) NO. QUESTION RESPONSE OPTIONS 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1806b)=2,3 A1807a Have you received/accessed any food coupons? By food coupons we mean a swipe card used to get food. 1 2 8 Yes No Don't know If (A1807a)=1, ask A1807b-A1807c. A1807b When was the first time you received/accessed any food coupons? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1807c Please tell me how often you have received/accessed such food coupons in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1807b)=2,3 A1808a Have you received/accessed any food vouchers? Vouchers are torn from a booklet and left with a shop when picking up the food. 1 2 8 Yes No Don't know If (A1808a)=1, ask A1808b-A1808c. A1808b When was the first time you received/accessed any food vouchers? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1808c Please tell me how often you have received/accessed such food vouchers in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1808b)=2,3 A1809a Have you received/accessed any vocational training scholarships? 1 2 8 Yes No Don't know If (A1809a)=1, ask A1809b-A1809c. A1809b When was the first time you received/accessed any vocational training scholarships? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1809c Please tell me how often you have received/accessed such scholarships in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1809b)=2,3 A1810a Have you received/accessed any information on sexually transmitted infections (STIs) other than HIV? 1 2 8 Yes No Don't know If (A1810a)=1, ask A1810b-A1810c. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 97 A1810b When was the first time you received/accessed any information on STIs other than HIV? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1810c Please tell me how often you have received/accessed information on STIs other than HIV in the last 12 months. 1 2 3 Rarely (a few times a year) Sometimes (once a month) Frequently (more than once a month) NO. QUESTION RESPONSE OPTIONS 4 Never in the last 12 months *Cannot select 4 if (A1810b)=2,3 A1812a Have you received/accessed any out-of-school literacy training or tutoring? 1 2 8 Yes No Don't know If (A1812a)=1, ask A1812b-A1812c. A1812b When was the first time you received/accessed any out￾of- school literacy training or tutoring? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1812c Please tell me how often you have received/accessed out￾of-school literacy training or tutoring in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1812b)=2,3 A1813a Have you accessed any youth clubs? 1 2 8 Yes No Don't know If (A1813a)=1, ask A1813b-A1813c. A1813b When was the first time you accessed any youth clubs? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1813c Please tell me how often you have accessed youth clubs in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1813b)=2,3 A1814a Have you accessed any Aflateen or financial literacy groups? 1 2 8 Yes No Don't know If (A1814a)=1, ask A1814b-A1814c. A1814b When was the first time you accessed any Aflateen or financial literacy groups? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1814c Please tell me how often you have accessed Aflateen or financial literacy groups in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1814b)=2,3 A1815a Have you accessed any savings and loans groups? 1 2 8 Yes No Don't know 98 Evaluation of Services for Orphans and Vulnerable Youth in Botswana If (A1815a)=1, ask A1815b-A1815c. A1815b When was the first time you accessed any savings and loans groups? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1815c Please tell me how often you have accessed such groups in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1815b)=2,3 NO. QUESTION RESPONSE OPTIONS A1816a Have you received/accessed any business and entrepreneurial skills training and mentoring? 1 2 8 Yes No Don't know If (A1816a)=1, ask A1816b-A1816c. A1816b When was the first time you received/accessed any business and entrepreneurial skills training and mentoring? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1816c Please tell me how often you have received/accessed such training and mentoring in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1816b)=2,3 A1817a Have you received/accessed any school uniforms? 1 2 8 Yes No Don't know If (A1817a)=1, ask A1817b-A1817c. A1817b When was the first time you received/accessed any school uniforms? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1817c Please tell me how often you have received/accessed school uniforms in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1817b)=2,3 A1818a Have you received/accessed any assistance with paying school fees? 1 2 8 Yes No Don't know If (A1818a)=1, ask A1818b-A1818c. A1818b When was the first time you received/accessed any assistance with paying school fees? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1818c Please tell me how often you have received/accessed any assistance with paying school fees in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1818b)=2,3 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 99 A1819a Have you received/accessed any transportation money for school? 1 2 8 Yes No Don't know If (A1819a)=1, ask A1819b-A1819c. A1819b When was the first time you received/accessed any transportation money for school? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1819c Please tell me how often you have received/accessed transportation money for school in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1819b)=2,3 A1820a Have you received/accessed any bereavement counseling? 1 2 Yes No NO. QUESTION RESPONSE OPTIONS 8 Don't know If (A1820a)=1, ask A1820b-A1820c. A1820b When was the first time you received/accessed any bereavement counseling? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1820c Please tell me how often you have received/accessed bereavement counseling in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1820b)=2,3 A1821a Have you received/accessed any other types of counseling? 1 2 8 Yes No Don't know If (A1821a)=1, ask A1821b-A1821c. A1821b When was the first time you received/accessed any other types of counseling? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1821c Please tell me how often you have received/accessed other types of counseling in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1821b)=2,3 A1822a Have you received/accessed any assistance with housing or accommodation? 1 2 8 Yes No Don't know If (A1822a)=1, ask A1822b-A1822c. A1822b When was the first time you received/accessed assistance with housing or accommodation? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months 100 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A1822c Please tell me how often you have received/accessed assistance with housing or accommodation in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1822b)=2,3 A1823a Have you received/accessed any education or counseling on sexual-decision making? 1 2 8 Yes No Don't know If (A1823a)=1, ask A1823b-A1823c. A1823b When was the first time you received/accessed any education or counseling on sexual-decision making? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months A1823c Please tell me how often you have received/accessed education or counseling on sexual-decision making in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1821b)=2,3 A1824a Have you received/accessed any information on gender- based violence (GBV)? 1 2 8 Yes No Don't know If (A1824a)=1, ask A1824b-A1824c. NO. QUESTION RESPONSE OPTIONS A1824b When was the first time you received/accessed information 1 More than 1 year ago on gender-based violence (GBV)? 2 Between 6 months and 1 year ago 3 Within the last 6 months A1824c Please tell me how often you have received/accessed information on gender-based violence (GBV) in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1824b)=2,3 A200 Now I need to determine if you will be able to self￾administer the remaining questions in this survey, or if you will need my help. First, I would like you to read this sentence to me (SHOW TO RESPONDENT): ------------------------------------ The rains came late this year. ------------------------------------ IF RESPONDENT CANNOT READ THE WHOLE SENTENCE, PROBE: Can you read part of the sentence? THEN MARK THE APPROPRIATE LITERACY LEVEL BELOW. 1 ABLE TO READ WHOLE SENTENCE 2 ABLE TO READ ONLY PARTS OF SENTENCE 3 CANNOT READ AT ALL 4 USES LANGUAGE OTHER THAN ENGLISH OR SETSWANA 5 BLIND/VISUALLY IMPAIRED A200b If (A200)=4: SPECIFY REQUIRED LANGUAGE: If (A200)=2,3,4,5: Okay, let us continue. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 101 If (A200)=1: ENUMERATOR, TAP THE DISC ICON IN THE UPPER-RIGHT CORNER TO SAVE THIS FORM. ENUMERATOR, READ: I would like you to use this tablet to answer the rest of the questions privately. First, I will show you some examples of questions to make sure you are comfortable with using this tablet-based form. WHEN YOU MOVE TO THE NEXT SCREEN, HAND THE TABLET TO THE RESPONDENT. ALLOW THE RESPONDENT TO ENTER RESPONSES TO AGE AND SEX HIM OR HERSELF. PROVIDE GUIDANCE AND CHANGE LANGUAGE IF NEEDED. AFTER THE RESPONDENT ENTERS HIS OR HER AGE AND SEX AND IS COMFORTABLE WITH THE TABLET, ALLOW THE RESPONDENT TO CONTINUE THE QUESTIONS PRIVATELY. IF THE RESPONDENT IS ULTIMATELY UNABLE TO USE THE TABLET, GUIDE THE RESPONDENT THROUGH THE REST OF THE QUESTIONNAIRE. SCA203 In this type of question, you will see a list of choices and select the response that is true for you. For example: Are you female or male? 1 Female 2 Male *Must equal (A203) SCA205 For some questions, you will see a line where you can tap and write in your response. For example: What is your age? *Must equal (A205) Some screens are like this one, with instructions but no questions. On such screens, please read what is written, then tap the right arrow when you're ready to continue. As you move through the form, please let me know if you have any challenges using the tablet or if you would like me to clarify the questions or response options. Please answer the questions as honestly as you can. I will not see your answers or share them with anyone. If you make a mistake, let me know and I will help you to clear the response. If you have any questions you'd like to ask before beginning, please ask now. You can always ask additional questions as you complete the survey. When you are ready, tap the right arrow at the bottom of the screen to begin the questions. A1001 Here are some questions about HIV. 1 Yes Have you ever heard of HIV? 2 No 98 REFUSED If (A1001)=1, ask A1002-A1018. A1002 Can people reduce their chances of getting HIV by having 1 Yes just one uninfected sex partner who has no other sex 2 No partners? 8 Don't know 98 REFUSED NO. QUESTION RESPONSE OPTIONS A1003 Can people reduce their chance of getting HIV by using a condom every time they have sex? 1 Yes 2 No 8 Don't know 98 REFUSED A1004 Is it possible for a healthy-looking person to have HIV? 1 Yes 2 No 8 Don't know 98 REFUSED A1005 Can people get HIV from mosquito bites? 1 Yes 2 No 8 Don't know 98 REFUSED A1006 Can people get HIV by sharing food with someone who has HIV? 1 Yes 2 No 8 Don't know 98 REFUSED 102 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A1007 Can people reduce their chance of getting HIV by not having sexual intercourse at all? 1 Yes 2 No 8 Don't know 98 REFUSED A1008 Can people get HIV because of witchcraft or other supernatural means? 1 Yes 2 No 8 Don't know 98 REFUSED A1010 Can people infected with HIV be cured by prayer? 1 Yes 2 No 8 Don't know 98 REFUSED A1011a What is the youngest age at which a child should be taught about using a condom to avoid getting HIV? 1 Less than 8 years old 2 At least 8 years old but still less than 18 years old 3 Only adults 18 years and older should be taught about using a condom to avoid HIV 88 Don't know 98 REFUSED A1011b If (A1011a)=2: What is the youngest age at which a child should be taught about using a condom to avoid getting HIV? IF REFUSED, ENTER 98. 8-17, 98 A1012 Can HIV be transmitted from a mother to her baby during pregnancy? 1 Yes 2 No 8 Don't know 98 REFUSED A1013 Can HIV be transmitted from a mother to her baby during delivery? 1 Yes 2 No 8 Don't know 98 REFUSED A1014 Can HIV be transmitted from a mother to her baby by breastfeeding? 1 Yes 2 No 8 Don't know NO. QUESTION RESPONSE OPTIONS 98 REFUSED A1015 Any yes of A1012, A1013, or A1014? (automatically computed) A1016 If (A1015)=1: Are there any special drugs that a doctor or a nurse can give to a woman infected with HIV to reduce the risk of transmission to the baby? 1 2 8 Yes No Don't know A1017 Have you heard about antiretroviral medicines (ARVs) that people infected with HIV can get from a doctor or a nurse? 1 2 8 Yes No Don't know A1018 If (A1017)=1: When a person with HIV takes these ARV medicines, does his or her risk of GIVING HIV to a sexual partner increase, decrease, or remain about the same? 1 2 3 8 Increase Decrease Remain the same Don’t know Here are some statements about the roles of females versus males. For each, please let me know if you agree or disagree. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 103 A1201 It is okay for men to have more than one sexual partner: 1 2 98 Agree Disagree REFUSED A1202 It is a woman’s duty to have sex with her spouse/partner even if she does not want to: 1 2 98 Agree Disagree REFUSED A1203 It is more important for a woman to respect her spouse/partner than it is for a man to respect his spouse/partner: 1 2 98 Agree Disagree REFUSED A1204 A man may beat his spouse/partner if she disobeys him: 1 2 98 Agree Disagree REFUSED A1205 A man may beat his spouse/partner if he believes she is having sex with another man: 1 2 98 Agree Disagree REFUSED A1206 It is more important for a boy to get an education than a girl: 1 2 98 Agree Disagree REFUSED A1301 Are you currently married, separated, divorced, widowed or never married? 1 2 3 4 5 98 Married/Cohabitating Separated Divorced Widowed Never been married REFUSED A1302 If (A1301)=2,3,4,5: Do you currently have a boyfriend or girlfriend? By boyfriend or girlfriend, I mean someone you have a romantic relationship with. 1 2 98 Yes No REFUSED A1303 If (A1302)=1: Are you currently living with your boyfriend or girlfriend? 1 2 98 Yes No REFUSED A1304 If (A1301)=1 or (A1302)=1: How old is your boyfriend or girlfriend (or your partner, if married/cohabitating)? ENTER AGE IN YEARS (8-85). IF UNKNOWN, ENTER BEST ESTIMATE. IF REFUSED, ENTER 98. 8-85, 98 NO. QUESTION RESPONSE OPTIONS A1304_ confirm If 8≤(A1304)≤85: We want to be sure we have understood you. You have indicated that your boyfriend or girlfriend (or your partner, if married/cohabitating) is (A1304) years old. Is that correct? 1 2 Yes No If (A1304_confirm)=2: ERROR: You indicated in the previous screen that the age was not recorded correctly. Please go back 2 screens and enter the correct age in question A1304. I would like to ask you some questions about your sexual activity. Try to answer as honestly as you can. None of your answers will be shared with anyone. These questions are not meant to make you feel uncomfortable. If (A200)=2,3,4,5: If there is a question that you really do not feel comfortable answering, you can skip that question. If (A200)=1: If there is a question that you really do not feel comfortable answering, you can tap 'REFUSED' to skip that question. 104 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A1305 Have you ever had sexual intercourse (sex) before? By ‘sex’ we mean ‘going all the way’, vaginal or anal sex. 1 2 98 Yes No REFUSED If (A1305)=1, ask A1306-A1320 as applicable. A1306 How old were you when you had sex for the first time? IF REFUSED, ENTER 98. 0-(A205), 98 A1306_con firm If (A1306) is not 98: y We want to be sure we have understood you. You have indicated that you were (A1306) years old when you first had sex. Is that correct? 1 2 98 Yes No REFUSED If (A1306_confirm)=2: ERROR: You indicated in the previous screen that the age at first sex was not recorded correctly. Please go back 2 screens and enter the correct age in question A1306. A1307 In the past 12 months how many different people have you had sex with? IF REFUSED, ENTER 998. 0-99, 998 A1308 If (A1307)>0: In the past 3 months, how many different people have you had sex with? IF REFUSED, ENTER 998. 0-(A1307), 998 If (A1308)>0, ask A1309-A1310. A1309 How many times have you had sex in the last 3 months? IF REFUSED, ENTER 998. 1-99, 998 A1310 Did you use a condom every time you had sex in the last 3 months? 1 2 98 Yes No REFUSED A1311 Now we would like to ask you some questions about your current (or most recent) sex partner. A sex partner is someone you have had sex with. Did you or your partner use a condom the last time you had sex? 1 Yes 2 No 98 REFUSED *Cannot select 2 if (A1310)=1. A1312 For the following questions, please think about your own experiences and tell me if you agree or disagree with the following about yourself. I have not always been able to use condoms when I wanted to. 1 2 98 Agree Disagree REFUSED A1313 Please tell me if you agree or disagree with the following about yourself. I have had sex with a person in exchange for protection or a place to stay. 1 2 98 Agree Disagree REFUSED NO. QUESTION RESPONSE OPTIONS A1314 I have had sex with a person in exchange for him or her to pay rent for me. 1 2 98 Agree Disagree REFUSED A1315 I have had sex at times when I did not want to. 1 2 98 Agree Disagree REFUSED If (A1307)>0: In the past six months, have you had sex with someone because you needed or thought you would get any of the following? MARK YES, NO, OR REF (REFUSED). Yes No REF A1316a Food 1 2 98 A1316b Shelter/Place to stay 1 2 98 A1316c School fees 1 2 98 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 105 A1316d Money 1 2 98 A1316e Anything else 1 2 98 If (A203)=2, ask A1317-A1320. A1317 Have you ever gotten a girl pregnant? 1 2 8 98 Yes No Don't know REFUSED If (A1317)=1, ask A1318-A1320. A1318 What was the outcome of her pregnancy? IF MULTIPLE PREGNANCIES, ANSWER ABOUT THE MOST RECENT ONE. 1 2 3 4 5 88 98 Live birth Still birth Miscarriage Abortion She is currently pregnant Don't know REFUSED A1319 How many living biological children do you have? IF UNKNOWN, ENTER 88. IF REFUSED, ENTER 98. 0-20, 88, 98 A1320 If (A1319)>0 and (A1319) is not 98: How many biological children do you have that live with you? IF UNKNOWN, ENTER 88. IF REFUSED, ENTER 98. 0-(A1319), 88, 98 A1401 Do you know of a place you can go to access reproductive health services such as family planning or to buy contraceptives? 1 2 98 Yes No REFUSED A1402 Do you know of a place you can go to access sex￾related information or services? 1 2 98 Yes No REFUSED A1403 Have you ever been to a clinic, hospital, or facility to get information about sex related issues (such as pregnancy or HIV) or to get condoms or other contraceptives? 1 2 98 Yes No REFUSED If (A1403)=1, ask A1404-A1406 as applicable. A1404 In the last 12 months, have you been to the clinic, hospital, or facility for sex-related information or services? 1 2 98 Yes No REFUSED A1405 The last time you went to a clinic, hospital or facility for sex related information or services, did you feel respected by the health staff? 1 2 98 Yes No REFUSED NO. QUESTION RESPONSE OPTIONS A1406 If (A1403)=1: The last time you went to a clinic, hospital or facility for any sex related information or services, did you feel comfortable asking for the information or services you needed? 1 2 98 Yes No REFUSED A1407 Do you know of a place where you can go to get HIV testing 1 Yes or counseling? 2 No 98 REFUSED A1408 Have you ever been referred for counseling or testing for 1 Yes STIs or HIV? 2 No 98 REFUSED If (A1408)=1, ask A1409-A1410e. A1409 Did you go to the facility you were referred to? 1 Yes 2 No 98 REFUSED 106 Evaluation of Services for Orphans and Vulnerable Youth in Botswana If (A1409)=2: Why did you not go for the referral? MARK YES, NO, OR REF (REFUSED). Yes No REF A1410a It was too far 1 2 98 A1410b It was too costly 1 2 98 A1410c I was worried about confidentiality 1 2 98 A1410d Other 1 2 98 A1410e If (A1410d)=1: Specify other reason: A1412 Have you ever been tested for HIV? 1 Yes 2 No 98 REFUSED If (A1412)=1, ask A1413-A1844c. A1413 How many months ago was your most recent HIV test? ENTER NUMBER OF MONTHS, 0-24. IF LONGER THAN 24 MONTHS (TWO YEARS) AGO, ENTER 95. 0-24, 95 A1414a Did you receive counseling before you were tested? 1 Yes 2 No 98 REFUSED A1414b Did you receive counseling after you were tested? 1 Yes 2 No 98 REFUSED A1415a The last time you were tested for HIV, where were you 1 Government facility tested? Was it at a government, private, or NGO facility? 2 Private facility IF NO: Were you tested at home? 3 NGO facility IF NO: Were you tested at another place by a community or 4 Home ward-based health worker? 5 Elsewhere by a community health worker or ward-based outreach worker 66 Other 88 Don't know 98 REFUSED A1415b If (A1415a)=1,2,3: 1 Hospital What type of facility was it? 2 Health center IF A MOBILE CLINIC, SELECT FAMILY PLANNING CLINIC OR 3 Stand-alone VCT center OTHER CLINIC HERE AS APPROPRIATE. 4 Family planning clinic 5 Other (not family planning) clinic 6 Pharmacy NO. QUESTION RESPONSE OPTIONS 66 88 98 Other medical facility Don't know REFUSED A1415c If (A1415b)=4,5: Was it a mobile clinic? 1 2 8 98 Yes No Don't know REFUSED A1415d If (A1415a)=66 or (A1415b)=66: Describe the facility/source that provided the HIV test: A1416 The last time you were tested, did anyone else accompany you to get tested? 1 2 98 Yes No, I went by myself REFUSED If (A1416)=1: The last time you were tested, did any of the following people accompany you to get tested? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 107 MARK YES, NO, OR REF (REFUSED). Yes No REF A1417a Parent or Caregiver 1 2 98 A1417b Sibling 1 2 98 A1417c Aunt, uncle or grandparent 1 2 98 A1417d Other family member 1 2 98 A1417e Boyfriend or Girlfriend (or partner if married/cohabitating) 1 2 98 A1417f Friend 1 2 98 A1417g Health care worker 1 2 98 A1417h Peer educator 1 2 98 A1417i Teacher 1 2 98 A1417j Other 1 2 98 A1418 The last time you were tested, did you get the results of the test? 1 Yes 2 No 98 REFUSED A1419 If (A1418)=1: The last time you got the results of the HIV test did you share the results with anyone? 1 Yes 2 No 98 REFUSED IF (A1419)=1: Who did you share your results with? MARK YES, NO, OR REF (REFUSED). Yes No REF A1420a Your boyfriend or girlfriend 1 2 98 A1420b Sexual partner(s) other than boyfriend/girlfriend 1 2 98 A1420c Mother 1 2 98 A1420d Father 1 2 98 A1420e Brother 1 2 98 A1420f Sister 1 2 98 A1420g Other relative 1 2 98 A1420h Friend 1 2 98 A1420i Classmate 1 2 98 A1420j Educator 1 2 98 A1420k Religious leader 1 2 98 A1420l Community leader 1 2 98 A1420m Your doctor, nurse, or other health care worker 1 2 98 A1420n Peer educator 1 2 98 A1420o Other 1 2 98 A1422a What was your HIV test result? 1 2 98 Positive (infected) Negative (not infected) REFUSED NO. QUESTION RESPONSE OPTIONS A1422b If (A1418)=2: Have you ever had a positive HIV test result showing that you are infected with HIV? 1 2 98 Yes No REFUSED A1844a If (A1422a)=1 or (A1422b)=1: Have you ever accessed any HIV positive support groups (also called HIV positive clubs)? 1 2 8 Yes No Don't know If (A1844a)=1: A1844b When was the first time you accessed any HIV positive support groups or HIV positive clubs? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months 108 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A1844c Please tell me how often you have accessed any HIV positive support groups or HIV positive clubs in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (A1844b)=2,3 If (A203)=1, ask A1503-A1522 as applicable. Now I would like to ask you about pregnancy. Remember, these questions are not meant to make you feel uncomfortable, and your answers will not be shared with anyone. If (A1305)=1, ask A1503-A1505. A1503 Are you currently pregnant? 1 2 8 98 Yes No Don't know REFUSED A1504 If (A1503)=1: How many weeks pregnant are you? ENTER THE NUMBER OF WEEKS (0-45). IF UNKNOWN, ENTER 88. IF REFUSED, ENTER 98. 0-45, 88, 98 A1505 Have you ever previously been pregnant? 1 2 98 Yes No REFUSED If (A1505)=1 or (A1503)=1, ask A1506-A1843c as applicable A1506 What was your age at first pregnancy? IF REFUSED, ENTER 98. (A1306)-(A205) *Cannot be less than (A1306) or greater than (A205); if (A1503)=1 and (A1505)=2, cannot be less than ((A205)-1). A1507 When you first got pregnant, were you planning to get pregnant at that time? 1 2 98 Yes No REFUSED If (A1505)=1, ask A1508-A1511. A1508 What was the outcome of your first pregnancy? 1 2 3 4 98 Live birth Still birth Miscarriage Abortion REFUSED A1509 IF (A1503) is not 1: How many times have you been pregnant? In addition to babies carried to term, include any miscarriages, babies that were stillborn, or pregnancies that were terminated. IF REFUSED, ENTER 98. IF (1503)=1: Not including your current pregnancy, how many times have you been pregnant? In addition to babies carried to term, include any miscarriages, babies that were stillborn, or pregnancies that were terminated. Do not include your current pregnancy in this number. IF REFUSED, ENTER 98. 1-20, 98 A1510 If (A1509)>1 or ((A1509)=1 and (A1509) is not 2,3,4): How many living children do you have, that you have given birth to? IF REFUSED, ENTER 98. 0-(A1509), 98 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 109 A1511 If (A1510)>0 and is not 98: How many children that you have given birth to live with you? IF REFUSED, ENTER 98. 0-(A1510), 98 A1843a Have you ever accessed any young mothers parenting groups? 1 Yes 2 No 8 Don't know 98 REFUSED If (A1843a)=1, ask A1843b-A1843c. A1843b When was the first time you accessed any young mothers parenting groups? 1 More than 1 year ago 2 Between 6 months and 1 year ago 3 Within the last 6 months 98 REFUSED A1843c Please tell me how often you have accessed such groups in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months 98 REFUSED *Cannot select 4 if (A1843b)=2,3 A1501 If (A1503) is not 1: How important is it for you to keep from getting pregnant now? If (1503)=1: How important is it for you to keep from getting pregnant again (after this pregnancy)? 1 Not important 2 Somewhat important 3 Very important 98 REFUSED A1502 If (A1503) is not 1: What do you think are the chances that you will fall pregnant before you finish school? If (A1503)=1: What do you think are the chances that you will fall pregnant again before you finish school? 1 No chance 2 Some chance 3 A very high chance 98 REFUSED If (A1305)=1, ask A1512-A1522 as applicable. A1512 Did you use birth control the last time you had sex? 1 Yes 2 No 98 REFUSED If (A1512)=1, ask A1513a-A1514. What birth control method(s) did you use the last time you had sex? MARK YES, NO, OR REF (REFUSED). Yes No REF A1513a Birth control pills 1 2 98 A1513b Injectables: Depo-Provera (1 injection per 3 months) 1 2 98 A1513c Injectables: NET-EN (known as Nuristerate, 1 injection per 2 months) 1 2 98 A1513d Male condoms 1 2 98 A1513e Female condoms 1 2 98 NO. QUESTION RESPONSE OPTIONS A1513f IUD/Mirena 1 2 98 A1513g Implant/Implanon 1 2 98 A1513h Patch 1 2 98 A1513i Cycle beads/Standard days method 1 2 98 A1513j Emergency contraception 1 2 98 A1513k Rhythm method/Observation of menstrual cycle 1 2 98 A1513l Traditional methods 1 2 98 A1513m Withdrawal 1 2 98 A1513n Other 1 2 98 110 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A1514 If (A1513n)=1: What other birth control did you use? If (A1512)=2: You said you did not use birth control the last time you had sex. Was it because of the following: MARK YES, NO, OR REF (REFUSED). Yes No REF A1515a I wanted to get pregnant 1 2 98 A1515b I was not planning on having sex. 1 2 98 A1515c It is too expensive 1 2 98 A1515d I do not know where to get it 1 2 98 A1515e I am too embarrassed to ask for it 1 2 98 A1515f I do not know about or understand birth control 1 2 98 A1515g I did not think about it 1 2 98 A1515h I am worried about the side effects 1 2 98 A1515i Healthcare worker refused to give me birth control 1 2 98 A1515j I am opposed to birth control 1 2 98 A1515k My partner is opposed to birth control 1 2 98 A1515l Other reason(s) 1 2 98 A1516 If (A1515l)=1: What are any other reasons you did not use birth control the last time you had sex? If (A1503)=1 or (A1505)=1, ask A1517-A1522 as applicable. A1517 Did you receive antenatal care for your most recent pregnancy? If (A1503)=1 and (A1505)=1: We are not asking about your current pregnancy, but rather your most recent pregnancy before this one. 1 Yes 2 No 98 REFUSED If (A1517)=1, ask A1518-A1522 as applicable. A1518 Were you offered a test for HIV as part of your antenatal care (ANC)? If (A1503)=1 and (A1505)=1: We are not asking about your current pregnancy, but rather your most recent pregnancy before this one. 1 Yes 2 No 98 REFUSED A1519 Were you tested for HIV as part of your antenatal care (ANC)? If (A1503)=1 and (A1505)=1: We are not asking about your current pregnancy, but rather your most recent pregnancy before this one. 1 Yes 2 No 98 REFUSED If (A1519)=1, ask A1520-A1521b. A1520 Did you get the results of that test? 1 Yes 2 No 98 REFUSED A1521a All women are supposed to receive counseling before and after being tested. When you were tested during your antenatal care (ANC), did you receive counseling before you were tested? 