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

Background: The mental and financial strain linked to unpaid caregiving has been amplified during the COVID-19 pandemic. In sub-Saharan Africa, carers of adolescents living with HIV (ALHIV) are critical for maintenance of optimum HIV treatment outcomes. However, the ability of caregivers to provide quality care to ALHIV is undermined by