1 Yes 2 No 98 REFUSED A1521b When you were tested during your antenatal care (ANC), did you receive counseling after you were tested? 1 2 98 Yes No REFUSED A1522 Was your partner tested for HIV during any of the ANC visits for your last pregnancy? If (A1503)=1 and (A1505)=1: We are not asking about your current pregnancy, but rather your most recent pregnancy before this one. 1 2 98 Yes No REFUSED Evaluation of Services for Orphans and Vulnerable Youth in Botswana 111 If (A200)=2,3,4,5: REMINDER: CARRY OUT THE REMAINDER OF THIS MODULE IN A PRIVATE ROOM OR PRIVATE LOCATION SO THAT OTHERS CANNOT HEAR THE QUESTIONS OR RESPONSES. IF PRIVACY IS COMPROMISED, STOP ASKING QUESTIONS UNTIL PRIVACY IS RE-ESTABLISHED. IF THE PARTICIPANT BECOMES DISTRAUGHT OR SAD, PAUSE AND ASK RESPONDENT IF HE/SHE IS OKAY. ALSO ASK IF HE/SHE WOULD LIKE TO CONTINUE, TO PAUSE MOMENTARILY, SKIP THESE QUESTIONS, OR SKIP TO THE NEXT SECTION. IF THE RESPONDENT ASKS WHERE HE/SHE CAN GET HELP, REFER TO THE HEALTH SERVICES CONTACT LIST. ENSURE CONFIDENTIALITY WHEN REFERRING. s17_confir m If (A200)=2,3,4,5: I would like to ask you a few questions about violence, including relationship violence. I want to reassure you that any information you share with me is private. I will not share it with your partner, caregiver, any family member, or anyone else in your house or community. I will not share it with another staff person at the research unit unless it suggests that there may be immediate harm to you or to someone else. However, there is still a risk that your family or your partner could find out that you participated in answering these questions. If you think there is any danger for you to answer these questions, please do let us know. If you do feel sad or uncomfortable, or you want some help, I can give you contact information for groups or services that help people when they are having difficulties with their partners, caregivers, other family members, or anyone else. May I continue? 1 2 Yes No s17_confir mSC If (A200)=1: Here are a few questions about violence, including relationship violence. As a reminder, any information you share here is private. It will not be shared with your partner, caregiver, any family member, or anyone else in your house or community. It will not be shared with another staff person at the research unit unless your answers suggest that there may be immediate harm to you or to someone else. However, there is still a risk that your family or your partner could find out that you participated in answering these questions. If you think there is any danger for you to answer these questions, please let the enumerator know. If you do feel sad or uncomfortable, or you want some help, the enumerator can give you contact information for groups or services that help people when they are having difficulties with their partners, caregivers, other family members, or anyone else. Are you okay with answering questions about violence? 1 2 Yes No NO. QUESTION RESPONSE OPTIONS If (s17_confirm)=2 or (s17_confirmSC)=2: Okay, let us skip those questions and move on to others. If (s17_confirm)=1 or (s17_confirmSC)=1, ask A1701a-A1742 as applicable. A1701a We’d like to know if any of the situations I describe have ever happened to you in your life. Have you ever seen your caregiver be slapped, punched, kicked or otherwise hurt by a spouse? (*selfCGmod1) 1 2 98 Yes No REFUSED 112 Evaluation of Services for Orphans and Vulnerable Youth in Botswana A1702a Have you ever seen your caregiver be slapped, punched, kicked or otherwise hurt by a boyfriend/girlfriend? (*selfCGmod1) 1 2 98 Yes No REFUSED A1703a Have you ever seen your caregiver be slapped, punched, kicked or otherwise hurt by someone else in the home? (*selfCGmod1) 1 2 98 Yes No REFUSED A1701b If (A1701a)=1: Have you seen your caregiver be slapped, punched, kicked or otherwise hurt by a spouse in the last 12 months? (*selfCGmod1) 1 2 98 Yes No REFUSED A1702b If (A1702a)=1: Have you seen your caregiver be slapped, punched, kicked or otherwise hurt by a boyfriend/girlfriend in the last 12 months? (*selfCGmod1) 1 2 98 Yes No REFUSED A1703b If (A1703a)=1: Have you seen your caregiver be slapped, punched, kicked or otherwise hurt by someone else in the home in the last 12 months? (*selfCGmod1) 1 2 98 Yes No REFUSED A1704a Have you ever seen a classmate be slapped, punched, kicked or otherwise hurt by a teacher? 1 2 98 Yes No REFUSED A1705a Have you ever seen a classmate be slapped, punched, kicked or otherwise hurt by another student? 1 2 98 Yes No REFUSED A1706a Have you ever seen a classmate be slapped, punched, kicked or otherwise hurt by someone else at the school? 1 2 98 Yes No REFUSED A1704b If (A1704a)=1: Have you seen a classmate be slapped, punched, kicked or otherwise hurt by a teacher in the last 12 months? 1 2 98 Yes No REFUSED A1705b If (A1705a)=1: Have you seen a classmate be slapped, punched, kicked or otherwise hurt by another student in the last 12 months? 1 2 98 Yes No REFUSED A1706b If (A1706a)=1: Have you seen a classmate be slapped, punched, kicked or otherwise hurt by someone else at the school in the last 12 months? 1 2 98 Yes No REFUSED A1707a Have you ever had a partner? When I say 'partner,' I mean a boyfriend or girlfriend or any other romantic or sexual partner. 1 Yes 2 No 98 REFUSED *Cannot be 2 if (A1301)=1 or (A1302)=1 If (A1707a)=1, ask A1707b-A1724. A1707b Have you had a partner in the last 12 months? 1 2 98 Yes No REFUSED Evaluation of Services for Orphans and Vulnerable Youth in Botswana 113 NO. QUESTION RESPONSE OPTIONS No matter how well a couple gets along, there are times when you disagree, or get upset with each other, each want different things, or have disagreements or fights just because you are in a bad mood, are tired, or for some other reason. Couples also have many different ways of trying to settle their differences. Has this ever happened? MARK YES, NO, OR REF (REFUSED). Yes No REF A1708a A partner twisted my arm or hair, or threw something at me that could hurt me: 1 2 98 A1709a I twisted a partner's arm or hair, or threw something at a partner that could hurt him or her: 1 2 98 Has this happened in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1708b If (A1707b)=1 and (A1708a)=1: A partner twisted my arm or hair, or threw something at me that could hurt me: 1 2 98 A1709b If (A1707b)=1 and (A1709a)=1: I twisted a partner's arm or hair, or threw something at a partner that could hurt him or her: 1 2 98 Has this ever happened? MARK YES, NO, OR REF (REFUSED). Yes No REF A1710a A partner pushed, grabbed, or slapped me: 1 2 98 A1711a I pushed, grabbed, or slapped a partner: 1 2 98 Has this happened in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1710b If (A1707b)=1 and (A1710a)=1: A partner pushed, grabbed, or slapped me: 1 2 98 A1711b If (A1707b)=1 and (A1711a)=1: I pushed, grabbed, or slapped a partner: 1 2 98 Has this ever happened? MARK YES, NO, OR REF (REFUSED). Yes No REF A1712a A partner kicked me, slammed me against a wall, punched me or hit me with something that could hurt me: 1 2 98 A1713a I kicked a partner, slammed them against a wall, punched or hit a partner with something that could hurt him or her: 1 2 98 Has this happened in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1712b If (A1707b)=1 and (A1712a)=1: A partner kicked me, slammed me against a wall, punched me or hit me with something that could hurt me: 1 2 98 A1713b If (A1707b)=1 and (A1713a)=1: I kicked a partner, slammed them against a wall, punched or hit a partner with something that could hurt him or her: 1 2 98 Has this ever happened? MARK YES, NO, OR REF (REFUSED). Yes No REF A1714a A partner beat me up, burned or scalded me on purpose: 1 2 98 A1715a I beat up, burned or scalded a partner on purpose: 1 2 98 Has this happened in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1714b If (A1707b)=1 and (A1714a)=1: A partner beat me up, burned or scalded me on purpose: 1 2 98 A1715b If (A1707b)=1 and (A1715a)=1: I beat up, burned or scalded a partner on purpose: 1 2 98 Has this ever happened? MARK YES, NO, OR REF (REFUSED). Yes No REF A1716a A partner choked me, or used a knife or gun on me: 1 2 98 A1717a I choked a partner, or used a knife or gun on a partner: 1 2 98 Has this happened in the last 12 months? 114 Evaluation of Services for Orphans and Vulnerable Youth in Botswana NO. QUESTION RESPONSE OPTIONS MARK YES, NO, OR REF (REFUSED). Yes No REF A1716b If (A1707b)=1 and (A1716a)=1: A partner choked me, or used a knife or gun on me: 1 2 98 A1717b If (A1707b)=1 and (A1717a)=1: I choked a partner, or used a knife or gun on a partner: 1 2 98 Has this ever happened? MARK YES, NO, OR REF (REFUSED). Yes No REF A1718a A partner said or did something to humiliate me in front of others: 1 2 98 A1719a I said or did something to humiliate a partner in front of others: 1 2 98 Has this happened in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1718b If (A1707b)=1 and (A1718a)=1: A partner said or did something to humiliate me in front of others: 1 2 98 A1719b If (A1707b)=1 and (A1719a)=1: I said or did something to humiliate a partner in front of others: 1 2 98 Has this ever happened? MARK YES, NO, OR REF (REFUSED). Yes No REF A1720a A partner used threats to make me have sex: 1 2 98 A1721a I used threats to make a partner have sex: 1 2 98 Has this happened in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1720b If (A1707b)=1 and (A1720a)=1: A partner used threats to make me have sex: 1 2 98 A1721b If (A1707b)=1 and (A1721a)=1: I used threats to make a partner have sex: 1 2 98 Has this ever happened? MARK YES, NO, OR REF (REFUSED). Yes No REF A1722a A partner used force, like hitting, holding me down, or using a weapon, to make me have sex: 1 2 98 A1723a I used force, like hitting, holding a partner down, or using a weapon, to make a partner have sex: 1 2 98 Has this happened in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1722b If (A1707b)=1 and (A1722a)=1: A partner used force, like hitting, holding me down, or using a weapon, to make me have sex: 1 2 98 A1723b If (A1707b)=1 and (A1723a)=1: I used force, like hitting, holding a partner down, or using a weapon, to make a partner have sex: 1 2 98 A1724 Have you ever had to go to the doctor or health center as a result of something a partner did to you? 1 2 98 A1725 Has anyone other than a partner ever hit, slapped, kicked, or done anything else to hurt you physically? 1 2 98 If (A1725)=1: Have you ever been physically hurt by a: MARK YES, NO, OR REF (REFUSED). Yes No REF A1726a Female caregiver? 1 2 98 A1726b Male caregiver? 1 2 98 A1726c Other female family member? 1 2 98 A1726d Other male family member? 1 2 98 A1726e Female non-family member? 1 2 98 A1726f Male non-family member? 1 2 98 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 115 NO. QUESTION RESPONSE OPTIONS If (A1726a)=1 or (A1726b)=1 or (A1726c)=1: In the last 12 months, have you been physically hurt by any: MARK YES, NO, OR REF (REFUSED). Yes No REF A1727a If (A1726a)=1: Female caregiver? 1 2 98 A1727b If (A1726b)=1: Male caregiver? 1 2 98 A1727c If (A1726c)=1: Other female family member? 1 2 98 If (A1726d)=1 or (A1726e)=1 or (A1726f)=1: In the last 12 months, have you been physically hurt by any: MARK YES, NO, OR REF (REFUSED). Yes No REF A1727d If (A1726d)=1: Other male family member? 1 2 98 A1727e If (A1726e)=1: Female non-family member? 1 2 98 A1727f If (A1726f)=1: Male non-family member? 1 2 98 A1728 Has anyone other than a partner used threats to make you have sex? 1 2 98 Yes No REFUSED If (A1728)=1: Did any of the following people ever use threats to make you have sex? MARK YES, NO, OR REF (REFUSED). Yes No REF A1729a Female caregiver: 1 2 98 A1729b Male caregiver: 1 2 98 A1729c Other female family member: 1 2 98 A1729d Other male family member: 1 2 98 A1729e Female non-family member: 1 2 98 A1729f Male non-family member: 1 2 98 If (A1729a)=1 or (A1729b)=1 or (A1729c)=1: Did any of the following people use threats to make you have sex in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1730a If (A1729a)=1: Female caregiver? 1 2 98 A1730b If (A1729b)=1: Male caregiver? 1 2 98 A1730c If (A1729c)=1: Other female family member? 1 2 98 If (A1729d)=1 or (A1729e)=1 or (A1729f)=1: Did any of the following people use threats to make you have sex in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1730d If (A1729d)=1: Other male family member? 1 2 98 A1730e If (A1729e)=1: Female non-family member? 1 2 98 A1730f If (A1729f)=1: Male non-family member? 1 2 98 A1731 Has anyone other than a partner used force like hitting, holding you down, or using a weapon to make you have sex? 1 2 98 Yes No REFUSED If (A1731)=1: Did any of the following people ever use force to make you have sex? MARK YES, NO, OR REF (REFUSED). Yes No REF A1732a Female caregiver: 1 2 98 A1732b Male caregiver: 1 2 98 A1732c Other female family member: 1 2 98 A1732d Other male family member: 1 2 98 A1732e Female non-family member: 1 2 98 A1732f Male non-family member: 1 2 98 116 Evaluation of Services for Orphans and Vulnerable Youth in Botswana NO. QUESTION RESPONSE OPTIONS If (A1732a)=1 or (A1732b)=1 or (A1732c)=1: Did any of the following people use force to make you have sex in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1733a If (A1732a)=1: Female caregiver: 1 2 98 A1733b If (A1732b)=1: Male caregiver: 1 2 98 A1733c If (A1732c)=1: Other female family member: 1 2 98 If (A1732d)=1 or (A1732e)=1 or (A1732f)=1: Did any of the following people use force to make you have sex in the last 12 months? MARK YES, NO, OR REF (REFUSED). Yes No REF A1733d If (A1732d)=1: Other male family member: 1 2 98 A1733e If (A1732e)=1: Female non-family member: 1 2 98 A1733f If (A1732f)=1: Male non-family member: 1 2 98 A1811a Have you received any medical care or psychological services due to gender-based violence? This includes any of the following: HIV post-exposure prophylaxis (PEP), emergency contraception, testing for STIs including HIV, and counseling for mental health. 1 Yes 2 No 8 Don't know 98 REFUSED If (A1811a)=1, ask A1811b-A1811c: A1811b When was the first time you received medical care or psychological services due to gender-based violence? 1 More than 1 year ago 2 Between 6 months and 1 year ago 3 Within the last 6 months 98 REFUSED A1811c Please tell me how often you have received medical care or psychological services in the last 12 months due to gender￾based violence. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months 98 REFUSED *Cannot select 4 if (A1811b)=2,3 A1734 If any of (A1720b), (A1722b), (A1730a-f), or (A1733a-f)=1: Thinking back over the last year, the last time you were made to have sex because of threats or forced to have sex against your will, did you receive GBV care? Again, this includes any of the following: HIV post-exposure prophylaxis (PEP), emergency contraception, testing for STIs including HIV, and counseling for mental health. 1 Yes 2 No 98 REFUSED If (A1734)=1, ask A1735-A1742. A1735 How long did you wait to seek medical care or psychological services after you were made to have sex because of threats or forced to have sex against your will? 1 Less than 3 days (72 hours) 2 3 days to 7 days 3 8 days up to 1 month 4 1 month to 6 months 5 More than 6 months 98 REFUSED I am going to ask you about basic care that you might have received when you sought this care. Tell me if you received the following: MARK YES, NO, OR REF (REFUSED). Yes No REF A1736 HIV post-exposure prophylaxis (PEP) 1 2 98 A1737 Emergency contraception 1 2 98 A1738 Testing for sexually transmitted infections 1 2 98 A1739 HIV testing 1 2 98 A1740 Counseling for mental health (Psycho-social services) 1 2 98 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 117 NO. QUESTION RESPONSE OPTIONS A1741 Other 1 2 98 A1742 If (A1741)=1: Specify other care received: If (A1422a)=1 or (A1422b)=1, ask A1901-A1914b as applicable. A1901 Here are a few more HIV-related questions. Thank you for 1 Yes sharing your HIV test results. 2 No Are you currently on antiretroviral medication (ARVs)? 98 REFUSED A1902 If (A1901)=1: 1 Yes Do you take ARVs daily? 2 No 98 REFUSED A1903 If ((A1901)=2 or (A1902)=2): 1 I have not been referred for ARVs yet What is the main reason for not taking ARVs daily? 2 I have been referred but have not obtained the drugs yet 3 Transportation Cost 4 Religious Reasons 5 Food/Nutritional Issues (not enough food to take ARVs) 6 Side Effects 7 Fear of being seen at ARV Clinic 66 Other 98 REFUSED A1903b If (A1903)=66: Specify other reason: If (A1902)=1, ask A1904y-A1904m. How long have you been taking daily ARVs? ENTER THE NUMBER OF YEARS AND MONTHS. IF 12 MONTHS OR MORE, ENTER THE NUMBER OF FULL YEARS, THEN ENTER THE NUMBER OF ADDITIONAL MONTHS. FOR EXAMPLE: IF '2 AND A HALF YEARS,' ENTER 2 FOR YEARS AND 6 FOR MONTHS. IF '2 MONTHS', ENTER 0 FOR YEARS AND 2 FOR MONTHS. IF REFUSED, ENTER 98 FOR A1904y AND A1904m. A1904y For how many years? 0-(A205), 98 A1904m And how many months? 0-11, 98 A1905 If (A1901)=1: 1 Yes In the past 30 days, have you missed taking any of your ARV 2 No pills? 8 Don't know 98 REFUSED If (A1505)=1, ask A1906_screen-A1914b as applicable. A1906_scr If (A1508) is not 1 and (A1510)=0: 1 Yes een Have you had any pregnancies that resulted in a live birth? 2 No 98 REFUSED If (A1508)=1 or (A1510)>=1 or (A1906_screen)=1, ask A1911-A1914 as applicable. A1911 Is the child that you most recently gave live birth to still 1 Yes, living living? 2 No longer living 98 REFUSED A1915a If (A1911)=1: 1 Less than 8 weeks How old is that child? 2 From 8 weeks to 17 months 3 18 months or older 98 REFUSED A1915b If (A1911)=2: 1 Less than 8 weeks How old was the child when he/she died? 2 From 8 weeks to 17 months 3 18 months or older 98 REFUSED 118 Evaluation of Services for Orphans and Vulnerable Youth in Botswana NO. QUESTION RESPONSE OPTIONS A1906 If (A1915a)=2,3 or (A1915b)=2,3: 1 Yes Was that child tested for HIV during the first 8 weeks of 2 No his/her life? 98 REFUSED A1907 If ((A1915a)=3 or (A1915b)=3) and (A1906) is not 1: 1 Yes Was that child tested for HIV during the first 18 months of 2 No his/her life? 98 REFUSED A1908 If (A1906)=1 or (A1907)=1 and (A1911)=2 and (A1915b)=1,2: Think about all the HIV tests that that child had. Did you get the results of any HIV test for the child? 1 2 98 Yes No REFUSED If (A1906)=1 or (A1907)=1 and ((A1911) is not 2 or (A1915b) is not 1,2): Think about all the HIV tests that that child had while in the first 18 months of his or her life. Did you get the results of any HIV test that was done in those 18 months? A1910a If (A1908)=1: Think about the last HIV test result you received for that child in those first 18 months of his or her life. What was the result? 1 2 98 Positive (infected) Negative (not infected) REFUSED A1910b If (A1910a) is not 1: 1 Yes Did that child ever have a positive HIV test showing that he 2 No or she was infected with HIV? 98 REFUSED A1912 If (A1911)=1 and ((A1910a)=1 or (A1910b)=1): 1 Yes Is that child currently taking antiretroviral medication 2 No (ARVs)? 98 REFUSED A1913 If (A1912)=1: 1 Yes Is that child taking their ARVs daily? 2 No 98 REFUSED A1914 If ((A1912)=2 or (A1913)=2): 1 I have not been referred for ARVs yet What is the main reason that the child is not taking ARVs 2 I have been referred but have not daily? obtained the drugs yet 3 Transportation Cost 4 Religious Reasons 5 Food/Nutritional Issues (not enough food to take ARVs) 6 Side Effects 7 Fear of being seen at ARV Clinic 66 Other 98 REFUSED A1914b If (A1914)=66: Specify other reason: Please tell me which of the following organizations you have received services from during the last 12 months: MARK YES, NO OR DK (DON'T KNOW). Yes No DK A1823 Bakgatla Bolokang Matshelo 1 2 8 A1824 Humana People to People 1 2 8 A1825 Mahalapye Orphan Care 1 2 8 A1826 Hope Worldwide Botswana 1 2 8 A1827 Stepping Stones International 1 2 8 A1828 Botswana-Baylor Children’s Clinical Centre of Excellence 1 2 8 A1829 Mother's Union 1 2 8 A1830 PCI, or Project Concern International 1 2 8 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 119 NO. QUESTION RESPONSE OPTIONS A1831 Peace Corps 1 2 8 A1832 Advancing Partners & Communities 1 2 8 Now I am going to show you some pictures of organizational names and logos. Please tell me which of these are logos of organizations from which you have received services during the last 12 months: MARK YES, NO OR DK (DON'T KNOW). Yes No DK A1833 Bakgatla Bolokang Matshelo logo 1 2 8 A1834 Humana People to People logo 1 2 8 A1835 Mahalapye Orphan Care logo 1 2 8 A1836 Hope Worldwide Botswana logo 1 2 8 A1837 Stepping Stones International logo 1 2 8 A1838 Botswana-Baylor Children’s Clinical Centre of Excellence logo 1 2 8 A1839 Mother's Union 1 2 8 A1840 PCI, or Project Concern International 1 2 8 A1841 Peace Corps 1 2 8 A1842 Advancing Partners & Communities 1 2 8 If (A200)=1: Thank you for participating in the interview! Please return the tablet to the enumerator. A1917b We have arrived at the end of the questions. Is there anything else you would like to tell me or ask me? ANSWER ANY QUESTIONS. If (A200) is not 1: Thank you for participating in the interview! END THE INTERVIEW, THEN COMPLETE THE REST OF THIS FORM. SC If (A200)=1: END THE INTERVIEW, THEN COMPLETE THE REST OF THIS FORM. WAS THE RESPONDENT ABLE TO ENTER HIS OR HER RESPONSES IN THE TABLET AS INTENDED? 1 Respondent completed all self￾completed questions on his/her own, as intended. 2 Respondent did NOT complete all the self-completed questions on his/her own. A1916h TIME OF INTERVIEW COMPLETION: HOUR (1-23) 0-23 A1916m TIME OF INTERVIEW COMPLETION: MINUTES 0-59 End of interview. If (vnum)=1: RECORD THE FOLLOWING VISIT 1 DETAILS: If (vnum)=2,3: CONFIRM THE VISIT 1 DETAILS BELOW. ############ YOU ARE ONLY CONFIRMING THESE DETAILS FROM THE FIRST VISIT. IF THESE DETAILS ARE CORRECT, DO NOT MAKE ANY CHANGES ON THIS SCREEN. ############ A007adv1 VISIT 1 DATE: DATE 1-31 A007amv1 VISIT 1 DATE: MONTH 8 AUGUST 9 SEPTEMBER 10 OCTOBER 11 NOVEMBER *Error message if invalid M/DD combination is entered A007bv1 VISIT 1 OUTCOME: SCROLL TO SEE ALL CHOICES. 1 BEGAN INTERVIEW BUT DID NOT COMPLETE 2 HOUSEHOLD NOT FOUND 3 RESPONDENT REFUSED 4 TARGETED RESPONDENT NOT AT HOME 5 TARGETED RESPONDENT INCAPACITATED 6 HOUSEHOLD INACCESSIBLE 120 Evaluation of Services for Orphans and Vulnerable Youth in Botswana NO. QUESTION RESPONSE OPTIONS 7 COMPLETED INTERVIEW 8 APPOINTMENT MADE FOR ANOTHER TIME 77 RESPONDENT INELIGIBLE DUE TO AGE 66 OTHER A007dv1 If (A007bv1)=66: OTHER VISIT 1 OUTCOME: A007ev1 If (A007bv1)=1: LAST QUESTION COMPLETED BY THE RESPONDENT: If (vnum)=2: RECORD THE FOLLOWING VISIT 2 DETAILS: If (vnum)=3: CONFIRM THE VISIT 2 DETAILS BELOW. ############ YOU ARE ONLY CONFIRMING THESE DETAILS FROM THE SECOND VISIT. IF THESE DETAILS ARE CORRECT, DO NOT MAKE ANY CHANGES ON THIS SCREEN. ############ A007adv2 If (vnum)=2 or (vnum)=3: VISIT 2 DATE: DATE 1-31 A007amv2 If (vnum)=2 or (vnum)=3: VISIT 2 DATE: MONTH 8 AUGUST 9 SEPTEMBER 10 OCTOBER 11 NOVEMBER *Error message if invalid MM/DD combination is entered A007bv2 If (vnum)=2 or (vnum)=3: VISIT 2 OUTCOME: 1 BEGAN INTERVIEW BUT DID NOT SCROLL TO SEE ALL CHOICES. COMPLETE 2 HOUSEHOLD NOT FOUND 3 RESPONDENT REFUSED 4 TARGETED RESPONDENT NOT AT HOME 5 TARGETED RESPONDENT INCAPACITATED 6 HOUSEHOLD INACCESSIBLE 7 COMPLETED INTERVIEW 8 APPOINTMENT MADE FOR ANOTHER TIME 77 RESPONDENT INELIGIBLE DUE TO AGE 66 OTHER A007dv2 If (A007bv2)=66: OTHER VISIT 2 OUTCOME: A007ev2 If (A007bv2)=1: LAST QUESTION COMPLETED BY THE RESPONDENT: If (vnum)=3, complete A007adv3-select_A007b_final: RECORD THE FOLLOWING VISIT 3 DETAILS HERE: A007adv3 VISIT 3 DATE: DATE 1-31 A007amv3 VISIT 3 DATE: MONTH 8 AUGUST 9 SEPTEMBER 10 OCTOBER 11 NOVEMBER *Error message if invalid MM/DD combination is entered select_A00 NOW RECORD THE FINAL OUTCOME HERE AND ON THE 1 BEGAN INTERVIEW BUT DID NOT 7b_final ENUMERATOR CONTROL SHEET. COMPLETE REMEMBER, BY RECORDING THIS FINAL OUTCOME, YOU 2 HOUSEHOLD NOT FOUND 3 RESPONDENT REFUSED Evaluation of Services for Orphans and Vulnerable Youth in Botswana 121 NO. QUESTION RESPONSE OPTIONS ARE INDICATING THAT YOU DO NOT NEED TO RETURN TO ATTEMPT THIS INTERVIEW AGAIN. 4 TARGETED RESPONDENT NOT AT HOME 5 TARGETED RESPONDENT INCAPACITATED 6 HOUSEHOLD INACCESSIBLE 7 COMPLETED INTERVIEW 77 RESPONDENT INELIGIBLE DUE TO AGE 66 OTHER c_finalatv1 If (vnum)=1 and (A007bv1) is not 7: YOU ENTERED THE OUTCOME: (A007bv1). IS THIS THE FINAL OUTCOME FOR THIS RESPONDENT? 1 Yes 2 No *Cannot select 1 if (A007bv1)=8 c_finalatv2 If (vnum)=2 and (A007bv2) is not 7: YOU ENTERED THE OUTCOME: (A007bv2). IS THIS THE FINAL OUTCOME FOR THIS RESPONDENT? 1 Yes 2 No *Cannot select 1 if (A007bv2)=8 If (c_finalatv1)=1 or (vnum)=1 and (A007bv1)=7): NOW RECORD THE FINAL OUTCOME ON THE ENUMERATOR CONTROL SHEET. YOU HAVE INDICATED THAT THE FINAL OUTCOME IS: (calc_textv1outcome). REMEMBER, BY RECORDING THIS FINAL OUTCOME, YOU ARE INDICATING THAT YOU DO NOT NEED TO RETURN TO ATTEMPT THIS INTERVIEW AGAIN. If (c_finalatv2)=1 or ((vnum)=2 and (A007bv2)=7): NOW RECORD THE FINAL OUTCOME ON THE ENUMERATOR CONTROL SHEET. YOU HAVE INDICATED THAT THE FINAL OUTCOME IS: (calc_textv2outcome). REMEMBER, BY RECORDING THIS FINAL OUTCOME, YOU ARE INDICATING THAT YOU DO NOT NEED TO RETURN TO ATTEMPT THIS INTERVIEW AGAIN. A007b_fina l Calculate final outcome If (vnum)=1 and ((A007bv1)=7 or (c_finalatv1)=1): A007bv1) If (vnum)=2 and ((A007bv2)=7 or (c_finalatv2)=1): A007bv2) If (vnum)=3: (select_A007b_final) 1 BEGAN INTERVIEW BUT DID NOT COMPLETE 2 HOUSEHOLD NOT FOUND 3 RESPONDENT REFUSED 4 TARGETED RESPONDENT NOT AT HOME 5 TARGETED RESPONDENT INCAPACITATED 6 HOUSEHOLD INACCESSIBLE 7 COMPLETED INTERVIEW 77 RESPONDENT INELIGIBLE DUE TO AGE 66 OTHER (automatically computed) A007b_fina lb If (A007b_final)=66: EXPLAIN OTHER FINAL OUTCOME: A007b_fina lc If (A007b_final)=1: WHAT WAS THE LAST QUESTION COMPLETED BY THE RESPONDENT? c_finalente red Final outcome entered? 1 Yes 2 No (automatically computed) A007a_day _final Final visit date: Date (automatically computed) A007a_mo nth_final Final visit date: Month (automatically computed) 122 Evaluation of Services for Orphans and Vulnerable Youth in Botswana CHECK THAT THESE VALUES BELOW MATCH WHAT IS ON YOUR CONTROL SHEET. HOUSEHOLD ID NUMBER: (A001) DISTRICT: (A002) SUB-DISTRICT: (A003) VILLAGE: (A004) WARD: (A005) FINAL OUTCOME: (A007b_final) (A007b_finalb) NO. QUESTION RESPONSE OPTIONS A1918 ENUMERATOR, ENTER ANY NOTES/COMMENTS ABOUT THIS INTERVIEW. BE SURE TO NOTE ANY DIFFICULTIES YOU FACED. intlead If (c_finalentered)=1: ############ TEAM LEADER, TAP HERE TO REVIEW ############ ARE YOU THE ENUMERATOR, OR ARE YOU THE TEAM LEADER READY TO REVIEW THIS FORM? 1 ENUMERATOR 2 TEAM LEADER READY TO REVIEW If (intlead)=2, complete A1919-verificationdate. TEAM LEADER, CONFIRM THAT (A008a) HAS CORRECTLY ENTERED THESE VALUES AND THAT THEY MATCH THE CONTROL SHEET. SCROLL TO SEE ALL VALUES TO VERIFY. IF THERE ARE ERRORS IN THE VALUES BELOW, GO BACK IN THE TABLET AND CORRECT THEM. HOUSEHOLD ID NUMBER: (A001) DISTRICT: (A002) SUB-DISTRICT: (A003) VILLAGE: (A004) WARD: (A005) FINAL OUTCOME: (A007b_final) (A007b_finalb) A1919 TEAM LEADER, ENTER ANY COMMENTS: verification sig SIGN TO ATTEST THAT YOU HAVE VERIFIED ALL VALUES ON THIS SCREEN. A1920 TEAM LEADER, ENTER YOUR NAME: verification date DATE YOU VERIFIED THIS FORM: / / 2018 If (intlead)=1: YOU HAVE REACHED THE END OF THIS FORM. ON THE NEXT PAGE, TAP 'Save Form and Exit'. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 123 APPENDIX D. CAREGIVER HOUSEHOLD SURVEY Caregiver Questionnaire NO. QUESTION RESPONSE OPTIONS Bdevice_id (automatically computed) Btime_form_lo aded (automatically computed) Btime_form_fir st_loaded (automatically computed) Welcome to the CAREGIVER questionnaire. Instructions and questions for the enumerator appear in BLUE UPPERCASE TEXT. Questions to read to the respondent appear in black text. (NOTE: THIS IS FORM VERSION 35.) B001 COMPLETE THIS INTRODUCTORY SECTION BEFORE APPROACHING THE TARGETED RESPONDENT. HOUSEHOLD IDENTIFICATION NUMBER: 1-9999 B002 DISTRICT: 1 2 3 4 5 6 7 8 66 Central Gaborone Goodhope Kgatleng Kweneng Mahalapye South East Southern Other district B002b If district is not listed: SPECIFY DISTRICT: B003 If (B002) is a listed district: SUB-DISTRICT: *Subdistrict list populated based on selection in B002 B003b If district or sub-district are not listed: SPECIFY SUB-DISTRICT: B004 If (B003) is a listed sub-district VILLAGE: *Village list populated based on selection in B003 B004b If district, sub-district, or village are not listed: SPECIFY VILLAGE: B005 WARD: B008a ENUMERATOR NAME ENTER FIRST AND LAST NAMES. B008b ENUMERATOR CODE #: 1-99 ############ ENUMERATOR, UPDATE THE RESPONSE ON THIS SCREEN EVERY TIME YOU VISIT THIS HOUSEHOLD. ############ vnum IS THIS THE FIRST, SECOND, OR THIRD TIME VISITING TO TRY AND INTERVIEW THIS CAREGIVER? 1 2 3 YES, THIS IS VISIT 1 NO, THIS IS VISIT 2 NO, THIS IS VISIT 3 ############ ENUMERATOR, UPDATE THE RESPONSE ON THIS SCREEN EVERY TIME YOU VISIT THIS HOUSEHOLD. ############ 124 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Bavail YOU HAVE INDICATED THAT THIS IS VISIT #(vnum) TO TRY AND INTERVIEW THE CAREGIVER AT HOUSEHOLD (B001). IF THAT IS INCORRECT, GO BACK AND CORRECT THE HOUSEHOLD NUMBER IN B001 OR THE VISIT NUMBER IN VNUM. ON THIS VISIT (VISIT (vnum)), ARE YOU ABLE TO BEGIN THE INTERVIEW WITH THE TARGETED CAREGIVER? 1 2 3 4 5 YES NO, RESPONDENT NOT AVAILABLE NO, RESPONDENT REFUSED NO, RESPONDENT INCAPACITATED NO, COULD NOT FIND OR REACH HOUSEHOLD c_textBava il Text for BAVAIL: If (Bavail)=1: 'YOU ARE ABLE TO BEGIN THE INTERVIEW WITH THE CAREGIVER'; If (Bavail)=2, 'THE CAREGIVER RESPONDENT IS NOT AVAILABLE'; If (Bavail)=3, 'THE RESPONDENT REFUSED TO PARTICIPATE'; If (Bavail)=4, 'THE RESPONDENT IS INCAPACITATED'; If (Bavail)=5, 'YOU COULD NOT FIND THE HOUSEHOLD OR YOU COULD NOT REACH IT' confirm_B avail CONFIRM: YOU HAVE INDICATED THAT THIS IS VISIT #(vnum) TO INTERVIEW THE CAREGIVER AT HH (B001), AND FOR THIS VISIT #(vnum), (c_textBavail). IS THAT CORRECT? 1 Yes 2 No *Cannot select 2 If (Bavail)=1: Begin interview. Bconfirm_c onsent READ THE INFORMED CONSENT FORM. DOCUMENT INFORMED CONSENT. 1 2 CONSENT CONFIRMED RESPONDENT REFUSED If (Bconfirm_consent)=1, continue interview. BIC101 Let us start with some questions about the child we plan to interview from this household. We have this child’s name recorded as (READ CHILD RESPONDENT'S NAME). Please confirm for me this child's initials. BA205 What is the age of this child (BIC101)? 16 17 18 Sixteen Seventeen Eighteen BA203 What is the sex of this child (BIC101)? 1 2 Female Male BA216 What is your relationship to the child (BIC101)? 1 2 3 4 5 6 7 8 9 10 11 12 13 66 88 Mother (biological) Father (biological) Step-mother and/or foster mother Step-father and/or foster father Sister Brother Aunt Uncle Grandmother Grandfather Non-family member (female) Non-family member (male) Self Other Don't know BA216b If BA216=66: Specify relationship to the child: Evaluation of Services for Orphans and Vulnerable Youth in Botswana 125 BIC105 Is this child (BIC101) enrolled in school? If so, in which level is the child registered? SCROLL TO SEE ALL CHOICES. 0 -1 1 2 3 4 5 6 7 8 9 10 11 Not registered Reception (Pre-primary) Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 Standard 6 Standard 7 Form 1 Form 2 Form 3 Form 4 126 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 12 13 14 15 16 88 Form 5 Form 6 Vocational training/Apprenticeship College University Registered but don't know level BIC106 If (BIC105)=0,13,14,15,16,88: Did this child complete Form 5? 1 2 Yes No BA316 If (BIC106)=1: Did this child sit for the Botswana General Certificate of Secondary Education Examination? 1 2 Yes No BA317 If (BA316)=1: How many points did this child have on the Exam? ENTER POINTS (0-48). IF UNKNOWN, ENTER -8 (NEGATIVE 8). 0-48, -8 BIC107 What age was this child (BIC101) when the child began living with you? IF SINCE BIRTH OR LESS THAN 1 YEAR OF AGE, ENTER 0. IF UNKNOWN, ENTER BEST ESTIMATE. 0-(BA205) B100 Now I will ask about other household members. When I say 'household members', I mean people who eat from the same pot. If (BA205)=18: How many children between the ages of 0 to 17 years live in this household? If (BA205)<18: Aside from the child we are here to interview, how many other children between the ages of 0 to 17 years live in this household? If (B100)>0: Ask BC101-BC107 as relevant. Now we will talk about this/these (B100) child(ren) between the ages of 0 and 17 years old. I will ask a few questions about each. If (BA205)=18: Remember not to list the child we are here to interview. BC101 Please tell me the initials of the (next) child. BC102y What is the age of this child (BC101)? ENTER YEARS. IF NOT YET 1 YEAR, ENTER 0. 0-17 B102m If (BC102y)=0: How many months old is this child (BC101)? 0-11 BC103 What is the sex of this child (BC101)? 1 2 Female Male BC104 What is your relationship to this child (BC101)? 1 2 3 4 5 6 7 8 9 10 11 12 13 66 Mother (biological) Father (biological) Step-mother and/or foster mother Step-father and/or foster father Sister Brother Aunt Uncle Grandmother Grandfather Non-family member (female) Non-family member (male) Self Other Evaluation of Services for Orphans and Vulnerable Youth in Botswana 127 88 Don't know BC105 Is this child (BC101) enrolled in school? If so, in which level is the child registered? 0 -1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 88 Not registered Reception Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 Standard 6 Standard 7 Form 1 Form 2 Form 3 Form 4 Form 5 Form 6 Vocational training/Apprenticeship College University Registered but don't know level BC106 If (BC105)=0,13,14,15,16,88: Did this child (BC101) complete Form 5? 1 2 Yes No BC107 What age was this child (BC101) when the child began living with you? IF CHILD LIVED WITH THIS CAREGIVER SINCE BIRTH OR LESS THAN 1 YEAR OF AGE, ENTER 0. IF UNKNOWN, ENTER BEST ESTIMATE. 0<=(BC102y) REPEAT BC101-BC107 until information for all (B100) children has been collected. Now I have some basic questions about you and other adults in this household. BID101 First, what are your initials? BID102 What was your age on your last birthday? 15-105 BID103 What is your sex? 1 2 Female Male B200 If (BA205)=18: Aside from you and the child we are here to interview, how many other adult members ages 18 or older does this household have? If (BA205)<18: Aside from you, how many other adult members ages 18 or older does this household have? 0-50 If (B200)>0: Ask BD101-BD103 as relevant. Now I will ask the same questions for the other adults in this household. If (BA205)=18: Remember not to list the child we are here to interview. BD101 What are the initials of the (first/next) adult? BD102 What was the age of this adult (BD101) on his or her last birthday? 18-105 BD103 To confirm, what is the sex of this adult (BD101)? 1 2 Female Male REPEAT BD101-BD103 until information for all (B200) adults has been collected. B201 Now I’m going to ask some other basic questions about you and your household. Have you ever attended school? 1 2 Yes No If (B201)=1, ask B202-B203. 128 Evaluation of Services for Orphans and Vulnerable Youth in Botswana B202 What was the highest level of education you attended (even if not completed)? 1 Standard 1 2 Standard 2 3 Standard 3 4 Standard 4 5 Standard 5 6 Standard 6 7 Standard 7 8 Form 1 9 Form 2 10 Form 3 11 Form 4 12 Form 5 13 Form 6 14 Vocational training/Apprenticeship 15 College 16 University B203 What was the highest level of education you completed? 0 Did not complete Standard 1 1 Standard 1 2 Standard 2 3 Standard 3 4 Standard 4 5 Standard 5 6 Standard 6 7 Standard 7 8 Form 1 9 Form 2 10 Form 3 11 Form 4 12 Form 5 13 Form 6 14 Vocational training/Apprenticeship 15 College 16 University *Unless 14, 15, or 16, (B203) cannot exceed (B202) B205a What is your current marital status? 1 Married/Cohabitating 2 Separated 3 Divorced 4 Widowed 5 Never been married B205b If (B205a) is not 1: Do you currently have a boyfriend or girlfriend? By boyfriend or girlfriend, I mean someone you have a romantic relationship with. 1 2 Yes No B206 If (B205b)=1: Are you currently living with your boyfriend or 1 Yes girlfriend? 2 No As you know, some people take up jobs for which they are paid in cash or in kind. Others sell things, have a small business or work on the family farm or in the family business. B207 In the last 7 days, did you do any type of work where you 1 Did work, paid in money (pula) only got paid money (pula), were paid in-kind, or were not paid? 2 Did work, paid in money (pula) AND By “in kind” I mean payment in goods, commodities or in kind services, instead of cash. 3 Did work, paid in kind only 4 Did work, NOT paid Evaluation of Services for Orphans and Vulnerable Youth in Botswana 129 5 DID NOT do these things nor any other work B208 In the last 12 months, did you do any type of work - work where you got paid money (pula), were paid in-kind, or were not paid? 1 Did work, paid in money (pula) only 2 Did work, paid in money (pula) AND in kind 3 Did work, paid in kind only 4 Did work, NOT paid 5 DID NOT do these things nor any other work *Cannot select 3,4,5 if (B207)=1; cannot select 1,3,4,5 if (B207)=2; cannot select 1,4,5 if (B207)=3; cannot select 5 if (B207)=4 B208b In the last 12 months, did you receive any money from a pension? 1 2 Yes No B209 If (B208)=1,2 or (B208b)=1: Averaging over the past 12 months, about how many Botswana pula did you earn on average per month? If (B208b)=1: Include any money received from a pension. ADD THE TOTAL AMOUNT EARNED OVER THE LAST 12 MONTHS AND DIVIDE BY 12. ENTER THIS AVERAGE AMOUNT OF PULA (1-999999). IF UNKNOWN, ENTER -8 (NEGATIVE EIGHT). 1-999999, -8 B210 If (B208)=1,2,3,4: 1 Subsistence farming What types of work/occupation do you do? 2 Commercial farming 3 Livestock farming 4 Mine labor 5 Skilled artisan 6 Business/Self-employment 7 Market vendor/Seller 8 Domestic/Cook/Gardening 9 Formal/Salaried employment 10 Piecework/Ipelegeng 66 Other B210b If (B210) includes 66: Specify other work/occupation: B211 Are you currently looking for (additional/other) work? 1 Yes 2 No B212 Do you or does any member of your household have a bank 1 Yes, bank account only account or a loan from a bank? 2 Yes, loan from a bank only 3 Yes, bank account AND loan from a bank 4 No 88 Don’t know B213 If (B212)=1,2,3: 1 First National Bank (FNB) What is the name of the bank(s) you/they use? 2 Post Office/Botswana Savings Bank DO NOT READ LIST. SELECT ALL MENTIONED. (BSB) 3 Stanbic Bank 4 Standard Chartered Bank 5 Barclays Bank 6 Botswana Building Society 7 Bank Gaborone 8 Bank Abc 130 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 9 Capital Bank 10 Bank of Baroda 11 Account with a microfinance group 66 Other 88 Don't know *Cannot select 88 with other options B213b If (B213) includes 66: Specify other bank(s): B214 Does your household have savings or something to sell if you need cash? 1 Yes 2 No B215 Did your household incur any unexpected household expenses, such as a house repair or urgent medical treatment, in the last 12 months? 1 Yes 2 No B216 If (B215)=1: Was your household able to pay for all these expenses? 1 Yes 2 No B217 If (B216)=1: Thinking about the last time you had to pay for an unexpected household expense, such as a house repair, or urgent medical treatment, where did the money come from? DO NOT READ RESPONSES. IF RESPONDENT GIVES MULTIPLE RESPONSES, ASK RESPONDENT TO PICK THE ONE THAT PAID FOR MOST OF THE UNEXPECTED HOUSEHOLD EXPENSE. 1 Current income (Cash) 2 Savings 3 Loan 4 Gift/Given money 5 Sold asset 66 Other B217b If (B217)=5: Specify asset sold: B217c If (B217)=66: Specify other source: B304 Compared to last year, do you feel that your household is more or less financially secure, or about the same? 1 More secure 2 Less secure 3 About the same Now I will ask about some items. Please tell me if your household has each of these. Does your household have a… READ EACH ITEM. MARK YES OR NO. Yes No B305a Radio 1 2 B305b Television 1 2 B305c Mobile telephone 1 2 B305d Non-mobile telephone 1 2 B305e Refrigerator 1 2 B305f Bed 1 2 B305g Chair 1 2 B305h Table 1 2 B305i Cupboard 1 2 B305j Sofa 1 2 B305k Clock 1 2 B305l Fan 1 2 B305m Sewing machine 1 2 B305n Cassette player 1 2 B305o Plough 1 2 B305p Grain grinder 1 2 B305q VCR/DVD 1 2 B305r Tractor 1 2 B305s Hammer mill 1 2 B305t Watch 1 2 B306a Bicycle 1 2 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 131 B306b Animal-drawn cart 1 2 B306c Motorcycle or Motor scooter 1 2 B306d Vehicle 1 2 B306e Boat with a motor 1 2 B306f Mokoro/Banana boat 1 2 B306g Donkey/Horse 1 2 B401 In the past 4 weeks, was there ever no food to eat in your household because of a lack of resources to get food? 1 Yes 2 No B402 If (B401)=1: In the past 4 weeks, how often was there no food to eat because of a lack of resources? 1 Rarely (1-2 times) 2 Sometimes (3-10 times) 3 Often (more than 10 times) B403 In the past 4 weeks, did you or any household member go to sleep at night hungry because there was not enough food? 1 Yes 2 No B405 If (B403)=1: In the past 4 weeks, how often did a household member go to sleep at night hungry because there was not enough food? 1 2 3 Rarely (1-2 times) Sometimes (3-10 times) Often (more than 10 times) B406 In the past 4 weeks, did you or any member of your household go a whole day and night without eating anything because there was not enough food? 1 2 Yes No B407 If (B406)=1: In the past 4 weeks, how often did a household member go a whole day and night without eating because there was not enough food? 1 2 3 Rarely (1-2 times) Sometimes (3-10 times) Often (more than 10 times) B501 Now I would like to talk about something else. Have you ever heard of HIV? 1 2 Yes No If (B501)=1, ask B502-B520 as relevant. B502 Can people reduce their chances of getting HIV by having 1 Yes just one uninfected sex partner who has no other sex 2 No partners? 8 Don't know B503 Can people reduce their chance of getting HIV by using a 1 Yes condom every time they have sex? 2 No 8 Don't know B504 Is it possible for a healthy-looking person to have HIV? 1 Yes 2 No 8 Don't know B505 Can people get HIV from mosquito bites? 1 Yes 2 No 8 Don't know B506 Can people get HIV by sharing food with someone who has 1 Yes AIDS? 2 No 8 Don't know B507 Can people reduce their chance of getting HIV by not 1 Yes having sexual intercourse at all? 2 No 8 Don't know B510 Can people living with HIV be cured by prayer? 1 Yes 2 No 8 Don't know B511a What is the youngest age at which a child should be taught 1 Less than 8 years old about using a condom to avoid getting HIV? 2 At least 8 years old but still less than 18 years old 132 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 3 Only adults 18 years and older should be taught about using a condom to avoid HIV 88 Don't know 98 REFUSED B511b If (B511a)=2: What is the youngest age at which a child should be taught about using a condom to avoid getting HIV? ENTER AGE IN YEARS (8-17). 8-17 Can HIV be transmitted from a mother to her baby: READ EACH. MARK YES, NO, OR DK (DON'T KNOW). Yes No DK B512a During pregnancy? 1 2 8 B512b During delivery? 1 2 8 B512c By breastfeeding? 1 2 8 B513 Any yes of B512a, B512b, or B512c? (automatically computed) B514 If (B513)=1: Are there any special drugs that a doctor or a nurse can give to a woman infected with HIV to reduce the risk of transmission to the baby? 1 2 8 Yes No Don't know B515 Have you heard about ARVs that people infected with HIV can get from a doctor or a nurse? 1 2 8 Yes No Don't know B516 If (B515)=1: When a person with HIV takes these ARVs, does his or her risk of GIVING HIV to a sexual partner increase, decrease, or remain about the same? 1 2 3 8 Increase Decrease Remain the same Don’t Know B517 Have you ever been tested to see if you have HIV? 1 2 Yes No If (B517)=1, ask B518-B520 as relevant. B518 How many months ago was your most recent HIV test? ENTER 0-24 MONTHS. IF LONGER THAN 24 MONTHS (TWO YEARS) AGO, ENTER 95. 0-24, 95 B519 Did you get the results of the test? 1 2 Yes No B521 If (B519)=1: What was your HIV test result? 1 2 98 Positive (infected) Negative (not infected) REFUSED B520 If (B519) is not 1: Have you ever had a positive HIV test result showing that you are infected with HIV? 1 2 98 Yes No REFUSED Now we will ask you about your communication with the child we are here to interview (BIC101). Have you shared information with that child about the following topics? READ EACH. MARK YES, NO, OR REF (REFUSED). Yes No REF B701 Contraception/preventing pregnancy? 1 2 98 B702 Sexually transmitted infections (STIs)? 1 2 98 B703 HIV/AIDS? 1 2 98 B704 Ways to protect yourself against STIs and AIDS? 1 2 98 B705 Condoms specifically? 1 2 98 B706 Postponing or not having sex? 1 2 98 B707 Peer pressure and sexual pressure from dating partners? 1 2 98 B708 How to resist sexual pressure from peers and dating partners? 1 2 98 Please let me know if you agree or disagree with the following statements about roles of females versus males. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 133 B801 It is ok for men to have more than one (sexual) partner. 1 2 Agree Disagree B802 It is a woman’s duty to have sex with her spouse/partner even if she does not want to. 1 2 Agree Disagree B803 It is more important for a woman to respect her spouse/partner than it is for a man to respect his spouse/partner. 1 2 Agree Disagree B804 A man may beat his spouse/partner if she disobeys him. 1 2 Agree Disagree B805 A man may beat his spouse/partner if he believes she is having sex with another man. 1 2 Agree Disagree B806 It is more important for a boy to get an education than a girl. 1 2 Agree Disagree Thank you very much for your participation so far. Now I will ask about some items or services you may have received or accessed. B1001a Have you received or accessed any advice on HIV prevention, testing, or treatment? 1 2 8 Yes No Don't know If (B1001a)=1, ask B1001b-B1001c. B1001b When was the first time you received/accessed any advice on HIV prevention, testing, or treatment? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1001c Please tell me how often you have received/accessed any such advice in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1001b)=2,3 B1002a Have you received/accessed any assistance with payment of medical fees? 1 2 8 Yes No Don't know If (B1002a)=1, ask B1002b-B1002c. B1002b When was the first time you received/accessed any assistance with payment of medical fees? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1002c Please tell me how often you have received/accessed assistance with payment of medical fees in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1002b)=2,3 B1003a Have you received/accessed any home-based medical care and advice? 1 2 8 Yes No Don't know If (B1003a)=1, ask B1003b-B1003c. B1003b When was the first time you received/accessed any home￾based medical care and advice? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months 134 Evaluation of Services for Orphans and Vulnerable Youth in Botswana B1003c Please tell me how often you have received/accessed such home-based medical care and advice in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1003b)=2,3 B1004a Have you received/accessed any referrals to clinics? 1 2 8 Yes No Don't know If (B1004a)=1, ask B1004b-B1004c. B1004b When was the first time you received/accessed any referrals to clinics? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1004c Please tell me how often you have received/accessed such referrals in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1004b)=2,3 B1005a Have you received/accessed any information on equitable relationships between men and women? 1 2 8 Yes No Don't know If (B1005a)=1, ask B1005b-B1005c. B1005b When was the first time you received/accessed any information on equitable relationships between men and women? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1005c Please tell me how often you have received/accessed such information in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1005b)=2,3 B1006a Have you received/accessed any food baskets? By food baskets, we mean actual food items received (not coupons/vouchers). 1 2 8 Yes No Don't know If (B1006a)=1, ask B1006b-B1006c. B1006b When was the first time you received/accessed any food baskets? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1006c Please tell me how often you have received/accessed food baskets in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1006b)=2,3 B1007a Have you received/accessed any food coupons? By food coupons we mean a swipe card used to get food. 1 2 8 Yes No Don't know If (B1007a)=1, ask B1007b-B1007c. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 135 B1007b When was the first time you received/accessed any food coupons? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1007c Please tell me how often you have received/accessed such food coupons in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1007b)=2,3 B1008a Have you received/accessed any food vouchers? Vouchers are torn from a booklet and left with a shop when picking up the food. 1 2 8 Yes No Don't know If (B1008a)=1, ask B1008b-B1008c. B1008b When was the first time you received/accessed any food vouchers? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1008c Please tell me how often you have received/accessed such food vouchers in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1008b)=2,3 B1009a Have you received/accessed any vocational training scholarships? 1 2 8 Yes No Don't know If (B1009a)=1, ask B1009b-B1009c. B1009b When was the first time you received/accessed any vocational training scholarships? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1009c Please tell me how often you have received/accessed such scholarships in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1009b)=2,3 B1010a Have you received/accessed any information on sexually transmitted infections (STIs) other than HIV? 1 2 8 Yes No Don't know If (B1010a)=1, ask B1010b-B1010c. B1010b When was the first time you received/accessed any information on STIs other than HIV? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1010c Please tell me how often you have received/accessed information on STIs other than HIV in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1010b)=2,3 B1012a Have you received/accessed any out-of-school literacy training or tutoring? 1 2 8 Yes No Don't know 136 Evaluation of Services for Orphans and Vulnerable Youth in Botswana If (B1012a)=1, ask B1012b-B1012c. B1012b When was the first time you received/accessed any out-of￾school literacy training or tutoring? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1012c Please tell me how often you have received/accessed out￾of-school literacy training or tutoring in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1012b)=2,3 B1013a Have you received/accessed any assistance with housing or accommodation? 1 2 8 Yes No Don't know If (B1013a)=1, ask B1013b-B1013c. B1013b When was the first time you received/accessed assistance with housing or accommodation? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1013c Please tell me how often you have received/accessed assistance with housing or accommodation in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1013b)=2,3 B1014a Have you received/accessed any counseling? 1 2 8 Yes No Don't know If (B1014a)=1, ask B1014b-B1014c. B1014b When was the first time you received/accessed any counseling? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1014c Please tell me how often you have received/accessed counseling in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1014b)=2,3 B1015a Have you received or accessed any parent￾child communication classes? 1 2 8 Yes No Don't know If (B1015a)=1, ask B1015b-B1015c. B1015b When was the first time you received or accessed any parent-child communication classes? 1 2 3 More than 1 year ago Between 6 months and 1 year ago Within the last 6 months B1015c Please tell me how often you have received or accessed parent-child communication classes in the last 12 months. 1 Rarely (a few times a year) 2 Sometimes (once a month) 3 Frequently (more than once a month) 4 Never in the last 12 months *Cannot select 4 if (B1015b)=2,3 Please tell me which of the following organizations you have received services from during the past 12 months: READ EACH. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 137 MARK YES, NO, OR DK (DON'T KNOW). Yes No DK B1101 Bakgatla Bolokang Matshelo 1 2 8 B1102 Humana People to People 1 2 8 B1103 Mahalapye Orphan Care 1 2 8 B1104 Hope Worldwide Botswana 1 2 8 B1105 Stepping Stones International 1 2 8 B1106 Botswana-Baylor Children’s Clinical Centre of Excellence 1 2 8 B1107 Mother's Union 1 2 8 B1108 PCI, or Project Concern International 1 2 8 B1109 Peace Corps 1 2 8 B1110 Advancing Partners & Communities 1 2 8 Now I am going to show you some pictures of organizational names and logos. Please tell me which of these are logos of organizations from which you have received services during the past 12 months. MARK YES, NO, OR DK (DON'T KNOW). Yes No DK B1111 Bakgatla Bolokang Matshelo logo 1 2 8 B1112 Humana People to People logo 1 2 8 B1113 Mahalapye Orphan Care logo 1 2 8 B1114 Hope Worldwide Botswana logo 1 2 8 B1115 Stepping Stones International logo 1 2 8 B1116 Botswana-Baylor Children’s Clinical Centre of Excellence logo 1 2 8 B1117 Mother's Union logo 1 2 8 B1118 PCI, or Project Concern International logo 1 2 8 B1119 Peace Corps logo 1 2 8 B1120 Advancing Partners & Communities logo 1 2 8 I have arrived at the end of the questions. Is there anything else that you wish to add or ask? Thank you for participating in the interview! END THE INTERVIEW. THEN COMPLETE THE REST OF THIS FORM. B1118h TIME OF INTERVIEW COMPLETION: HOUR 0-23 B1118m TIME OF INTERVIEW COMPLETION: MINUTES 0-59 B301 RECORD OBSERVATION: MAIN MATERIAL OF THE FLOOR 1 EARTH/SAND 2 DUNG 3 WOOD PLANKS 4 PALM/BAMBOO/REEDS 5 PARQUET OR POLISHED WOOD 6 VINYL (PVC) OR ASPHALT STRIPS 7 CERAMIC/TERRAZZO TILES 8 CONCRETE CEMENT 9 CARPET 66 OTHER floor B301b If (B301)=66: SPECIFY OTHER MAIN FLOOR MATERIAL: B302 RECORD OBSERVATION: MAIN MATERIAL OF THE ROOF 1 NO ROOF 2 THATCH/PALM LEAF 3 RUSTIC MAT 4 PALM/BAMBOO 5 CARDBOARD 6 METAL/IRON SHEETS 7 WOOD 8 CALAMINE/CEMENT FIBERS (ASBESTOS) 9 CERAMIC TILES/HARTEY TILES 10 CEMENT 138 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 11 ROOFING SHINGLES 12 MUD TILES 66 OTHER B302b If (B302)=66: SPECIFY OTHER MAIN ROOF MATERIAL: B303 RECORD OBSERVATION: MAIN MATERIAL OF THE EXTERIOR 1 NO WALLS WALLS 2 CANE/PALM/TRUNKS 3 MUD 4 BAMBOO/POLE WITH MUD 5 STONE WITH MUD 6 PLYWOOD 7 CARDBOARD 8 REUSED WOOD 9 CEMENT 10 STONE WITH LIME/CEMENT 11 BRICKS 12 WOOD PLANKS 66 OTHER B303b If (B303)=66: SPECIFY MAIN MATERIAL OF THE ROOF: End of interview. If (vnum)=1: RECORD THE FOLLOWING VISIT 1 DETAILS: If (vnum)=2,3: CONFIRM THE VISIT 1 DETAILS BELOW. ############ YOU ARE ONLY CONFIRMING THESE DETAILS FROM THE FIRST VISIT. IF THESE DETAILS ARE CORRECT, DO NOT MAKE ANY CHANGES ON THIS SCREEN. ############ B007adv1 VISIT 1 DATE: DATE 1-31 B007amv1 VISIT 1 DATE: MONTH 8 AUGUST 9 SEPTEMBER 10 OCTOBER 11 NOVEMBER *Error message if invalid MM/DD combination is entered B007bv1 VISIT 1 OUTCOME: SCROLL TO SEE ALL CHOICES. 1 BEGAN INTERVIEW BUT DID NOT COMPLETE 2 HOUSEHOLD NOT FOUND 3 RESPONDENT REFUSED 4 TARGETED RESPONDENT NOT AT HOME 5 TARGETED RESPONDENT INCAPACITATED 6 HOUSEHOLD INACCESSIBLE 7 COMPLETED INTERVIEW 8 APPOINTMENT MADE FOR ANOTHER TIME 77 RESPONDENT INELIGIBLE DUE TO AGE 66 OTHER B007dv1 If (B007bv1)=66: OTHER VISIT 1 OUTCOME: B007ev1 If (B007bv1)=1: LAST QUESTION COMPLETED BY THE RESPONDENT: If (vnum)=2: RECORD THE FOLLOWING VISIT 2 DETAILS: Evaluation of Services for Orphans and Vulnerable Youth in Botswana 139 If (vnum)=3: CONFIRM THE VISIT 2 DETAILS BELOW. ############ YOU ARE ONLY CONFIRMING THESE DETAILS FROM THE SECOND VISIT. IF THESE DETAILS ARE CORRECT, DO NOT MAKE ANY CHANGES ON THIS SCREEN.############ B007adv2 If (vnum)=2,3: VISIT 2 DATE: DATE 1-31 B007amv2 If (vnum)=2,3: VISIT 2 DATE: MONTH 8 AUGUST 9 SEPTEMBER 10 OCTOBER 11 NOVEMBER *Error message if invalid MM/DD combination is entered B007bv2 If (vnum)=2,3: VISIT 2 OUTCOME: SCROLL TO SEE ALL CHOICES. 1 BEGAN INTERVIEW BUT DID NOT COMPLETE 2 HOUSEHOLD NOT FOUND 3 RESPONDENT REFUSED 4 TARGETED RESPONDENT NOT AT HOME 5 TARGETED RESPONDENT INCAPACITATED 6 HOUSEHOLD INACCESSIBLE 7 COMPLETED INTERVIEW 8 APPOINTMENT MADE FOR ANOTHER TIME 77 RESPONDENT INELIGIBLE DUE TO AGE 66 OTHER B007dv2 If (B007bv2)=66: OTHER VISIT 2 OUTCOME: B007ev2 If (B007bv2)=1: LAST QUESTION COMPLETED BY THE RESPONDENT: If (vnum)=3, complete B007adv3-select_B007b_final. RECORD THE FOLLOWING VISIT 3 DETAILS HERE: B007adv3 VISIT 3 DATE: DATE 1-31 B007amv3 VISIT 3 DATE: MONTH 8 AUGUST 9 SEPTEMBER 10 OCTOBER 11 NOVEMBER *Error message if invalid MM/DD combination is entered select_B00 7b_final NOW RECORD THE FINAL OUTCOME HERE AND ON THE ENUMERATOR CONTROL SHEET. REMEMBER, BY RECORDING THIS FINAL OUTCOME, YOU ARE INDICATING THAT YOU DO NOT NEED TO RETURN TO ATTEMPT THIS INTERVIEW AGAIN. 1 BEGAN INTERVIEW BUT DID NOT COMPLETE 2 HOUSEHOLD NOT FOUND 3 RESPONDENT REFUSED 4 TARGETED RESPONDENT NOT AT HOME 5 TARGETED RESPONDENT INCAPACITATED 6 HOUSEHOLD INACCESSIBLE 7 COMPLETED INTERVIEW 66 OTHER 140 Evaluation of Services for Orphans and Vulnerable Youth in Botswana c_finalatv1 If (vnum)=1 and (B007bv1) is not 7: YOU ENTERED THE OUTCOME: (B007bv1). IS THIS THE FINAL OUTCOME FOR THIS RESPONDENT? 1 Yes 2 No *Cannot select 1 if (B007bv1)=8 c_finalatv2 If (vnum)=2 and (B007bv2) is not 7: YOU ENTERED THE OUTCOME: (B007bv2). IS THIS THE FINAL OUTCOME FOR THIS RESPONDENT? 1 Yes 2 No *Cannot select 1 if (B007bv2)=8 If (c_finalatv1)=1 or ((vnum)=1 and (B007bv1)=7): NOW RECORD THE FINAL OUTCOME ON THE ENUMERATOR CONTROL SHEET. YOU HAVE INDICATED THAT THE FINAL OUTCOME IS: (B007bv1). REMEMBER, BY RECORDING THIS FINAL OUTCOME, YOU ARE INDICATING THAT YOU DO NOT NEED TO RETURN TO ATTEMPT THIS INTERVIEW AGAIN. If (c_finalatv2)=1 or ((vnum)=2 and (B007bv2)=7): NOW RECORD THE FINAL OUTCOME ON THE ENUMERATOR CONTROL SHEET. YOU HAVE INDICATED THAT THE FINAL OUTCOME IS: (B007bv2). REMEMBER, BY RECORDING THIS FINAL OUTCOME, YOU ARE INDICATING THAT YOU DO NOT NEED TO RETURN TO ATTEMPT THIS INTERVIEW AGAIN. B007b_fina l Calculate final outcome If (vnum)=1 and ((B007bv1)=7 or (c_finalatv1)=1): (B007bv1) If (vnum)=2 and ((B007bv2)=7 or (c_finalatv2)=1): (B007bv2) If (vnum)=s: (select_B007b_final) if( ((vnum)=1 and ((B007bv1)=7 or (c_finalatv1)=1)),(B007bv1), if( ((vnum)=2 and ((B007bv2)=7 or (c_finalatv2)=1)),(B007bv2), (select_B007b_final))) B007b_fina lb If (B007b_final)=66: EXPLAIN OTHER FINAL OUTCOME: B007b_fina lc If (B007b_final)=1: WHAT WAS THE LAST QUESTION COMPLETED BY THE RESPONDENT? c_finalente red Final outcome entered? 1 Yes 2 No (automatically computed) B007a_day _final Final visit date: Date (automatically computed) B007a_mo nth_final Final visit date: Month (automatically computed) CHECK THAT THESE VALUES BELOW MATCH WHAT IS ON YOUR CONTROL SHEET. HOUSEHOLD ID NUMBER: (B001) DISTRICT: (B002) SUB-DISTRICT: (B003) VILLAGE: (B004) WARD: (B005) FINAL OUTCOME: (B007b_final) (B007b_finalb) B1918 ENUMERATOR, ENTER ANY NOTES/COMMENTS ABOUT THIS INTERVIEW. BE SURE TO NOTE ANY DIFFICULTIES YOU FACED. intlead If (c_finalentered)=1: ############ TEAM LEADER, TAP HERE TO REVIEW ############ ARE YOU THE ENUMERATOR, OR ARE YOU THE TEAM LEADER READY TO REVIEW THIS FORM? 1 ENUMERATOR 2 TEAM LEADER READY TO REVIEW If (intlead)=2, complete B1919-verificationdate. TEAM LEADER, CONFIRM THAT (B008a) HAS CORRECTLY ENTERED THESE VALUES AND THAT THEY MATCH THE CONTROL SHEET. SCROLL TO SEE ALL VALUES TO VERIFY. IF THERE ARE ERRORS IN THE VALUES BELOW, GO BACK IN THE TABLET AND CORRECT THEM. HOUSEHOLD ID NUMBER: (B001) DISTRICT: (B002) SUB-DISTRICT: (B003) VILLAGE: (B004) WARD: (B005) FINAL OUTCOME: (B007b_final) (B007b_finalb) Evaluation of Services for Orphans and Vulnerable Youth in Botswana 141 B1919 TEAM LEADER, ENTER ANY COMMENTS: verification sig SIGN TO ATTEST THAT YOU HAVE VERIFIED ALL VALUES ON THIS SCREEN. B1920 TEAM LEADER, ENTER YOUR NAME: verification date DATE YOU VERIFIED THIS FORM: / / 2018 If (intlead)=1: YOU HAVE REACHED THE END OF THIS FORM. ON THE NEXT PAGE, TAP 'Save Form and Exit'. 142 Evaluation of Services for Orphans and Vulnerable Youth in Botswana APPENDIX E. YOUTH MOBILE SURVEY Follow up questionnaire for Form 5 youth Name of interviewer ENTER LAST NAME Name of interviewer ENTER FIRST NAME Date of interview ENTER DATE (1‐ 31) Date of interview SELECT MONTH Youth ID# Did you complete Form 5? When did you complete Form 5? SELECT MONTH When did you complete Form 5? SELECT YEAR Did you sit for the Botswana General Certificate of Secondary Education Examination in the year 2018? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 143 If yes, how many points did you have on the Exam? I am asking about the total points across your best 6 subjects. ENTER POINTS (0‐48) Are you enrolled in any level of education this school year? If yes, what level are you enrolled in this school year? In the last 3 months, did you do any type of work ‐ work where you got money (pula), were paid in kind, or were not paid? By 'in kind' I mean payment in goods, commodities or services, instead of cash. In the past 3 months have you started a small business (i.e., an income generating activity)? Tele‐ interview outcome Comments 144 Evaluation of Services for Orphans and Vulnerable Youth in Botswana APPENDIX F. QUALITATIVE GUIDE FOR COMMUNITY SERVICE PROVIDER INTERVIEWS Interview Guide for Community Service Provider Interviews (Volunteers with BCCSOVC) Note: Volunteers eligible to be interviewed will have volunteered with BCCSOVC for at least six months prior to interview date Date of Interview: Start Time: End Time: Interviewer: Participant code: Community Based Organization: District: Language: Participant Sex: Male  Female  1. Please describe your role within the Botswana Comprehensive Care OVC (BCCSOVC) project or [INSERT LOCAL IMPLEMENTING PARTNER NAME: Botswana-Baylor Children’s Clinic (Baylor), Hope World Wide, Stepping Stones International (SSI), Botswana Family Welfare Association (BOFWA), Mother’s Union (probe: what is it that you do to support the OVC youth and households supported by the BCCSOVC project? MAKE SURE THEY TALK ABOUT THIS PARTICULAR ROLE THEY SERVE, AND NOT OTHER COMMUNITY WORK THEY HAVE DONE ON OTHER PROJECTS). 2. How long did you work with BCCSOVC in this capacity? 3. What specific project activities have you been involved in while working withBCCSOVC? a. Any economic strengthening activities, such as (GROW, Aflateen)? b. Educational support activities, such as (after school care, kids’ clubs, school clubs)? c. Life skills training? d. Gender-based violence activities? e. HIV education or HIV-related activities? f. Household visits to provide case management services? 4. Through your experiences with the BCCSOVC project, what changes (positive or negative) did you see in the lives of youth you served? (specify age 16-18) a. Why do you think this is? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 145 b. Can you give me some specific examples of experiences you had that led you to believe this? 5. What was the most significant change related to youth’s educational achievement? [probe: changes related to staying enrolled in school, attending regularly, being able to graduate, transitioning into university or other training projects] a. What types of project activities helped lead to this change, if any? 6. What could a similar project do differently in the future to help youth even more in achieving their educational goals? 7. What was the most significant change related to youth’s economic or financial situations [probe if respondent needs prompting: changes related to obtaining jobs, job skills, starting a business, or managing money] a. What types of project activities helped lead to this change? 8. What could a similar project do differently in the future to help youth even more in achieving their economic goals? 9. What was the most significant change related to youth’s relationships, sexual decision making and behavior, and/or contraception? Why was this change most significant? a. What types of project activities helped lead to this change? 10. What could a similar project do differently in the future to help youth even more to promote healthy relationships, sexual decision making and behavior, and contraception? 11. What was the most significant change related to youth’s understanding of gender￾based violence? Why was this change most significant? a. What types of project activities helped lead to this change? 12. What could a similar project do differently in the future to help participants better understand or avoid gender-based violence? 13. What was the most significant change related to youth’s knowledge and ability to stay HIV- negative? Why was this change mostsignificant? 146 Evaluation of Services for Orphans and Vulnerable Youth in Botswana a. What types of project activities helped lead to this change? 14. What could a similar project do differently in the future to help participants better understand HIV and stay HIV-negative? 15. If you served youth who are HIV-positive, what was the most significant change related their ability to stay healthy and prevent the spread of HIV? Why was this change most significant? a. What types of project activities helped lead to this change? 16. What could a similar project do differently in the future to help HIV-positive participants stay healthy and prevent the spread of HIV? Finally, thinking about the project as a whole: 17. What are areas in which you think the project could be strengthened or improved for future participants? [probe: could you provide specific examples? Anything else?] 18. Taking it all together, what part of the BCCSOVC project influenced youth’s lives the most? Please explain. 19. Of all the ways the project affected youth’s lives, what changed the most? What in their lives was most impacted? 20. Is there anything else you’d like to tell me about youth in the BCCSOVC project? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 147 APPENDIX G. QUALITATIVE GUIDE FOR IMPLEMENTING PARTNER INTERVIEWS Interview Guide for BCCSOVC Implementing Partner Staff Name of Interviewer: Date of Interview: Type and Name of Level: National, Regional District, Community Job Title: Length of Interview: Introductory Questions We’d like to ask you a few questions to get started. 1. How long have you worked with the project? 2. What is your role with the BCCSOVC project? Questions on the Objectives 3. Please describe BCCSOVC’s education focused activities for youth. a. Successes and Challenges in each Partner’s Work i. Baylor’s work ii. Mother’s Union iii. Stepping Stones iv. B BM v. 4. ** FOR EACH ACTIVITY MENTIONED ABOVE, ASK THE FOLLOWINGQUESTION** ((THIS ACTIVITY)) has or has not improved educational outcomes for youth in theproject. a. Which specific interventions had the greatest impact on improving educational achievement of youth? How did they make a difference? Can you provide examples? b. Which of the education interventions had the least impact on improving educational achievement of youth? Why? 5. Please describe BCCSOVC’s economic focused activities for youth. 6. Please describe the extent to which you think the project has or has not improved the livelihoods of vulnerable youth and their households. a. Which specific interventions had the greatest impact on improving the livelihoods of vulnerable youth and their households? How did they make a difference? Can 148 Evaluation of Services for Orphans and Vulnerable Youth in Botswana you provide examples? Why? b. Which of the economic interventions had the least impact on improving the livelihoods of vulnerable youth and their households? Why? 7. Please describe the BCCSOVC activities that focused on relationships, sexual decision making, or contraception? 8. Please describe the extent to which the project has or has not improved youth’s understanding and skills with respect to relationships, sexual decision making and behavior, or contraception? a. Which specific interventions had the greatest impact on improving relationships, sexual decision making and behavior, and/or contraception? How did they make a difference? Can you provide examples? b. Which specific interventions had the least impact on improving relationships, sexual decision making and behavior, and/or contraception? Why? 9. Please describe BCCSOVC activities that focused on gender and/or gender-basedviolence? 10. Please describe the extent to which the project has or has not improved youth’s understanding or wellbeing with respect to gender and gender-based violence? a. Which specific interventions had the greatest impact on improving understanding and wellbeing with respect to gender and gender-based violence? How did they make a difference? Can you provide examples? b. Which specific interventions had the least impact on improving understanding and wellbeing with respect to gender and gender-based violence? Why? 11. Please describe the BCCSOVC activities that focused on substance abuse (use of drugs and alcohol). 12. Please describe the extent to which the project has or has not improved youth’s understanding and ability to resist drugs and alcohol? a. Which specific interventions had the greatest impact on improving youth’s ability to resist drugs and alcohol? How did they make a difference? Can you provide examples? b. Which specific interventions had the least impact on improving youth’s ability to resist drugs and alcohol? Why? 13. Please describe BCCSOVC activities that focused on HIV prevention? 14. Please describe the extent to which the project has or has not improved youth’s knowledge and ability to stay HIV-negative? a. Which specific interventions had the greatest impact on improving youth’s knowledge and ability to stay HIV-negative? How did they make a difference? Can you provide examples? Which specific interventions had the least impact on improving youth’s knowledge and ability to prevent HIV? Why? 15. Please describe BCCSOVC activities that focused on support for HIV positive youth. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 149 16. Please describe the extent to which the project has or has not improved HIV positive youth’s ability to stay healthy and prevent the spread of HIV? a. Which specific interventions had the greatest impact on improving HIV-positive youth’s ability to stay health and prevent the spread HIV? How did they make a difference? Can you provide examples?Which specific interventions had the least impact on improving HIV-positive youth’s ability to stay health and prevent the spread HIV? Why? 17. Please describe the household interventions that BCCSOVC delivered? 18. Which of those interventions most impacted the youth? Please explain. 19. Which of those interventions least impacted the youth? Please explain. Questions on Lessons Learned 20. What were some of the barriers to project implementation? a. How did they affect the ability of the project to meet the needs of youth? 21. What were some of the contributors to project implementation (ie: what led to successful project implementation)? a. How did they affect the ability to meet the needs of youth? 22. Please describe any changes you think future projects could make to improve how they work with vulnerable youth [probe for specific examples]. Most Significant Change and Wrap up 23. From your perspective, what was the most significant change in the youth served by the project? [probe: who was most affected? how were they affected by the project? How did this most significant change occur?] 24. Summarizing what you have told me, what are the greatest strengths of the BCCSOVC project for youth? Why? 25. Summarizing what you have told me, what are the greatest weaknesses of the BCCSOVC project for youth? Why? 26. Is there anything else about the BCCSOVC project you would like to tell me? Those are all of the questions I have for today. Is there anything else you’d like to tell me about you or your involvement with the BCCSOVC project before we complete the interview? 150 Evaluation of Services for Orphans and Vulnerable Youth in Botswana APPENDIX H. QUALITATIVE GUIDE FOR REM FOCUS GROUP DISCUSSION Discussion Guide for Ripple Effect Mapping Method for the Botswana Comprehensive Care and Support (BCCSOVC) Project Groups of 8-10 Date: Location: Participant Unique ID : REM Group Number: Participant Number Sex (M/F) Age Form What [NAME ORGANIZATION] services or activities have you participated in? 1 2 3 4 5 6 7 8 9 10 Team: 1 Facilitator, 1 Mapper/Note-taker To Bring:  Sign-in sheet  Agendas for participants  Informed Consent forms  Facilitator Guide  Watch/clock/timer  Flip chart  Multiple color marker(s)  Tape/sticky tack Evaluation of Services for Orphans and Vulnerable Youth in Botswana 151 Introductions [2 minutes] READ: Welcome. Thank you for taking the time and making the effort to be with us. Our names are and we work with . As we explained during the informed consent process, the main purpose of this research study is to understand more about how the OVC program influenced the health, education, and economic situation of youth like you who participated in the BCCSOVC project. This will help the Government of Botswana and USAID to improve future programs for people like you. We will not use your names or otherwise identify you personally in the analysis and reporting of the results of our discussion today. Ground Rules [1 minute] We encourage everyone to participate, knowing there are no right or wrong answers. Each of you was invited here because you have received services from [ORGANIZATION NAME]. Speak up if you agree or disagree with someone, as we want to understand everyone’s experiences and opinions. We are recording this discussion which will help us capture everything we need for the analysis and summary, but we will not identify you personally. This discussion will probably take about two hours. Do you have any questions before we get started? Appreciative Inquiry interview [20 minutes] Today will be composed of two parts: first a peer interview, and second a group reflection. In the first part we will ask you to pair up with someone who you don’t know well or is not a good friend. You will interview each other, asking each other a set of standard questions that are on your agenda. You may ask tailored follow-up questions for clarification of your partner’s response. You’ll have 20 minutes to interview each other- so each interview should last 10 minutes. We’ll announce when it is time to switch. We’ll all come back together and share in the next part, so it might be helpful for you to take notes as you’re interviewing. Do you have any questions before we break out and start our interviews? Instructions for participants: 1. Find a partner (not a good friend) 2. Share your experiences with the BCCSOVC project following these questions: a. Tell me a story about how you have used the information received or skills learned through the project. b. Has the project helped your financial or economic situation? i. New job or business skills? c. Has the project helped your education achievement? i. Staying in school or completing graduation? Transition to university? d. Has the project helped maintain or improve your health? i. Relationship health or physical health (including related to HIV or STIs)? e. Discuss an achievement or a success you had based on your learning from the project – what made it possible? f. Did anything unexpected happen as a result of your involvement that differed from what you thought might happen? Mapping [45–75 minutes] Now that everyone has had a chance tointerview and be interviewed, we’re going to pull all this information together. This will give us a chance, as a group, to reflect on the various strengths and challenges associated with the program. You may want to look at your own experience and how it compares to others’ experiences with the program. If 152 Evaluation of Services for Orphans and Vulnerable Youth in Botswana you’re listening to someone else share and have a similar experience but maybe a different explanation or would like to add something, I encourage you to raise your hand and share. We’ll also be drawing out these experiences on the flip- chart so we can see how one event effects other things or ripples out. Instructions for facilitator: 1. Ask each pair to offer one story (only one at a time so everyone has an opportunity to share) and ripple it out (draw out some of the details of the outcomes discussed), welcoming input from all. Use a different marker color for each ripple. Probing questions can include: • Then what happened? • Who was involved? • What skill, approach, or tool from the project, if any, was involved? • What are you doing differently? • How have your relationships changed as a result? 2. Continue until at least one story from each pair has been captured andrippled. Tips for successful mapping: • Individual learning and action items may be the easiest to get the conversation going. • When mapping, get as many details as possible. • After you collect information for the “map,” allow opportunities for other participants to add further and give greater detail. This provides ideas about how to dig deeper. You may also get people who have different ideas- those should be noted on the map. Reflection [5–15 minutes] Before we leave, we want you to reflect on this mapping process. Think on all the stories and experiences we heard. Instructions for facilitator: 1. What in this map shows that the project is making a difference? 2. Can you identify the most significant/important/meaningful change(s) for youth participating in the program on the map. Why do you feel that way? 3. What have you learned from this discussion today? 4. What other services or activities do you wish would have been provided? Closing [10–15 minutes] Thank you again for joining us today and participating! The pictures we drew today will be digitized and analyzed. NOTE TO FACILITATOR: TAKE A PHOTO OF THE MAP Evaluation of Services for Orphans and Vulnerable Youth in Botswana 153 APPENDIX I. QUALITATIVE GUIDE FOR SOCIAL WORKER INTERVIEWS Interview Guide for Government Volunteer Social Workers Note: Social workers eligible to be interviewed will have volunteered with the GOB for at least six months prior to interview date Date of Interview: Start Time: End Time: Interviewer: Participant code: Community Based Organization: District: Language: Participant Sex: Male  Female  1. Please describe your role within the Government of Botswana (GOB) (probe: what is it that you do to support the OVC youth and households supported by the GOB? MAKE SURE THEY TALK ABOUT THIS PARTICULAR ROLE THEY SERVE, AND NOT OTHER COMMUNITY WORK THEY HAVE DONE ON OTHER PROJECTS). 2. How long have you volunteered with the Government of Botswana in this capacity? 3. Please describe your roles as a volunteer social worker in your community. 4. What types of activities have you been involved in as a GOB Social Worker? (Probe about respondent role for each item below. OVC services vary by district for items b-f; be sure to probe for details on the following for each service area: learning objectives/content covered, timing/frequency of service, observed change/specific examples. a. Distribution of food baskets/vouchers/coupons b. Bereavement counseling c. Life skills counseling d. Social skills counseling e. Parent/Caregiver skills workshops f. Other? 5. Through your experiences as a GOB social worker, what changes (positive ornegative) have you seen in the lives of youth you serve? (specify ages 16-18) a. Why do you think this? 154 Evaluation of Services for Orphans and Vulnerable Youth in Botswana b. Can you give me some specific examples of experiences you had that led you to believe this? 6. What was the most significant change related to youth’s lifeskills? a. What types of services helped lead to this change? 7. How, if at all, did GOB-provided services contribute to youth educational attainment? 8. What additional services could the GOB provide in the future to help youth even more in achieving their educational goals? 9. How, if at all, did GOB-provided services improve youth’s economic or financial situations [probe if respondent needs prompting: changes related to obtaining jobs, or managing/saving money, or household economic well-being] a. What types of services helped lead to this change? 10. What additional services could the GOB provide in the future to help youth even more in achieving their economic goals? 11. How, if at all, did GOB-provided services improve youth’s overall health? [probe: what type of improved health outcomes were affected, specifically? Nutrition/healthy living environment/sexual health/HIV testing and treatment] a. What types of services helped lead to this change? 12. What additional services could the GOB provide in the future to help youth even more to promote healthy lifestyles? 13. How, if at all, did GOB-provided services affect youth’s knowledge about HIV and ability to stay HIV-negative? a. What types of services contributed to this? 14. What additional services could the GOB provide in the future to help participants better understand HIV and stay HIV-negative? 15. If you served youth who are HIV-positive, what was the most significant change related to their ability to stay healthy and prevent the spread of HIV? Why was this change the most significant? a. What types of services helped lead to this change? 16. What additional services could the GOB provide in the future to help HIV￾positive participants stay healthy and prevent the spread of HIV? 17. Please describe the extent to which GOB-provided services have improved parenting skills for caregivers of vulnerable youth. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 155 a. How, if at all, did these services affect youth living in these households? 18. What challenges were there, if any, in working with caregivers in this context? 19. Could you tell me about the process of staying engaged with youth in your caseload? a. What challenges did you face in keeping contact with specific youth? b. What strategies did you find successful in keeping contact? Finally, thinking about the services provided as a whole: 20. What are areas in which you think GOB-provided services could be strengthened or improved for future participants? [probe: could you provide specific examples? Anything else?] 21. Taking it all together, what GOB services influenced youth’s lives the most? Pleaseexplain. 22. Is there anything else you’d like to tell me about youth served by the GOB? 156 Evaluation of Services for Orphans and Vulnerable Youth in Botswana APPENDIX J. QUALITATIVE GUIDE FOR SOCIAL AND COMMUNITY DEVELOPMENT OFFICE INTERVIEWS Interview Guide for Government of Botswana Social & Community Development Office Name of Interviewer: Date of Interview: Type and Name of Level: National, Regional District, Community Job Title: Length of Interview: Introductory Questions We’d like to ask you a few questions to get started. 1. What is your role with the Government of Botswana (GOB)? 2. How long have you worked for the GOB in this capacity? Questions on the Objectives 3. Please describe GOB’s services focused on vulnerable youth and their households. a. Distribution of food baskets/vouchers/coupons b. Bereavement counseling c. Life skills counseling d. Social skills counseling e. Parent/Caregiver skills workshops f. Other? 4. Please describe the intended impact of these services for youth. (Probe about each individual service or package of services provided to youth). 5. Please describe the extent to which you think the services have or have not improved the livelihoods of vulnerable youth and their households. a. Which specific services had the greatest impact on improving the livelihoods of vulnerable youth and their households? Why? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 157 b. Which of the services had the least impact on improving the livelihoods of vulnerable youth and their households? Why? 6. Please describe the extent to which you think the GOB-provided services has or has not improved youth’s economic or financial situations [probe if respondent needs prompting: changes related to obtaining jobs, or managing/saving money, or household economic well- being] 7. What additional services could the GOB provide in the future to help youth even more in achieving their economic goals? 8. Please describe the extent to which GOB household support has improved educational outcomes? a. What specific services had the greatest impact on improving educational outcomes? b. Which specific services have the least impact on improving educationaloutcomes? 9. Were there any health-related services provided by the GOB program to the youth that you’ve worked with? Please describe. a. How, if at all, did these services improve health outcomes for youth? 10. Were there any services that focused on promoting HIV prevention? Please describe. a. Please describe the extent to which the GOB-provided services have or have not improved youth’s ability to stay HIV-free. 11. Were there any GOB services that focused on support for HIV positive youth? Please describe. a. Please describe the extent to which the GOB-provided services have or have not improved HIV positive youth’s ability to stay healthy and prevent the spread of HIV? 12. Please describe the extent to which the GOB-provided services have improved parenting skills for caregivers of vulnerable youth. a. How, if at all, did these services affect youth living in these households? Questions on Lessons Learned 13. What were some of the barriers to service delivery? 158 Evaluation of Services for Orphans and Vulnerable Youth in Botswana a. How did they affect the ability of the GOB social workers to meet the needs of youth? 14. What were some examples of support provided to the GOB social workers to successfully deliver services? a. How did this affect social workers’ ability to meet the needs of youth? 15. Please describe any changes you think could be made in the future to improve how the S&CD Office works with vulnerable youth and their families [probe for specific examples]. Most Significant Change and Wrap up 16. From your perspective, what was the most significant change in the youth served by the GOB? [probe: who was most affected? how were they affected? How did this most significant change occur?] 17. Summarizing what you have told me, what are the greatest strengths of the GOB services provided to youth? Why? 18. Summarizing what you have told me, what are the greatest weaknesses of the GOB services for youth? Why? 19. Is there anything else about the GOB services you would like to tell me? Those are all of the questions I have for today. Is there anything else you’d like to tell me about you or your involvement with the GOB services before we complete the interview? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 159 APPENDIX K. QUALITATIVE GUIDE FOR YOUTH INTERVIEWS For ALL participants Demographic Profile 1) How old are you? Program Exposure Education: Exposure to any Education-Related Support or Services 2) [Program Exposure] Please describe any services or activities related to education you have received in the past two years. Prompt recall specifically with community service provider’s name. Examples Stepping Stones (PCI partner in area) • Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Literacy Clubs • “Homework assistance” or tutoring • Time management & Study Methods (Life Skills Plus) • Matching personal talents with job opportunities (Life Skills Plus) • Discussions about your attendance (SSI “monitors school attendance”) Examples GoB • Referrals to education services • School uniforms; • Clothes; • Toiletries; • Assistance with paying school fees; • Transportation money for school; • Vocational training scholarships 3) [Program Evaluation] For each of those mentioned… • What organization provided this service or activity? • When did it happen? 160 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Economic Stability: Exposure to any Economic stability-related Support or Services 4) [Program Exposure] Please describe any workshop or educational session related to working or managing and saving money you have participated in over the past two years. Prompt recall specifically with community service provider’s name. 5) Examples Stepping Stones (only PCI partner in area) • Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Working with people • Managing Money session (budgeting, savings) • Business and entrepreneurial skills training and mentoring; • Work skills (e.g. applying for jobs, CVs) Examples GoB • Referrals to economic stability related services (e.g. food baskets, poverty eradication programs) • Assistance with paying school fees; • Food baskets, food vouchers, food coupons; • Assistance with housing or accommodation; 6) [Program Evaluation] For each of those services received or session participatedin… i. What organization provided this service or activity? ii. When did it happen? Parent-child Communication: Exposure to any parent-child communication Support or Services 7) [Program Exposure] Please describe any education or skills training related to parent-child communication you have received over the past two years. Prompt recall specifically with community service provider’s name. • [Program Exposure] Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Workshop on caregiver-child communication 8) [Program Evaluation] For each of those mentioned… • What organization provided this service or activity? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 161 • When did it happen? Gender-Based Violence: Exposure to any GBV Support or Services 9) [Program Exposure] Have you participated in any form of education or skills training on gender- based violence over the last 2 years? Prompt recall specifically with community service provider’s name. Anything else? • Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Group discussions on abuse, signs of abuse, preventing abuse, and where to seek help 10) [Program Evaluation] • What organization provided this service or activity? • When did it happen? GoB program Exposure 11) [Exposure] Have you ever seen a GoB social worker? When? Why? 12) [Exposure] Have you received any GoB assistance such as food baskets, school uniforms, shoes, toiletries and household goods, or counseling? When was the last time you received each of these? How often do you receive them? (For example: once a month, once every three months, twice a year etc.) Education 13) What did you learn from your participation in the education activities you described? • Did you find it helpful? • [If Yes] how was it helpful? • [If No] why wasn’t it helpful? • [Gaps] What would have been helpful? Education: Status and motivation 14) [Status] Are you enrolled at a school, or a tertiary institution? • [If YES] What form or level are you in? • [If NO] When did you leave school? Why? 162 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 15) [Motivation] How important is getting an education? Please explain. Education: Attendance 16) [Status] Have you been enrolled in school consistently over the past two years? [If there were GAPS], when were there gaps? Why were there gaps? 17) [Status] How many days of school did you miss in the past month? 18) [Change Story] Do you feel your attendance has changed since you began receiving services from [organization]? In what way/ways? 19) [Change – Influences] • (If Change) • Do you feel your participation in the project activities influenced the change/changes you described? 20) [Challenges] Can you identify any challenges (self, others or environment) to regularly attending school? Education: Performance 21) [Status] How do you feel about your academic performance now? 22) [Change Story] Has your academic performance changed since you began receiving services from [organization]? In what way/ways? 23) [Change – Influences] • (If Changed) Do you feel your participation in the project activities influencedthe change/changes you described? 24) [Challenges] Can you identify any challenges (self, others or environment) to improving your academic performance? Education: Recommendations 25) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help youth achieve their academic goals in the future? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 163 Education: Most Significant Change 26) [Most Significant change] Looking back over the last two years, what do you feel is the most meaningful/important change in your attitudes or achievements related to education due to your participation in the project activities? Why do you feel thatway? Economic Stability 27) What did you learn from your participation in the economic stability activities you described? • Did you find it helpful? • [If Yes] how was it helpful? • [If No] why wasn’t it helpful? • [Gaps] What would have been helpful? Household Economic Situation 28) [Status] How would you describe the economic situation in your household? Are your basic needs met, e.g. food, shelter, clothing, transportation? What is not met? Financial Independence: Working 29) [Status] Please describe your sources of income over the past year (2018). E.g. jobs, piece work, others? What sources of income did you have the year before (2017)? 30) [Change Story] Has your ability to work or make an income changed since you began receiving services from [organization]? In what way(s)? 31) [Change – Influences] • (If Changed) Do you feel your participation in the project activities influenced the change/changes you described? 32) [Challenges] Can you identify any challenges (self, others or environment) to your ability to work or make an income? Financial Literacy: Managing and Saving Money 33) [Understanding] What does “managing money” mean to you? 34) [Status] Please can you describe how you spent the money you earned? ((use answer above to set timeframe, e.g. money “earned 100 in last month” or “earned 1000 last spring”)) 164 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 35) [Process] Please can you describe how those decisions were made? ((E.g. was there a plan, who decided, was considered when decision was made.)) 36) [Change Story – Ability] Has your ability to manage money (budgeting or saving) changed since you began receiving services from [organization]? In what way/ways? 37) [Change – Influences] • (If Changed) Do you feel your participation in the project activities influencedthe change/changes you discussed? • [Challenges] Can you identify any challenges (self, others or environment) to your ability to manage money? Economic Stability: Most Significant Change 38) [Most Significant change] Looking back over the last two years, what do you feel is the most meaningful/important change related to your economic situation due to your participation in the project activities? Why do you feel that way? In what way was it significant? Economic Stability: Recommendations 39) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help youth achieve their economic goals in the future? SKIP HIV Status 40) Do you know your HIV status? • If yes, would you be willing to share with me if you are HIV- orHIV+? o If HIV Negative, continue. o If HIV Positive, ASK: how did you discover you are HIV positive? Then go to HIV Positive Section. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 165 HIV Testing For HIV Negative (or don’t know status) 41) [Status – Ever Tested] Have you been tested for HIV in the past two years? o (If yes) What were your reasons for testing? Where did you test? o Did you receive the results? • (If no) What were your reasons for not testing? 42) [Status - Attitude] How do you feel about HIV testing now? 43) [Change story] Has your attitude towards HIV testing changed since you began receiving services from [organization]? In what way/ways? 44) [Change – Influences] • (If Changed) What influenced the change? 45) [Challenges] Can you identify any challenges (self, others or environment) to testing regularly? Recommendations 46) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help motivate youth to test regularly? For HIV Positive Exposure to any Sexual and reproductive health related Support or Services 47) [Program Exposure] Please describe any services or activities related to the following topics that you have received over the past 2 years. Prompt recall specifically with community service provider’s name. • Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Referrals to health services • Health education, e.g. healthy living • Disclosure to your partners, • Decisions about having sex, or • Your ability to negotiate condom use to prevent transmission of HIV 48) [Program Evaluation] For each of those mentioned… • What organization provided this service or activity? 166 Evaluation of Services for Orphans and Vulnerable Youth in Botswana • When did it happen? • What did you learn? • Did you find it helpful? o [If Yes] how was it helpful? o [If No] why wasn’t it helpful? o [Gaps] What would have been helpful? Exposure to any HIV-related Support or Services 49) [Program Exposure] Please describe any support related to the following topics you have received over the past 2 years. Prompt recall specifically with community service provider’s name. 50) Examples Stepping Stones [PCI partner in the area] • Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Referrals to health services • Health education, e.g. healthy living • Coping with HIV • Taking your medications as prescribed • Consistently attending doctor’s appointments 51) [Program Evaluation] For each of those mentioned… • What organization provided this service or activity? • When did it happen? • What did you learn? • Did you find it helpful? o [If Yes] how was it helpful? o [If No] why wasn’t it helpful? [Gaps] What would have been helpful? Living with HIV Coping (including stigma and depression if mentioned) 52) [Status] How do you feel you are coping with living HIV now? What do you find difficult? 53) [Status] Have you experienced Stigma? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 167 54) [Status] How has living with HIV impacted your life? 55) [Change story] Has your ability to cope with HIV changed since you began receiving services from [organization]? Please explain. 56) [Change – Influences] • (If Changed) What influenced the change? 57) [Challenges] Can you identify any challenges (self, others or environment) to coping more effectively with HIV? Adherence to Regimes – Medications 58) [Status] Are you currently on medications for HIV? 59) [Change Story] Has your ability to take your medications as prescribed changed since you began receiving services from [organization]? In what way (s)? 60) [Change – Influences] • (If Changed) What influenced the change? 61) [Challenges] Can you identify any challenges (self, others or environment) to following the prescribed regime? Attending Doctor’s Appointments 62) [Status] Have you missed any doctor’s appointments in the past year? 63) [Change story] Has your ability to attend your doctor’s appointments regularly changed since you began receiving services from [organization]? In what way (s)? 64) [Change – Influences] • (If Changed) What influenced the change? 65) [Challenges] Can you identify any challenges (self, others or environment) to regularly attending appointments? Living with HIV: Most Significant Change 66) [Most Significant change] Looking back over the last two years, what do you feel is the most meaningful/important change in your life in relation to living with HIV due to your participation in the project activities? Why do you feel that way? In what way was it important? 168 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Recommendations 67) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION NAME] could help young people living with HIV • Cope with living with HIV? • Deal with Stigma? • Take medications as prescribed? • Attend doctor appointments? SKIP 68) Have you ever had sex? • If NO, answer Not Sexually Active section. 69) Have you had sex in the past 2 years? a. If YES to, answer Sexually Active section. b. If NO, answer Not Sexually Active section. NOT Sexually Active (positive or negative) Decision-Making around Sex 70) [Status – relationships] Have you had a boyfriend / girlfriend at any point over the last two years? 71) [Status] Have you ever communicated to any of your boyfriends / girlfriends about sex or abstaining from sex? 72) [Change Story] Has your ability to communicate to your partner about sex and/or abstaining from sex changed since you began receiving services from [organization]? In whatway/s? 73) [Change – Influences] • (If Changed) What influenced the change? 74) [Challenges] Can you identify any challenges (self, others or environment) to communicate with your partner about sexual risk? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 169 Sexually Active Over Past 2 Years (positive or negative) Sexual and Reproductive Health 75) [Challenges] Have you had any challenges with accessing pregnancy prevention methods? Please explain. Have you had any difficulties using pregnancy prevention methods? 76) [Change] Has your participation in the project activities influenced your ability to access pregnancy prevention methods? HIV+ Disclosure HIV Positive 77) [Status] How comfortable do you feel disclosing your status to a partner? Can you share an experience? 78) [Change Story] Has your ability to speak to your sexual partners about your status changed since you began receiving services from [organization]? In what way (s)? 79) [Change – Influences] • (If Changed) What influenced the change? 80) [Challenges] Can you identify any challenges (self, others or environment) to improving your ability to speak to your sexual partners about your status? Recommendations 81) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could make it easier to disclose your status to a partner? HIV+ Negotiating Sex 82) [Status] How would you describe your ability to negotiate when or if you have sex with a partner? 83) [Change Story] Has your ability to negotiate when and if you have sex changed since you began receiving services from [organization]? In what way/ways? 84) [Change – Influences] • (If Changed) What influenced the change? 85) [Challenges] Can you identify any challenges (self, others or environment) to improving your ability to negotiate? 170 Evaluation of Services for Orphans and Vulnerable Youth in Botswana HIV+ Prevention 86) [Status] How easy is it to negotiate condom use with your partner? 87) [Change Story] Has your ability to negotiate condom use changed since you began receiving services from [organization]? In what way/ways? 88) [Change – Influences] • (If Changed) What influenced the change? What has had the greatest influence on the change? 89) [Challenges] Can you identify any challenges (self, others or environment) to improving your ability to prevent transmitting the virus? HIV+ Most Significant Change: Communication with Sexual Partners 90) [Most Significant change] Looking back over the last two years, what do you feel is the most meaningful/important change related to your communication with sexual partners due to your participation in project activities, for example, disclosure, decisions about having sex or ability to negotiate condom use to prevent the transmission of HIV? Recommendations 91) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could improve youth’s ability to • disclosure to their partners, • make better decisions about having sex, and • negotiate condom use to prevent transmission of HIV? HIV Negative Exposure to any Sexual and reproductive health related OVC Support or Services 92) [Program Exposure] Please describe any services or activities you have received related to the following topics over the past 2 years. Prompt recall specifically with community service provider’s name. • [Program Exposure] Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Referrals to health services • Health education, e.g. healthy living • Relationships, • Decisions about having sex, or Evaluation of Services for Orphans and Vulnerable Youth in Botswana 171 • Ability to protect yourself from HIV • Information on HIV testing 93) [Program Evaluation] For each of those mentioned… • What organization provided this service or activity? • When did it happen? • What did you learn? • Did you find it helpful? o [If Yes] how was it helpful? o [If No] why wasn’t it helpful? o [Gaps] What would have been helpful? Negotiating Sex 94) [Status] How would you describe your ability to negotiate when and if you have sex with a partner? 95) [Change Story] Has your ability to negotiate when and if you have sex changed since you began receiving services from [organization]? In what way/ways? 96) [Change – Influences] • (If Changed) What influenced the change? 97) [Challenges] Can you identify any challenges (self, others or environment) to improving your ability to negotiate sex? Negotiating HIV prevention 98) [Status] How easy is it to negotiate condom use with your partner? 99) [Change Story] Has your ability to negotiate condom use changed since you began receiving services from [organization]? In what way/ways? 100) [Change – Influences] 101) • (If Changed) What influenced the change? [Challenges] Can you identify any challenges (self, others or environment) to improving your ability to negotiate HIV prevention? Sexual behavior: Most Significant Change 102) [Most Significant change] Looking back over the last two years, what do you feel is the most meaningful/important change related to communication with your partner due to your participation in project activities, for example, related to decisions about sex, and 172 Evaluation of Services for Orphans and Vulnerable Youth in Botswana your ability to negotiate condom use to prevent the transmission of HIV? Recommendations 103) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help youth… • improve their relationships, • make decisions about having sex, or • improve their ability to protect yourself or others from HIV? For ALL participants 104) What did you learn from the parent-child communication activities you participatedin? • Did you find it helpful? • [If Yes] how was it helpful? • [If No] why wasn’t it helpful? Caregiver Youth Communication Caregiver-Youth communication: General 105) [Status] How would you describe the way you and your caregiver communicate? 106) [Status] What do you talk about? Please give specific examples. Who initiated these discussions? How did it go? 107) [Change Story] Do you feel communication with your caregiver has changed since you began receiving services from [organization]? In what way/ways? Can you give an example or two? 108) [Change – Influences] • (If Changed) What influenced the change? What has had the greatest influence on the change? 109) [Challenges] Can you identify any challenges (self, others or environment) to communicate with your caregiver? Caregiver-youth communication: Intervention Areas 110) [Status] In the past two years, have you talked to your caregiver about any ofthe following topics? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 173 • Your education, e.g. about how you feel about your education, your experiences at school, any issues you are having. • Your work plans. About how you feel about your work now or in the future, e.g. your plans, experiences, satisfaction, any challenges (self, others or environment), needsto succeed. • Your health or relationships, for example, a. relationships with partners or b. topics related to HIV prevention or c. how to prevent pregnancy. 111) Probe (for each area discussed): • How comfortable do you feel talking to him/her about these topics? • (For each discussed) Can you tell me about what you discussed? Did you find the conversation helpful? 112) [Challenges] Can you identify any challenges (self, others or environment) to discussing [this topic] with your caregiver? Caregiver-Child Communication: Most Significant Change 113) [Most Significant change] Looking back over the last two years, what do you feel is the most meaningful/important change related to communication with your caregiver due to your participation in project activities? Recommendations 114) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help youth and parents communicate better? Gender-based Violence 115) What did you learn from your participation in the gender-based violenceactivities? • Did you find it helpful? • [If Yes] how was it helpful? • [If No] why wasn’t it helpful? • [Gaps] What would have been helpful? 116) [Knowledge] What do you think Gender Based Violence is? 117) [Change Story] Has your understanding of GBV changed since you began receiving services from [organization]? In what way/ways? 174 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 118) [Change – Influences] 119) • (If Changed) What influenced the change? What has had the greatest influence on the change? [Challenges] Can you identify any challenges (self, others or environment) to an improved understanding of GBV? Recommendations 120) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help youth better understand gender-based violence? 121) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help youth better find help for gender-basedviolence? Recommendations GoB 122) [GoB assistance] Do you feel the assistance you received from the GoB helped you improve your education, economic situation or health? If yes, please provideexamples. 123) [Recommendations] Do you have any recommendations for how the GoB could improve the services they provide to youth? PCI partners 124) Do you have any recommendations for how [INSERT ORGANIZATION NAME] could improve the services they provide to youth? Thank you! Those are all the questions that I have for you. Do you have any questions for me? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 175 APPENDIX L. QUALITATIVE GUIDE FOR CAREGIVER INTERVIEWS For ALL participants Demographic Profile 1) How old are you? 2) How old is [child’s name]? Is he/she a boy or a girl? Education Education: Exposure to any Education-Related OVC Support or Services 3) [Program Exposure] Please describe any services or activities related to education you or your child have received in the past two years. Prompt recall specifically with community service provider’s name. Examples Stepping Stones (only PCI partner in area) • Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Literacy Clubs • “Homework assistance” or tutoring • Time management & Study Methods (Life Skills Plus) • Matching personal talents with job opportunities (Life Skills Plus) • Discussions about your attendance (SSI “monitors school attendance”) Examples GoB • Referrals to education-related services; • School uniforms; • Clothes; • Toiletries; • Assistance with paying school fees; • Transportation money for school; • Vocational training scholarships 4) [Program Evaluation] For each of those mentioned… • What organization provided this service or activity? When did it happen? 176 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Economic Stability: Exposure to any Economic stability-related OVC Support or Services 5) [Program Exposure] Please describe any services received that has improved his or the household’s economic situation? Please describe any workshops or educational session related to working or managing and saving money he has participated in over the past two years. Prompt recall specifically with community service provider’s name. Examples Stepping Stones (only PCI partner in area) • Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Working with people • Managing Money session (budgeting, savings) • Business and entrepreneurial skills training and mentoring; • Work skills (e.g. applying for jobs, CVs) Examples GoB • Referrals to services (e.g. social workers for counselling, food baskets, poverty eradication programs) • Assistance with paying school fees; • Food baskets, food vouchers, food coupons; • Assistance with housing or accommodation; 6) [Program Evaluation] For each of those services received or session participated in… • What organization provided this service or activity? • When did it happen? Exposure parent-child communication 7) [Program Exposure] Please describe any education or skills training related to parent-child communication you have received over the past two years. Prompt recall specifically with community service provider’s name. • [Program Exposure] Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Workshop on caregiver-child communication 8) [Program Evaluation] For each of those mentioned… • What organization provided this service or activity? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 177 • When did it happen? Exposure Gender-based Violence education 9) [Program Exposure] Have you participated in any form of education or skills training on gender-based violence over the last 2 years? Prompt recall specifically with community service provider’s name. • Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Group discussions on abuse, signs of abuse, preventing abuse, and where to seek help 10) [Program Evaluation] a. What organization provided this service or activity? b. When did it happen? GoB program Exposure 11) [Exposure] Have you or [child’s name] ever seen a GoB social worker? When?Why? 12) [Exposure] Have you or [child’s name] ever received any GoB assistance such as food baskets, school uniforms, shoes, toiletries and household goods, or counseling? When was the last time you or he/she received each of these? How often do you or he/she receive them? (For example: once a month, once every three months, twice a year etc.) Education 13) What did he/she learn from the education activities mentioned previously? • Do you think it was helpful? o [If Yes] how was it helpful? o [If No] why wasn’t it helpful? o [Gaps] What would have been helpful? Education: Status and motivation 14) [Status] Is [child’s name] enrolled at a school, or a tertiary institution? • [If YES] What form or level is he/she in? • [If NO] When did he/she leave school? Why? 15) [Motivation] How important is it for [child’s name] to get an education? Please explain. 178 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Education: Attendance 16) [Status] Have [child’s name] been enrolled in school consistently over the past two years? [If there were GAPS], when were there gaps? Why were there gaps? 17) [Status] How many days of school did he/she miss in the past month? 18) [Change Story] Has his/her attendance changed since he/she began receiving services from [organization]? In what way/ways? 19) [Change – Influences] • (If Change) What influenced the change? 20) [Challenges] Can you identify any challenges (self, others or environment) to his/her regularly attending school? Education: Performance 21) [Status] How do you feel about his/her academic performance? How did you find out? 22) [Change Story] Has his/her academic performance changed since he/she began receiving services from [organization]? In what way/ways? 23) [Change – Influences] • (If Changed) What influenced the change? 24) [Challenges] Can you identify any challenges (self, others or environment) to improving his/her academic performance? Education: Recommendations 25) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help youth achieve their academic goals in the future? Education: Most Significant Change 26) [Most Significant change] Looking back over the last two years, what do you feel is the most meaningful/important change related to his/her attitudes towards education or achievements? Why do you feel that way? Economic Stability 27) What did he/she learn from the economic stability activities mentioned previously? • Do you think it was helpful? o [If Yes] how was it helpful? o [If No] why wasn’t it helpful? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 179 o [Gaps] What would have been helpful? Household Economic Situation 28) [Status] How would you describe the economic situation in your household? Are your basic needs met, e.g. food, shelter, clothing, transportation? What is not met? Financial Independence: Working 29) [Status] Please describe his/her current sources of income. 30) [Change Story] Has his/her ability to work or make an income changed since he/she began receiving services from [organization] In what way(s)? 31) [Change – Influences] • (If Changed) What influenced the change? 32) [Challenges] Can you identify any challenges (self, others or environment) to his/her ability to work or make an income? 33) [Outlook] How would you like him/her to earn money in the future? What will it take for him/her to get there? Financial Literacy: Managing and Saving Money 34) [Understanding] What does “managing money” mean to you? 35) [Status] Do you know how he/she spends his/her money? Please can you describe what you know? ((if possible, use answer above to set timeframe, e.g. money “earned 100 in last month” or “earned 1000 last spring”)) 36) [Process] Do you know how those decisions were made? How? ((E.g. was there a plan, who decided, was considered when decision was made.)) 37) [Change Story – Ability] Has his/her ability to manage money (budgeting or saving) changed since he/she began receiving services from [organization]? 38) [Change – Influences] • (If Changed) What influenced the change? 39) [Challenges] Can you identify any challenges (self, others or environment) to his/her ability to manage money? 40) [Outlook] How would you like him/her to manage money in the future? What will it for him/her take to get there? Economic Stability: Most Significant Change 41) [Most Significant change] Looking back over the last two years, what do you feel is the 180 Evaluation of Services for Orphans and Vulnerable Youth in Botswana most meaningful/important change related to the household or the youth’s economic situation? Why do you feel that way? In what way was it significant? Economic Stability: Recommendations 42) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help youth achieve their economic goals in the future? SKIP HIV Status 43) Do you know [child’s name] HIV status? • If yes, would you be willing to share with me if [child’s name] is HIV- orHIV+? o If HIV Negative, continue. o If HIV Positive, ASK: how did he/she discover that he/she is HIV positive? Then go to HIV Positive section. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 181 For HIV Negative (or don’t know status) Exposure to any HIV-related OVC Support or Services 44) [Program Exposure] Please describe any experience with services or activities related to HIV testing received over the past 2 years. Prompt recall specifically with community service provider’s name. Examples • Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Advice on HIV prevention, testing, and treatment; • Education or counselling on sexual-decision making; • Assistance with payment of medical fees; • Home-based medical care and advice; • Referrals to clinics; • Information on sexually transmitted infections (STIs) other than HIV; • Counselling; • Youth clubs. 45) [Program Evaluation] For each of those services he/she received or session participatedin… • What organization provided this service or activity? • When did it happen? • What did he/she learn? • Do you think it was helpful? o [If Yes] how was it helpful? o [If No] why wasn’t it helpful? o [Gaps] What would have been helpful? HIV Testing 46) [Status – Ever Tested] Has he/she been tested for HIV in the past two years? • (If yes) What were the reasons for him/her to test? o Where did he/she test? o Do you know if he/she received the results? o Did he/she tell you the results? 182 Evaluation of Services for Orphans and Vulnerable Youth in Botswana • (If no) What were the reasons for him/her to not test/not to receive the results/or not to tell you the results? 47) [Status – Caregiver Attitude] How do you feel about him/her testing for HIV? 48) [Status – Youth Attitude] How does he/she feel about testing for HIV? 49) [Change story] Has his/her attitude towards HIV testing changed since he/she began receiving services from [organization]? In what way/ways? 50) [Change – Influences] • (If Changed) What influenced the change? 51) [Challenges] Can you identify any challenges (self, others or environment) to testing regularly? Recommendations 52) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help motivate youth to test regularly? For HIV Positive Exposure to any HIV-related OVC Support or Services 53) [Program Exposure] Please describe any support related to the following topics you have received over the past 2 years. Prompt recall specifically with community service provider’s name. 54) Examples Stepping Stones [Only PCI partner in the area] • Prompt with partners names first. Mention all those active in the area & show logos: e.g. Stepping Stones, Baylor, Hope World Wide, Humana People to People, Mothers Union, Bakgatla Bolokang Matshelo • Referrals to health services • Health education, e.g. healthy living • Coping with HIV • Taking your medications as prescribed • Consistently attending doctor’s appointments 55) [Program Evaluation] For each of those mentioned… • What organization provided this service or activity? • When did it happen? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 183 • What did your child learn? • Did you think it was helpful for them? o [If Yes] how was it helpful? o [If No] why wasn’t it helpful? o [Gaps] What would have been helpful? Living with HIV Coping (including stigma and depression if mentioned) 56) [Status] How do you feel he/she is coping with living HIV now? What does he/she find difficult? 57) [Status] Has he/she experienced stigma? 58) [Status] How has living with HIV impacted his/her life? 59) [Change story] Has his/her ability to cope with HIV changed since he/she began receiving services from [organization]? In what way/ways? 60) [Change – Influences] • (If Changed) What influenced the change? 61) [Challenges] Can you identify any challenges (self, others or environment) to coping more effectively with HIV? Adherence to Regimes – Medications 62) [Status] Is he/she currently on medications for HIV? 63) [Status] When did he/she start treatment? 64) [Change Story] Has his/her ability to take his/her medications as prescribed changed since he/she began receiving services from [organization]? In what way (s)? 65) [Change – Influences] • (If Changed) What influenced the change? 66) Challenges] Can you identify any challenges (self, others or environment) to following the prescribed regime? 184 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Attending Doctor’s Appointments 67) [Status] Has he/she missed any doctor’s appointments in the past year? 68) [Change story] Has his/her ability to attend his/her doctor’s appointments regularly changed since he/she began receiving services from [organization]? In what way (s)? 69) [Change – Influences] • (If Changed) What influenced the change? 70) [Challenges] Can you identify any challenges (self, others or environment) to regularly attending appointments? Living with HIV: Most Significant Change 71) [Most Significant change] Looking back over the last two years, what do you feel is the most meaningful/important change in his/her life in relation to living with HIV? Why do you feel that way? In what way was it important? Recommendations 72) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION NAME] could help young people living with HIV? • Cope with living with HIV? • Deal with Stigma? • Take medications as prescribed? • Attend doctor appointments? For ALL participants Caregiver Youth Communication 73) What did you learn from the caregiver youth communications you participated in? • Did you find it helpful? o [If Yes] how was it helpful? o [If No] why wasn’t it helpful? Evaluation of Services for Orphans and Vulnerable Youth in Botswana 185 Caregiver-Youth communication: General 74) [Status] How would you describe the way you and [child’s name] communicate? 75) [Status] What do you talk about? Please give specific examples. Who initiated these discussions? How did it go? 76) [Change Story] Do you feel communication with [child’s name] has changed since you and your child started receiving services from [organization]? In what way/ways? Can you give an example or two? 77) [Change – Influences] • (If Changed) What influenced the change? 78) [Challenges] Can you identify any challenges (self, others or environment) to communicate with [child’s name]? Caregiver-youth communication: Intervention Areas 79) [Status] In the past two years, have you ever talked to [child’s name] about any of the following topics? • His/her education…. o About how he/she feels or you feel about his/her education? o About his/her experiences at school? o About any issues he/she is having? • His/her work plans… o About how he/she feels or you feel about his/her work now or in the future… a. his/her ambition, goals, plans b. any challenges (self, others or environment) • His/her health or relationships, for example, a. relationships with partners or b. topics related to HIV prevention or c. how to prevent pregnancy. 80) Probe (for each area discussed): • How comfortable do you feel talking to him/her about these topics? • (For each discussed) Can you tell me about what you discussed? Did you find the conversation helpful? 186 Evaluation of Services for Orphans and Vulnerable Youth in Botswana • (If not discussed) Can you identify any challenges (self, others or environment) to discussing [this topic] with [child’s name]? Caregiver-Child Communication: Most Significant Change 81) [Most Significant change] Looking back over the last two years, what do you feel is the most meaningful/important change related to communication with [child’s name]? Recommendations 82) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help youth and parents communicate better? Gender-based Violence 83) What did he/she learn from the gender-based violence activities you mentioned previously? • Do you think it was helpful? o [If Yes] how was it helpful? o [If No] why wasn’t it helpful? o [Gaps] What would have been helpful? 84) [Knowledge] Does [child’s name] understand what Gender Based Violence is? How do they understand it? 85) [Change Story] Has your [child’s name] understanding of GBV changed since they began receiving services from [organization]? In what way/ways? 86) [Change – Influences] • (If Changed) What influenced the change? 87) [Challenges] Can you identify any challenges that make it difficult for your child to have an improved understanding of GBV? Recommendations 88) [Recommendations] Do you have any recommendations for how [INSERT ORGANIZATION/S NAME] could help youth better understand gender-based violence? 89) [Recommendations] Do you have any recommendations for how [INSERT Evaluation of Services for Orphans and Vulnerable Youth in Botswana 187 ORGANIZATION/S NAME] could help youth better find help for gender-based violence? Recommendations Other Organizations 90) Do you have any recommendations for how [INSERT ORGANIZATION NAME] could improve the services they provide to youth? GoB program 91) Do you feel that this assistance from the GoB helped him/her … • with his/her education? How? Please provide examples. • with his/her economic situation? How? Please provide examples. • with his/her health? How? Please provide examples. 92) [Recommendations] Do you have any recommendations for how the GoB could improve the services they provide to youth? Thank you! Those are all the questions that I have for you. Do you have any questions for me? 188 Evaluation of Services for Orphans and Vulnerable Youth in Botswana APPENDIX M. RIPPLE EFFECT MAPPING XMIND MAPS Evaluation of Services for Orphans and Vulnerable Youth in Botswana 189 190 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Evaluation of Services for Orphans and Vulnerable Youth in Botswana 191 192 Evaluation of Services for Orphans and Vulnerable Youth in Botswana APPENDIX N. RIPPLE EFFECT MAPPING ILLUSTRATIONS OF THE TWO GROUPS Evaluation of Services for Orphans and Vulnerable Youth in Botswana 193 194 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Evaluation of Services for Orphans and Vulnerable Youth in Botswana 195 196 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Evaluation of Services for Orphans and Vulnerable Youth in Botswana 197 198 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Evaluation of Services for Orphans and Vulnerable Youth in Botswana 199 200 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Evaluation of Services for Orphans and Vulnerable Youth in Botswana 201 202 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Evaluation of Services for Orphans and Vulnerable Youth in Botswana 203 204 Evaluation of Services for Orphans and Vulnerable Youth in Botswana APPENDIX O. STUDY PROTOCOL AND EVALUATION TEAM MEMBERS Evaluation of Services for Orphaned and Vulnerable Youth in Botswana Study Protocol July 12, 2018 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 205 Contents 1 Background ................................................................................................................................................. 4 1.1 Evaluation Purpose ............................................................................................................................. 4 1.2 Country Setting................................................................................................................................... 4 1.3 Government of Botswana Response ................................................................................................... 4 1.3.1 Government of Botswana OVC Program................................................................................... 5 1.4 PEPFAR/USAID Response ................................................................................................................ 5 1.4.1 Tsela Kgopo OVC & Gender Project......................................................................................... 6 1.4.2 Botswana Comprehensive Care and Support for Orphans and Vulnerable Children................. 6 2 Study Aims and Objectives ......................................................................................................................... 8 2.1 Aims.................................................................................................................................................... 8 2.2 Research Objectives............................................................................................................................ 8 2.3 Main Exposures, Outcomes, and Theory of Change........................................................................... 9 3 Quantitative Study Methods...................................................................................................................... 10 3.1 Quantitative Study Design ................................................................................................................ 10 3.2 Quantitative Study Sites.................................................................................................................... 11 3.3 Quantitative Study Population .......................................................................................................... 11 3.4 Quantitative Study Main Exposure, Outcomes, and Theory of Change ........................................... 11 3.5 Quantitative Sampling Plan and Sample Size Estimates .................................................................. 12 4 Quantitative Study Procedures .................................................................................................................. 15 4.1 Quantitative Data Collection Procedures.......................................................................................... 15 4.2 Quantitative Study Instruments......................................................................................................... 15 4.3 Quantitative Study Data Management and Security ......................................................................... 16 4.4 Quantitative Study Data Analysis..................................................................................................... 16 5 Qualitative Study Methods........................................................................................................................ 16 5.1 Qualitative Study Design .................................................................................................................. 17 5.2 Qualitative Study Sites...................................................................................................................... 17 5.3 Qualitative Study Population ............................................................................................................ 17 5.4 Qualitative Sampling Plan and Sample Sizes ................................................................................... 18 6 Qualitative Study Procedures .................................................................................................................... 18 6.1 Qualitative Data Collection Procedures............................................................................................ 18 6.2 Qualitative Instruments..................................................................................................................... 18 6.3 Qualitative Data Management and Security ..................................................................................... 19 6.4 Qualitative Data Analysis................................................................................................................. 19 6.5 Dissemination ................................................................................................................................... 20 7 Ethical Considerations............................................................................................................................... 20 7.1 Confidentiality .................................................................................................................................. 20 7.2 Risks and Benefits ............................................................................................................................ 21 7.3 Informed Consent ............................................................................................................................. 21 7.4 Safety Procedures for Research on Intimate Partner Violence ......................................................... 22 7.5 Disclosure of Abuse Reported by Minors......................................................................................... 22 7.6 Response Plan and Referral Process for Adverse Effects................................................................. 23 7.7 Acute Cases ...................................................................................................................................... 24 7.8 Ethical Approval............................................................................................................................... 24 8 Logistics .................................................................................................................................................... 25 8.1 Investigators...................................................................................................................................... 25 8.2 Management and Collaboration........................................................................................................ 27 206 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 1 Background 1.1 Evaluation Purpose USAID/Botswana has requested MEASURE Evaluation, in coordination with the Government of Botswana (GOB) and other local partners, to design and implement an outcome evaluationwith the aim of understanding how orphans and vulnerable children (OVC) programming provided by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and GOB prepares youth to transition to healthy, productive young adults. Specifically, USAID/Botswana seeks to understand how PEPFAR and GOB OVC services have affected the education, economic, and health trajectories and outcomes of older youth graduating from OVC programs. MEASURE Evaluation will examine the effect of current GOB OVC services and the current PEPFAR/USAID OVC award, the Botswana Comprehensive Care and Support for Orphans and Vulnerable Children (BCCSOVC) project. BCCSOVC was awarded on August 31, 2016 and will end on August 30, 2021. 1.2 Country Setting Botswana is a land-locked country in Southern Africa with just over two million people. About ten percent of the population lives in the capital and largest city, Gaborone. Botswana has the third highest HIV prevalence of the world, at 18%. The highest HIV prevalence in the general population is among females ages 35-39 years old, at 50.5%, and girls ages 15-19 are twice as likely to be infected with HIV as boys of the same age. The HIV epidemic has left a large number of children orphaned and vulnerable. In 2007, the National Situation Analysis on OVC in Botswana estimated the number of orphans at 137,805, constituting 17.2 percent of the number of children below 18 years1 . Botswana’s 2008 National Guidelines on the Care of Orphans and Vulnerable Children define a vulnerable child as any child under the age of 18 years who lives in an abusive environment, a poverty￾stricken family unable to access basic services, or a child-headed household; a child who lives with sick parents or outside family care; or who is HIV positive2 . Due to this broad definition, there are currently no available estimates of the number of children vulnerable because of HIV, poverty, or other causes inBotswana. Among youth15-17 years old, 23.8% are orphans, compared to 11.9% of children less than 15 years old3 . Orphanhood puts many children at risk for poor health, including increased risk of acquiring HIV and AIDS, low education levels, and poor economic outcomes. 1 Government of Botswana. 2008. National Situation Analysis on Orphans and Vulnerable Children in Botswana. Gaborone, Botswana: Ministry of Local Government, Department of Social Services 2 Government of Botswana, 2008. National Guidelines on the Care of Orphans and Vulnerable Children. Gaborone, Botswana: Ministry of Local Government, Department of Social Services 3 Government of Botswana. 2013. Botswana AIDS Impact Survey IV (BAIS) Summary Results. Gaborone, Botswana: Statistics Botswana. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 207 1.3 Government of Botswana Response 1.3.1 Government of Botswana OVC Program In the mid- to late-1990s, as the number of orphans increased in Botswana, health practitioners (nurses and family welfare educators) and social workers, supported by the Ministry of Health and Ministry of Local Government, began providing home-based care to orphans. This care consisted of in-kind support, including provision of food, clothing, and toiletries; increasing orphans’ access to education; and protecting orphans from abuse. Vulnerable children were not a focus of these services at that time4 . In 2008, the Ministry of Local Government/Department of Social Services approved the National OVC Guidelines5 and the National Monitoring and Evaluation Framework for OVC6 . The National OVC Guideline address issues relating to vulnerable children as well as orphans, and emphasize five programming principles: 1) strengthening family capacity to care for OVC by prolonging the lives of parents and providing economic, psychosocial, and other support; 2) mobilizing and supporting community-based responses; 3) ensuring OVC access to “essential services, including education, health care, birth registration, and others:; 3) ensuring governments protect the most vulnerable children through improved policies and by channeling resources to families and communities; and 5) creating a supportive environment for children and families affected by HIV through awareness raising, advocacy, and social mobilization at all levels. In June 2009, the Government of Botswana approved the Children’s Act of 20097 , which is the current legal framework guiding Botswana’s OVC program. Under the Act, social workers are assigned a variety of responsibilities, including supporting parents and caregivers in the community, investigating cases of abuse or neglect, and arranging alternative care for children where needed. The core of GOB OVC services is the food baskets, vouchers or coupons. Food baskets, vouchers or coupons, along with school uniforms, other clothes and shoes, and toiletries are provided to every OVC beneficiary served by the government of Botswana (GOB). Additionally, household and psychosocial support is provided to some OVCs, but this varies by district and sub-district. Psychosocial support includes a variety of individual and group counseling sessions such as bereavement counseling, life skills counseling and social skills counseling. Some districts also provide workshops for caregivers to improve parenting skills. 1.4 PEPFAR/USAID Response 4 Feranil, I., B. Herstad, W. Jallow, and R. Mbuya-Brown. 2010. Assessing Implementing of Botswana’s Program for Orphans and Vulnerable Children. Washington, DC: Futures Group, Health Policy Initiative, Task Order I. 5 Government of Botswana. 2008. National Guidelines on the Care of Orphans and Vulnerable Children. Gaborone, Botswana: Ministry of Local Government. Department of Social Services. 6 Government of Botswana. 2008. National Monitoring and Evaluation Framework for Orphans and Vulnerable Children. Gaborone, Botswana: Ministry of Local Government, Department of Social Services 7 Government of Botswana. 2009. Children’s Act. Gaborone, Botswana: Parliament of Botswana 208 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 1.4.1 Tsela Kgopo OVC & Gender Project From 2011-2015, Project Concern International implemented the Tsela Kgopo OVC & Gender (TK) Project, funded by PEPFAR through the United States Agency for International Development. The project supported efforts to improve the quality of life of OVCs and their parents/caregivers, and improved gender-based responses and programming in HIV/AIDS interventions in Botswana. The objectives of the project were to 1) improve livelihoods of vulnerable girls and women; 2) improve child developmental interventions for vulnerable children and adolescents; 3) reduce the risk of neglect, exploitation and abuse of vulnerable children and women; and 4) improve the development, implementation and coordination of national frameworks and policies that address the needs of women and children. Interventions targeting youth10-17 included life skills interventions. Through kids’ clubs, teen clubs for HIV positive adolescents, school clubs and other existing groups the project reached a total of 8,957 youth over the life of the project. The project worked with school management to provide life skills education within these existing clubs and groups and the sessions were conducted by partner staff and trained teachers. Life skill education included topics on sexual and reproductive health, HIV prevention, self-efficacy and decision-making, drugs and alcohol prevention, and gender norms as well as gender-based violence. Youth also received group- based psychosocial support; and one-on-one psychosocial support and counseling from community-based workers. Other interventions focused on youth included financial literacy and economic strengthening activities such as Aflateen and Youth Employment Program. Aflateen empowered youth ages 14-24 years old to become productive member of the community by teaching them financial literacy and business and social development skills. As part of this program, youth held weekly meetings to discuss savings and budgeting and personal development as well as HIV/AIDS prevention issues. Youth Employment Program provided youth with job readiness and life skills and placed them into positions of employment or vocational training. The program also helped youth get practical experience through partnership with the private sector. TK also provided tutoring and literacy classes, particularly for adolescent girls underperforming at school. As part of improving educational goals, Girls’ Literacy Clubs were facilitated by retired teachers who volunteered to tutor after school. Adolescent girls also had leadership camps to improve their confidence, self-esteem, and leadership skills. 1.4.2 Botswana Comprehensive Care and Support for Orphans and Vulnerable Children In August 2016, PCI was awarded the five-year USAID funded Botswana Comprehensive Care and Support for Orphans and Vulnerable Children project, which has an end date of August 30, 2021. The project objectives are to: 1) strengthen households and community structures to support OVCs; and 2) improve policy implementation for delivery of coordinated quality social services. The focus of the project is on the OVC sub populations of vulnerable adolescent girls and young women at high risk of HIV acquisition. The project is building on the work already undertaken by the TK project in the seven PEPFAR priority sites of Mahalapye, Goodhope, Southern, and greater Gaborone (Kweneng East, Gaborone, Evaluation of Services for Orphans and Vulnerable Youth in Botswana 209 Kgatleng, and South East). PCI has partnered with seven local and international organizations (see Table 1). Table 1. Botswana Comprehensive Care and Support for Orphans and Vulnerable Children Districts of Operation and Implementing Partners PEPFAR Scale￾Up District Health District(s) Administrative Division(s) Partner Greater Gaborone Cluster Gaborone Gaborone City Council Botswana-Baylor Children’s Clinical Centre of Excellence (Baylor) Hope World Wide Stepping Stones International (SSI) Humana People to People (HPP) Kweneng East Kweneng East Sub District Hope world wide Baylor Kgatleng Kgatleng District SSI, Bakgatla Bolokang Matshelo (BBM) South East South East Sub District SSI Hope World Wide Baylor Mahalapye District Mahalapye Central – Mahalapye Sub District Mothers Union Baylor Southern District Southern Kanye Sub District HPP Hope World Wide Baylor Moshupa Sub District BOFWA Goodhope District Goodhope Goodhope/Borolong Sub District SSI, Baylor Hope World Wide 210 Evaluation of Services for Orphans and Vulnerable Youth in Botswana The core package of OVC services includes: • Provision of and linkages to pediatric HIV testing/treatment and sexual and reproductive health, family planning, tuberculosis, and gender-based violence services • Home-based and facility-based case management • Peer-to-peer approaches: teen clubs, Young Mothers Clubs, Kids Clubs, and Literacy Clubs • Household economic strengthening (HES) and empowerment • IECD (through play and stimulation groups and pre-schools), for children age 2-6 • Parenting skills development and parent-child communication skills development Services focused on youth include increasing uptake of HIV prevention, care, and treatment services through increased linkages to services through community- and school-based interventions; developing and using a social and behavior change communication strategy to motivate youth and those who influence youth to choose positive behaviors; and delivering post-violence care services to adolescent girls and young women. BCCOVC will also improve the financial literacy and strengthen the economic opportunities of youth through continuing and expanding the Aflateen program from TK; supporting youth savings and loans groups that foster social and economic empowerment through access to financial services and training in leadership and collective action; building the skills of youth to help them enter the workforce; and linking youth to business and entrepreneurial skills training and vocational opportunities. Finally, BCCSOVC will focus on improving school completion and building social assets among adolescent girls to reduce their risk of HIV. Activities will include mentoring, role modeling, and follow-up for OVC enrolled in school; collaborating with guidance and counseling teachers and career guidance teachers to facilitate parent-student-teacher consultations for comprehensive support and positive role modeling. 2 Study Aims and Objectives 2.1 Aims The aim of this evaluation is to understand how OVC programming provided by GOB and the PEPFAR BCCSOVC project prepares older youth to be healthy, productive young adults. Specifically, the study will examine the effect OVC services have on the education, economic, and health trajectories and related outcomes of older youth graduating from the programs. 2.2 Research Objectives This study has two objectives: Objective 1: To qualitatively examine how factors at the personal, family, school, community, and service delivery levels, including OVC services, have influenced the Evaluation of Services for Orphans and Vulnerable Youth in Botswana 211 education, economic and health trajectories and related outcomes of orphaned and vulnerable youth beneficiaries Objective 2: To quantitatively determine whether orphaned and vulnerable youth beneficiaries who have participated in 1-2 years of OVC services from both USG and GOB have better education, economic, and health outcomes compared to orphaned and vulnerable GOB-only youth beneficiaries 2.3 Main Exposures, Outcomes, and Theory of Change The primary exposure for this mixed methods study is participation in BCCSOVC + GOB OVC program for 1-2 years. Orphaned and vulnerable youth receive the following PEPFAR OVC services via the BCCSOVC program: linkage to HIV services such as counseling and testing and anti-retroviral therapy, referrals for other health problems, and life skills education; financial education, work readiness training, and training to start small business; literacy courses and tutoring; and individual and group psychosocial support. Orphaned and vulnerable youth receive the following GOB services via the GOB program: monthly food baskets, coupons or vouchers; monthly toiletries; school supplies and school￾related services such as school uniforms and transportation for school trips; and casual clothing, shoes and blankets as needed. Caregivers of orphaned and vulnerable youth who are in the BCCSOVC + GOB OVC program receive parenting skills building sessions focused on improving parent-child communication. Adolescent and caregiver services are theorized to lead to: increased access to counseling and testing and antiretroviral therapy and adherence to treatment; increased HIV, economic, and education-related knowledge, skills, and behaviors; and increased coping skills, resilience, and self-efficacy. Achieving these intermediary factors depend on a broader supportive environment in the community. See figure 2 for the theory of change for Botswana Comprehensive Care and Support for Orphans and Vulnerable Children. 212 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Figure 1. Botswana Comprehensive Care and Support for Orphans and Vulnerable Children and Government of Botswana Theory of Change Key: 3 Quantitative Study Methods The evaluation will include a quasi-experimental design surveying youth beneficiary of BCCSOVC + GOB OVC programs (the intervention group); and GOB￾only (the comparison group), and their primary caregivers at one point in time. 3.1 Quantitative Study Design USAID/BCCSOVC only USAID/BCCSOVC + GOB GOB only Evaluation of Services for Orphans and Vulnerable Youth in Botswana 213 Quantitative data will be collected via household-based surveys from youth ages 16-18 and their primary caregivers at one point in time in intervention and comparison households. The evaluation will compare PEPFAR + GOB OVC program beneficiaries (intervention group) to GOB- only OVC program beneficiaries (comparison group). Youth in the intervention arm will be selected from the seven current PEPFAR districts where youth are receiving PEPFAR OVC services. Youth in the comparison arm will be selected from six non-PEPFAR sites, where youth are receiving OVC services from only the GOB. 3.2 Quantitative Study Sites The quantitative study will take place in the seven current PEPFAR Districts: Gaborone, Kweneng East, Kgatleng, South East, Mahalapye, Southern, Goodhope; and six non-PEPFAR towns/villages – Kumakwane and Letlhakeng (Kweneng West District); Molapowabojang (Southern District); Radisele and Topisi (Central District); and Mmanyana (Southern). 3.3 Quantitative Study Population The study population for the quantitative study will consist of: • PEPFAR and GOB OVC program beneficiaries ages 16-18; • Primary caregivers of PEPFAR and GOB OVC beneficiaries ages 16-18. Exclusion criteria for all quantitative study participants includes failure to provide either parental consent or youth assent and if a participant is not physically or mentally able to participate in the interview. 3.4 Quantitative Study Main Exposure, Outcomes, and Theory of Change The study will examine three primary and various secondary outcome indicators in education, economic stability, and health. These outcomes will be analyzed by age, sex, and HIV status, as applicable. The primary outcomes are asfollows: 1. Education: Percent of youth who sat for and received 36 points or of higher onthe Botswana General Certificate of Secondary Education [BGCSW]) 2. Economic stability: Percent of youth who have basic financial literacy 3. Health: Percent of youth who had an HIV test in the last 12 months and know their test results The secondary outcomes are as follows: Education • Percent of youth regularly attending school, training center, college or university • Mean number of school days youth missed during the last school yearPercent of youth who re-enrolled or repeated a grade • Percent of youth enrolled in tertiary school or vocationalschool Economic stability 214 Evaluation of Services for Orphans and Vulnerable Youth in Botswana • Percent of youth who perceive they have the skill necessary for employment or starting a business • Percent of youth who have savings (formal or informal) • Percent of youth who report having worked for cash in the past three months • Percent of adolescent who report having started a small business, i.e. income generating activities, in the past 12 months • Percent of youth in internship or job training program Health • Mean age of sexual debut (among youth who have had sexual intercourse) • Percent of sexually active youth who engage in risky sexual behavior, including having multiple sex partners, using condoms inconsistently or not at all, and/or engaging in transactional sex, in the past 12 months • Percent of youth who have accessed HIV services in past 12 months • Percent of youth who have accessed reproductive health services in the past 12 months • Percent of youth who report having experienced sexual violence in past 12 months,and percent of those who sought help • Percent of HIV positive youth reporting being on antiretroviral therapy (ART) • Percent of HIV positive youth reporting adherence to ART • Percent of youth who have used drugs and/or alcohol in the past 12 months 3.5 Quantitative Sampling Plan and Sample Size Estimates Two sampling frames will be created, one for the intervention sample and the other for the control sample. The intervention sampling frame will be created by collating two OVC beneficiary lists: the active GOB OVC beneficiary list in all study sites and the active PEPFAR OVC beneficiary list in intervention sites. Using the active PEPFAR beneficiary list, we will identify beneficiaries that also appear on the active GOB beneficiary list and create a third list of common beneficiaries. The intervention group will be sampled from this third combined beneficiary list. The comparison group will be sampled from the active GOB program beneficiary list. The exact sampling strategy will depend on the size of the sampling frame. If the number of 16- 18-year-old youth on the PEPFAR + GOB and GOB-only OVC beneficiary lists is similar to the sample size required for the study, then all 16-18 year olds from the lists will be selected for inclusion in the study. If the number of 16-18-year-old youth on one or both OVC beneficiary list exceeds the sample size required for the study by at least 100, then simple random sampling will be used to select a sample of 16-18 year-old beneficiaries from the list. Sample size estimation is motivated by the need to detect certain potential differences in population values for key indicators between intervention and comparison groups at endline. We selected the three priority outcome indicators to power the study. The key indicators are: Indicator 1: Percent of youth who sat for and received a score of 36 points or of higher on the Botswana General Certificate of Secondary Education [BGCSW]) Indicator 2: Percent of youth who have basic financial literacy Evaluation of Services for Orphans and Vulnerable Youth in Botswana 215 Indicator 3: Percent of youth who had an HIV test in the last 12 months and know their test results In Table 2 we indicate the sampling goal for each indicator at the time of data collection. For instance, the goal is to be able to detect an eight-percentage point difference in the population value for indicator 1 (percent of youth who completed and passed senior secondary school) between the PEPFAR + GOB beneficiaries and the GOB-only beneficiaries. Table 2. Sampling Goal Study Population Indicator 1: Education Indicator 2: Economic Stability Indicator 3: Health PEPFAR + GOB beneficiaries 33%8 50%9 30% GOB-only beneficiaries 25% 43% 23%10 We use Fleiss’ “two-proportion” formula for sample size estimation (Equation 1): Where, N = Estimated sample size Z1−α/2 = Value of Z for level of significance alpha (at 0.05 level of significance, value of Z is 1.96) Z1−β = Value of Z for power 1-β (at .80 power, level of Z1−β is 0.84 p1 = Value of study outcome at Time 1 (Baseline) p2 = Value of study outcome at Time 2 (Endline) p = (p1 + p2)/2 8 Figure based on Botswana General Certification of Secondary Education 2016 Provisional Summary of Results 9 Figure chosen as most conservative estimate of indicator 10 Figure based on Bodia SM, Lekone P, Loeto P, et al. 2016. Prevalence of HIV testing and counseling and associated factors among secondary school students in Botswana. Journal of International Adolescent Medicine and Health;8(2). 216 Evaluation of Services for Orphans and Vulnerable Youth in Botswana We make the following additional assumptions to calculate estimated sample sizes: Parameters/Assumptions Power 80% Two-tailed alpha 0.05 for 2-arm study Non-response due to inability to locate eligible sample from compiled beneficiary lists 0.10 Response rate among eligible and located sample 0.90 Proportion of eligible 18-year-old youth (Indicator 1) 0.50 In Table 3 we indicate the sample sizes required at sample selection and analysis to achieve the sampling goals. The sampling goals require a sample of about 982 youth in each study arm (intervention and control) at the time of sample selection. Youth attending Form 5 will be oversampled: 622 Form 5 students will be sampled from each study arm. The study requires about 796 youth in each study arm (post 10% non-response due to inability to locate eligible sample from compiled beneficiary lists; and 90% response rate among eligible and located sample) to estimate the prevalence of each indicator. Table 3. Estimated sample sizes Indicator 1: Education Indicator 2: Economic Stability Indicator 3: Health Sample size (of Form 5 students) needed at sample selection Sample size needed at analysis Sample size needed at sample selection Sample size needed at analysis Sample size needed at sample selection Sample size needed at analysis PEPFAR + GOB 622 504 982 796 769 623 GOB-only 622 504 982 796 769 623 Total 1244 1008 1965 1592 1538 1246 This set of sample size estimates are feasible given the FY17 PEPFAR OVC target for 15-17- year- old youth (3,000). Note that the above sample size does not allow for statistical comparison of results between the subgroups (e.g. males vs. females, etc.). 4 Quantitative Study Procedures 4.1 Quantitative Data Collection Procedures Data collection, which will occur during household visits, will consist of an interviewer￾administered tablet-based survey of the primary caregiver of 16-18-year-old youth; and a combined interviewer- and self-administered tablet-based survey of 16-18 year-old youth. Seventy five tablets will be preprogrammed by MEASURE Evaluation with the survey questionnaires. The data will be downloaded to a secure central server at least one time per day, if feasible. All interview teams will carry paper copies of the study instruments in case of equipment malfunction. Completion of each youth survey and primary caregiver survey is Evaluation of Services for Orphans and Vulnerable Youth in Botswana 217 estimated to take approximately 90 minutes and 60 minutes, respectively. It is estimated that each data collector will complete surveys from 2-3 households each day. Data collectors will be trained on how to administer the survey as well as on human subjects’ protection. Data collectors will leave their contact card with the respondent, which will include information on who to contact for more information on the study, or in the case where redress is sought. Each participant will be assigned a unique, anonymous ID. No personal identification information will be captured on the tablet. All tablets will be password protected. The district supervisor will upload the data from the tablet daily to University of North Carolina’s secure data repository for cleaning and analysis. Six to seven months after initial data collection, interviewers will conduct a follow-up phone call with youth who, at the time of the interview, stated they were attending Form 5. Interviewers will ask the youth a short series of questions about whether the student completed Form 5 and number of point s/he received on the Botswana General Certificate of Secondary Education. This data will be entered the pre-programed tablets and then uploaded to UNC’s secure data repository for cleaning and analysis. 4.2 Quantitative Study Instruments Two surveys will be used for the youth and caregiver data collection. The surveys and consent forms were created in English and translated in Setswana. The surveys have been designed to elicit primary and secondary outcome measures and exposure measures outlined in Section 3.4 and potential confounding and mediating factors. The youth and primary caregiver surveys will be piloted with a convenience sample of 40 youth-primary caregiver dyads in Thamaga. See appendices 1 and 2 for the youth and primary caregiver surveys, respectively. 4.3 Quantitative Study Data Management and Security Data collection for the quantitative component will be done with Windows-based tablets equipped with Open Data Kit (ODK) software. There will be 15 field supervisors who will supervise teams of four enumerators. After enumerators or youth respondents enter interview data into the tablets, supervisors will check each interview for completeness and consistency. The tablets will be password protected, and the hard drives will be encrypted. At the end of each data collection day, supervisors will back up the data on each enumerator’s tablet by making a copy on the tablet itself, and they will also regularly transfer the backups from the enumerator tablet directly to UNC via secure file transfer protocol (FTP) and in keeping with UNC data security requirements. Once transferred, the data will be stored on a secure server at UNC. To ensure data protection and confidentiality across the study, all partners will sign a data use agreement and will have committed to using reasonable data protection measures, as outlined in the 218 Evaluation of Services for Orphans and Vulnerable Youth in Botswana agreement, to protect the data. When data collection is complete, tablets will be returned to MEASURE Evaluation, checked for completeness of data delivery, and cleared of all survey data. Paper copies of completed surveys (completed in case of tablet failure) will be stored in a secure filing cabinet accessible to only co-investigators, for a period of 10 years. 4.4 Quantitative Study Data Analysis First the distribution of primary and secondary indicators will be examined. Second, bivariate associations between group membership (intervention vs. comparison group) and primary and secondary indicators will be estimated. Finally, multivariable logistic regression will be used to evaluate whether the education, economic and health outcomes of beneficiaries receiving PEPFAR/BCCSOVC + GOB services are significantly and meaningfully different than beneficiaries receiving GOB-only services. We will include youth- and primary caregiver-level covariates (e.g. socioeconomic status) in the models to control for possible confounders. 5 Qualitative Study Methods The evaluation of services for orphaned and vulnerable youth will include a qualitative design with a sub-sample of orphaned and vulnerable youth from the quantitative study who are participating in PEPFAR/BCCSOVC + GOB OVC programming. 5.1 Qualitative Study Design The qualitative study will use a modified life history methodology and the ripple effect mapping method with a sub-sample of orphaned and vulnerable youth ages 16-18 from the quantitative study to better understand the transition period of their lives from mid￾adolescence (15-16 years) to late adolescence and early adulthood (17-18 years), and how their experiences were influenced by their participation in the OVC program. The modified life history method will use in-depth interviews with orphaned and vulnerable young adults ages 16-18 who participated in both the PEPFAR BCCSOVC and the GOB national OVC program. The interviews will focus on important events that occurred during the adolescent/young adult period of ages 15-18. These interviews will allow for in-depth understand of how their choices, decisions, actions; family, school, and community environments; gender norms and other social factors; and access to OVC and other services shaped the trajectory and related outcomes of their health, education, and economic status. Interviews will also be conducted with a sub-set of orphaned and vulnerable young adults living with HIV and AIDS to understand their unique circumstances. The study will also include in-depth interviews with primary caregivers of the orphaned and vulnerable youth; and key program and community staff of the OVC programs (both PEPFAR and GOB) to understand variations over time in adolescent-specific OVC policies and services provided by the OVC programs. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 219 Finally, the qualitative study will use the ripple effect mapping method (REM), a group participatory mind-mapping method, with youth participants of the BCCSOVC project. REM will be used to visually map the “performance story” resulting from the BCCSOVC project and GOB OVC program to document their intended and unintended effects. 5.2 Qualitative Study Sites The qualitative study will take place in the following four towns/villages: Mahalapye (Central District); Gaborone (Greater Gaborone); Molepolole (Kweneng East District); and Mochudi (Kgatleng District). These four villages/towns were served by the TK project and continue to be served by the BCCSOVC project. 5.3 Qualitative Study Population The study population for the qualitative study will consist of: • Youth ages 16-18 years old who previously received or are currently receiving services from the BCCSOVC project and GOB; • Primary caregivers of BCCSOVC youth participants; • Implementing partner staff of BCCSOVC project; • Community service providers of BCCSOVC project; • Principal welfare social officers; and • Government of Botswana social workers Exclusion criteria for all qualitative study participants includes failure to provide consent and if participant is not physically or mentally able to participate in the interview. Exclusion criteria for youth and primary caregivers includes those who did not complete the quantitative survey. 5.4 Qualitative Sampling Plan and Sample Sizes Youth and adults for the qualitative study will be recruited from the intervention sample of the quantitative study (PEPFAR/BCCSOVC + GOB beneficiaries). After youth and primary caregivers complete the tablet survey, each respondent will complete a follow-up contact sheet including his her contact details as well as contact details of two people in her household and two people outside of his/her household for possible participation in a qualitative in-depthinterview. Youth will be selected to ensure that the sex distribution of participants is representative of the beneficiaries served. We will implement a quota sampling strategy to ensure we have a sufficient sample of youth participants who are living with HIV/AIDS. The remaining groups of respondents (implementing partner staff of BCCS OVC; community service providers; principal welfare social officers, and Government social workers) will be automatically eligible based on the study sites. 220 Evaluation of Services for Orphans and Vulnerable Youth in Botswana The sample size for the qualitative study is as follows: 1. BCCSOVC project youth participants ages 16-18 years not living with HIV/AIDS, n=30 2. BCCSOVC project youth participants ages 16-18 years living with HIV/AIDS, n=10 3. Primary caregivers of BCCSOVC project youth participants interviewed as part of qualitative study, n=40 (i.e. there will be 40 youth-primary caregiver dyads) 4. Implementing partner staff of BCCSOVC project, n=7 5. Community service providers (i.e., community volunteers) of BCCSOVC project, n=4 6. Principle social welfare officers of GOB, n=4 7. GOB social workers, n=4 8. Ripple effect mapping method groups of BCCSOVC project participants ages 16-18 years(8- 10 persons per group), n=4 6 Qualitative Study Procedures 6.1 Qualitative Data Collection Procedures In-depth interviews and REM group discussions will be digitally recorded and transcribed verbatim in Setswana. Transcripts will be anonymized, meaning that all identifying information will be redacted at this stage. Anonymized transcripts will be translated into English for analysis. English transcripts will be imported into a qualitative data software program such as Dedoose. 6.2 Qualitative Instruments The interview and REM guides have been designed to measure education, economic, and health outcomes as well as contextual factors at the individual, family, school, community, and service delivery levels (including OVC services). The youth interview guide will be piloted with a convenience sample of approximately two youth not currently enrolled in the new program and the REM guide will be piloted with one group of pilot test youth participants in Gaborone not selected in the final sample. See appendices 3-11 for the qualitative guides. 6.3 Qualitative Data Management and Security Digital recordings, which may contain identifiable information, will be destroyed after all analyses are complete, the final report has been disseminated, and any manuscripts have been published. Consent forms, original notes from the interviews and REM groups, and REM maps will be stored in a secure filing cabinet accessible to only study co-investigators, for a period of 10 years. Anonymized interview and REM transcripts will be stored on password-protected computers and made available to study co-investigators, as needed, for analysis. Electronic files of survey data will comply with the USAID Data Development Library (DDL) and will be uploaded to the DDL after the completion of the study including all phases of the dissemination. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 221 6.4 Qualitative Data Analysis Five interrelated steps for the data analysis will be followed at each step: reading, coding, displaying, reducing, and interpreting.11 , 12. For the first step of reading, the study investigators will immerse themselves in the data, read the transcripts multiple times, and begin to develop questions about the data and identify preliminary emergent themes. For the second step of coding, study staff will develop an initial codebook with topical codes based on questions from the interview guides. Using the draft codebook, two independent coders will code the same five transcripts to test the reliability of the coding scheme and identify additional themes and codes. The codebook will be finalized, and the two coders will code the remaining interviews. During this initial round of coding, coders will assign topical codes to sections of text so that the text can be more easily and meaningfully searched and extracted. Additional emergent codes (codes developed based on new concepts and ideas not directly linked to the interview questions) will be identified and separated/combined with the other codes as needed. The revised codes will then be applied during a second round of coding. In order to ensure that codes are applied in accordance with codebook definitions, three transcripts will be randomly selected and independently coded by another researcher. Any discrepancies in the coding will be assessed and resolved as needed and adjustments to code applications made. After this, we will generate code reports for the final codes. For the third step, displaying, code summaries will be developed for each of the final codes in order to identify key sub-themes within each code and to examine the evidence supporting these sub-themes. In the fourth step, reducing, key elements and themes will begin to form and essential concepts and relationships between the different themes and sub-themes will be identified by developing matrices. During the fifth and final step of interpretation the principal investigator and local research coordinator will identify and explain the core meaning of the data and synthesize and communicate the findings through the process of writing up and presenting the data. Analysis of data from REM groups will be conducted as follows: The physical maps and drawings resulting from the Ripple Effect Mapping activity will be documented through photographs and replicated in a mapping software, such as XMind or FreeMind. Two researchers will review the visual maps and written transcripts to identify emerging themes, perceived results of the project, and the impact of those results according to participants. Researchers will develop a coding framework based on the broad outcomes of interest (educational achievement, financial stability/success, and health) and, if possible, classify these into individual, household and community-level results. REM maps will be coded in an excel spreadsheet to consolidate the themes linking identified project results to the outcome of interest, and its impact on OVC youth. 11 Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook: Sage. 12 Ulin, P., Robinson, E., & Tolley, E. (2005). Qualitative methods in public health: A field guide for public health research: San Francisco: Jossey-Bass. 222 Evaluation of Services for Orphans and Vulnerable Youth in Botswana 6.5 Dissemination Dissemination of the evaluation study results is planned for March 2019. A dissemination meeting will be held, and will be attended by USAID/Botswana, BCCSOVC partners, GOB, and other invited stakeholders. This meeting will provide an overview of the overall mixed methods study design and results, followed by a discussion of how results can be used to inform project planning. We will also develop numerous publications including a mixed methods final report and one brief, showcasing results of the study to improve uptake of findings. 7 Ethical Considerations 7.1 Confidentiality Unique identification numbers will be used on all questionnaires, interviews, and group discussions. Care will be taken during the presentation of the research findings so the information presented is sufficiently aggregated to ensure that no single individual can be identified. Personal identifiers, including name, phone numbers, home address, and social media usernames, will be gathered as part of this study to re-contact youth after the first time point of data collection. During this re-contact, interviewers will collect data on whether youth who were in Form 5 at the first time point of data collection completed Form 5 and sat for the Botswana General Certificate of Secondary Education exam, and if so, the score they received on the exam. Personal identifiers will not be collected on tablets; these will be collected using only a Youth Contact Sheet (see Appendix 25) that will be completed by the interviewer and/or respondent after the initial survey data have been collected. Contact sheets will be kept in a locked filing cabinet and accessible to only research staff. All information gained from interviews will be kept confidential. Researchers, supervisors and data collectors will be required to sign a confidentiality agreement (see Appendix 10). All electronic devices were data will be stored will be password protected. 7.2 Risks and Benefits We believe that participation in this study presents minimal risk to respondents. However, this research covers a broad range of issues that could be sensitive, such as sexual behavior. The investigators recognize that many of the problems that participants may be faced with are sensitive and stigmatizing issues, and care will be taken to ensure that all questions are asked in a supportive and non-judgmental manner. The interview team will be selected carefully to ensure they have experience conducting interviews and focus groups and that they have good interpersonal skills. Interviewers and REM facilitators will receive training to make them aware of the potential reactions participants may have and will agree to terminate the interview if the respondent shows significant distress. Interviewers and REM facilitators will be required to sign a Confidentiality Agreement (see Appendix 12). Although there is no immediate direct benefit to participants, the data generated from this study will improve service provision for this group in the short and long term. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 223 7.3 Informed Consent Before collecting any information, data collectors will seek and document informed consent to participate. Consent and assent to participate will be written for survey participants, interview participants, and REM group participants. For 16-17-year-old youth written parental consent and assent of the youth will be obtained and for 18-year-old youth, written youth consent will be obtained. We recognize the difference between consent and informed consent. We will provide potential participants (and the parents of minors) with appropriate information about the study and their involvement in the study so they can make an informed choice. At the start of all surveys, interviews and REM groups, potential participants will be informed verbally of the purpose and nature of the study and the expected risks and benefits. All potential participants will be made aware that their participation is voluntary and does not affect their eligibility to receive services from any program now or in the future. The participation of youth and primary caregivers in the survey will be anonymous. All participants will be informed that the data collected will be held in strict confidence. To ensure that participants are aware that the survey includes questions on highly personal and sensitive topics, the interviewer will forewarn them that some topics are difficult to talk about. Participants will be made aware at the outset that they are free to terminate the discussion/interview at any point, and to skip any questions to which they do not wish to respond. Consent and assent forms will be stored in a locked filing cabinet for a period 10 years. See Appendices 13-25. 7.4 Safety Procedures for Research on Intimate Partner Violence Special considerations are required for the administration of survey questions on intimate partner violence (IPV). The data collection team will follow the World Health Organization (2001) ethical and safety recommendations for research on IPV. Precautions include: • Names of respondents are not disclosed and are excluded from all data sets • Instruction is built into the survey module requiring the interviewer to continue the interview only if privacy is confirmed. If privacy cannot be obtained, the interviewer must skip the IPV module and explain in the tablet what happened. • At the start of the IPV module, the respondent is read a statement to inform herthat the following set of questions are personal and will explore different facts of a woman’s life. The statement also assures that her answers are confidential and will not be shared beyond the study team. This statement is in addition to the informed consent already obtained at the start of the interview. • Special training is provided for interviewers and supervisors to sensitize them to issues surrounding IPV and to the specific concerns regarding collection of data on violence. • Information on local organization that provide services/referrals related to IPV is given to any respondent who asks the interviewer for help (See Section 7.6 Referral Process). 7.5 Disclosure of Abuse Reported by Minors The Children’s Act (2009) of Botswana provides for mandatory reporting of child sexual abuse and exploitation. Section 25 of the Act requires that a parent, guardian, teacher or 224 Evaluation of Services for Orphans and Vulnerable Youth in Botswana any other person who, without reasonable excuse, fails to report a case of child abuse or exploitation of which he or she is aware shall be guilty of an offence and liable to a fine or imprisonment for a term of not less than two years but not more than three years, or both. However, enumerators and interviewers are exempt from mandatory reporting for research purposes, and therefore, enumerators and interviewers will not report such cases. Enumerators and interviewers will refer any child who needs or requests assistance to deal with his/her encounter, as provided in the Response Plan. Youth will be given a safe and confidential forum to respond to past and or current abuse situations that they have been involved in. There is evidence indicating that youth will disclose their personal abuse experiences in situations where there is “enough privacy and promptsthat they could share their experiences”.i Many studies indicate that individuals participating in research on past trauma have found the experience non-stressful and constructive.ii,iii,iv Once the respondent discloses any form of abuse and or maltreatment, respondents will beoffered the appropriate referrals as per Children’s Act 2009 Section 43. Referrals will also be offeredif they indicate that they do not feel safe in their current living situation, or become upset during the interview as described in section 7.6 (Response Plan). No services will be forced upon any respondent who does not wish to report abuse. 7.6 Response Plan and Referral Process for Adverse Effects In case where respondents recall frightening, humiliating, or painful experiences due to violence, abuse, and neglect, the research team will provide help through direct service referrals to respondents who need and want assistance. This aspect of the protocol will be referred to asthe Response Plan. The basic tenants of the Response Plan include: 1. All respondents will be provided with a list of services. In order to ensure that the nature of the survey or interview is not revealed to non-respondents, the list of services will include numerous and varied services, including medical centers, tutoring, and family welfare services. Services specific to violence, abuse, and neglect response will be embedded in the overall list. The list will continue to be updated and revised until survey implementation to provide the most up-to-date and complete information on services available by District. Interviewers will be instructed to indicate to respondents which organizations and agencies provide services for violence, abuse, and neglect so that the respondents clearly understand where to obtain the necessary services 2. Respondents who meet any one of the following criteria will be offered a direct referral: • The respondent becomes upset during the interview (for example, tearful, angry, sad, shaking body, difficulty breathing, withdrawn etc.); or • The respondent shares at any point during the interview that he or she does not feel safe in his or her current living situation, including in his or her home or community due to violence, abuse, or neglect; or • The respondent has experienced violence in the past 12 months; or • The respondent is under the age of 18 and traded sex for money or goods in the Evaluation of Services for Orphans and Vulnerable Youth in Botswana 225 past 12 months (i.e. sex trafficking of minors); or • The respondent reports that he or she is in immediate danger (see 3.13 on acute cases) • Orthe respondent asksfor help for violence, regardless of what they may or may not have disclosed during the interview 3. If a respondent meets any of these criteria, the interviewer will offer a direct referral by offering to place the respondent in direct contact with Social and Community Development Office (S&CDO) of the Ministry of Local Government & Rural Development(MLG&RD). 4. If the respondent indicates that he or she would like a direct referral, the interviewers will ask permission to obtain his/her contact information, including name and a safe place or way where a social worker can find him/her. It is important to note that the interviewers will not give any of the information shared during the interview to the service provider unless the respondent requests that they do so. Further, the contact information will be recorded on a separate form which would not be connected with the questionnaire. 5. In order to respect and protect the respondent’s confidentiality, once the referral form has been completed the interviewer will give the form to the team leader so the interviewer and other members of the team have no documents identifying respondents who requested a referral. 6. The interviewer will be provided with air-time to allow him/her to contact a social worker at the MLG&RD. 7. The team leader will then contact a focal point at the social work office of ML&GRD with the referral information and provide the contact information of the respondent requestinghelp. One designated focal point will be on call for the duration of the study, organize assignments forsocial workers, and monitor all referralsfor the duration of data collection. Once the focal point at the MLG&RD has received the referral information, he or she will be responsible for assigning a social worker within 48 hours and following up with the assigned social worker to ensure that all necessary travel and logistics have been arranged, depending on the best method identified for the respondent. The social worker would then work directly with the respondents to determine the best and most appropriate services needed, as well as determine which organization(s) would best provide any additional follow-up support. 8. With support from the focal point, the social worker will make every effort to respond to the request for a direct referral within one week of the interview. 9. The focal point at the MLG&RD will monitor all response plan activations and will follow-up with assigned counselors/social worker on the outcome of each request. 10. The focal point will prepare a final report to include the anonymized number of referrals received from the study teams as well asthe outcome of each request, disaggregated by sex. 7.7 Acute Cases For this study, an acute case is defined as any respondent who self-identifies as being in immediate danger. If a respondent indicates to the enumerator or interviewer that she or he is in immediate danger, then the interviewer will activate the response plan for acute cases. The interviewer will immediately alert her or his team leader to the situation and the 226 Evaluation of Services for Orphans and Vulnerable Youth in Botswana team leader will immediately call the pre-identified contact at the MLG&RD. Appropriate action plans for acute cases will be conducted on a case-by-case basis to best respond to the individual situation and ensure that the respondent is not placed in any additional danger. However, as a basis of action, the MLG & RD will make every effort to ensure that the child is offered immediate help in removal from the dangerous situation as well as offered appropriate medical, psychosocial and legal service and program referrals. For cases of which the respondents are in immediate danger, MLG & RD will make every effort to reach the respondent requiring referral within 72 hours. We anticipate the number of acute cases to be few. 7.8 Ethical Approval This study will adhere strictly to United States and international research ethics guidelines, including 45 CFR 46 and Council for International Organizations of Medical Sciences. Human subject review of the complete study protocol and data collection instruments from the Botswana Ministry of Health Human Resources Development Council (HRDC) and UNC￾Chapel Hill Institutional Review Board will be obtained prior to data collection. 8 Logistics 8.1 Investigators This study is being conducted by a team of investigators from the MEASURE Evaluation project in collaboration with USAID/Botswana. The team is led by Dr. Mahua Mandal, PhD, MPH. She is responsible for the overall development of the evaluation design as well as implementation of the evaluation. She will have primary responsibility for collaborating with local partners and consultants as well as coordination with USAID/Botswana. Dr. Mandal has 15 years of experience in global public health and has conducted mixed methods research and evaluation in women’s and adolescent health for eight years. As a Monitoring & Evaluation Specialist with MEASURE Evaluation Dr. Mandal leads or supports activities focused on youth, OVC and gender. Dr. Mandal has conducted evaluations of HIV/AIDS, reproductive health, adolescent health and gender-based violence programs in Africa and Asia. Currently, Dr. Mandal is leading the qualitative portion of a mixed methods impact evaluation of a life skills curriculum for adolescents; and is co-leading a national adolescent health and wellbeing survey in Bangladesh. Prior to conducting research and evaluation, Dr. Mandal was the Youth Reproductive Health Technical Advisor at USAID/Washington. Lisa Parker, PhD, is PI for the qualitative study and OVC specialist. In this role her responsibilities include developing and implementing the qualitative study and contributing to choose of key indicators for the quantitative study. Dr. Parker has more than 15 years of experience working in the fields of public health, monitoring and evaluation (M&E), and international development with a focus on HIV/AIDS, sexual and reproductive health, household economic strengthening, and vulnerable children. Currently a Senior Technical Advisor in Data, Informatics, and Analytical Solutions at Palladium she oversees a portfolio of Orphan and Vulnerable Children (OVC) M&E capacity-building programs. She serves as the lead OVC advisor for the MEASURE Evaluation project and in this role is responsible for providing technical support to OVC stakeholders to develop M&E systems and aids in the Evaluation of Services for Orphans and Vulnerable Youth in Botswana 227 collection and use of OVC data and information. She is also responsible for designing operations research and evaluation studies, including recently acting as Principal Investigator for the HIV Core qualitative retrospective evaluation of a community savings group intervention for OVC in Haiti and as Co-Investigator for the MEASURE Evaluation Impact Evaluation of the Improved Services for Vulnerable Populations project in Rwanda. She has extensive experience living, working, and conducting research in Sub-Saharan Africa including in Burkina Faso, Cameroon, Cote d’Ivoire, DRC, Malawi, Niger, Nigeria, Rwanda, and South Africa. Lisa is fluent in both English and French. Milissa Markiewicz, MPH, PMP, is a Research Associate at UNC’s Carolina Population Center (CPC), and has served as a MEASURE Evaluation project manager and/or research associate for impact, outcome, and process evaluations focusing on HIV/AIDS, cross-border health, malaria, maternal and child health, and gender in East and Southern Africa. Responsibilities include recruitment of local research partners, obtaining country ethics approvals, training both quantitative and qualitative data collection teams, data quality oversight in the field, qualitative data analysis, and report writing. She previously served as project manager for the Southeast Region of the Network for Public Health Law at UNC’s Gillings School of Global Public Health and as a program director at the Terry Sanford Institute of Public Policy at Duke University. Ms. Markiewicz worked in Uganda for over three years as an academic director and special projects coordinator for the School for International Training. Abby Cannon, MPH, MSW, will assist with the technical aspects of the quantitative study. Ms. Cannon is a research associate and Gender Specialist for USAID’s MEASURE Evaluation Project at the University of North Carolina. She joined the MEASURE Evaluation team in 2010 and has since spearheaded efforts to integrate gender across project technical areas, international health information systems, and capacity building. Her research focuses on the intersection of gender and health within HIV, women’s economic empowerment, gender￾based violence, and orphans and vulnerable children. She has worked with OVC domestically and internationally, both in direct care, as well as research, scale-up, and M&E. Elizabeth Millar, MPH, will assist with the technical aspects of the qualitative study. Ms. Millar is a Research Associate in Evaluation and Learning for USAID’s MEASURE Evaluation Project at the University of North Carolina. Ms. Millar has experience developing and leading health program evaluations, including qualitative components, in Honduras, Nicaragua, Lesotho, Tanzania, and Kenya. She has created content for and taught portions of MEASURE Evaluation’s 50-hour short course on qualitative evaluation methods for professionals involved in implementing and evaluating health programs. Ms. Millar currently project manages MEASURE Evaluation’s Health Information System (HIS) Strengthening Learning Agenda, a systematic approach designed to generate evidence for HIS strengthening. Stephanie Watson-Grant, DrPH, will serve as Country Portfolio Manager for the evaluation. She will provide oversight and support to the MEASURE Evaluation team throughout the implementation of this activity. S/he will monitor compliance with MEASURE Evaluation Phase IV Agreement conditions, reporting requirements, and approved work plan deliverables. Dr. Watson-Grant has over 12 years of experience in the field of international health and development. Her areas of expertise are HIV planning and program 228 Evaluation of Services for Orphans and Vulnerable Youth in Botswana implementation, HIV M&E systems assessment, management of USAID-funded projects, survey implementation, capacity building training, and measurement of country ownership. Gaelebale Nnunu Tsheko, PhD, is a local co-Principal Investigator based with 5 AM, the local quantitative research partner, and a Professor at the University of Botswana. She is a research methodologist with experience in surveys and evaluations focused on youth and gender, and was formerly the lead research consultant on the Botswana Violence Against Children national survey. Dr. Tsheko will contribute to quantitative study design, field procedures, and data analysis. Iris Halldorsdottir, PhD, is a co-Principal Investigator and director of Research 4 Results (R4R), the local qualitative research partner. She has experience in qualitative research with adolescents in Botswana, including the Qualitative Assessment of Botswana’s Centre of Child and Adolescent Nutrition Referral Process. Dr. Halldorsdottir will contribute to qualitative study design, field procedures, and data analysis. Ellen Kgotlhang is a local co-Investigator and the Acting Director of the Department of Social Protection in the Ministry of Local Government and Rural Development, and will contribute to study design and community entry. Ookame Makabathebe is local co-Investigator and Deputy Director of the Department of Social Protection in the Ministry of Local Government and Rural Development, and will contribute to study design and community entry. Segametsi Duge, MPH, is the Project Development Specialist in Monitoring and Evaluation with USAID. She is a study advisor on this evaluation Mosarwa Segwabe, MPH, is a Project Development Specialist with USAID. She is a study advisor on this evaluation. 8.2 Management and Collaboration The MEASURE Evaluation-led project will conduct the study in partnership with a local research organization. The local research partner organization will lead data collection activities with oversight and support from MEASURE Evaluation. MEASURE Evaluation will assume overall management responsibility and lead data analysis and report writing. Key study collaborators include 1) Government of Botswana, who will authorize data collection activities, 2) Government of Botswana district-level offices and staff 3) Project Concern International and their partners for the BCCSOVC project; 3) USAID technical advisors in Botswana and Washington, DC. All partners and collaborators will participate in validating findings, dissemination, and in developing recommendations based on findings. i Jensen, T.K., et al., Reporting possible sexual abuse: a qualitative study on children's perspectives and the context for disclosure.Child Abuse Negl, 2005. 29(12): p. 1395-413. iiDraucker, C., The emotional impact of sexual violence research on participants. Arch PsychiatrNurs, 1999. 13(4): p. 161- 169. iii Walker, E.A., et al., Does the study of victimization revictimize the victims? Gen Hosp Psychiatry, 1997. 19(6): p. 403-10. ivWorld Health Organization.Global school-based student health survey report. 2008. Evaluation of Services for Orphans and Vulnerable Youth in Botswana 229 APPENDIX P. CONFLICT OF INTEREST STATEMENTS 230 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Evaluation of Services for Orphans and Vulnerable Youth in Botswana 231 232 Evaluation of Services for Orphans and Vulnerable Youth in Botswana Evaluation of Services for Orphans and Vulnerable Youth in Botswana 233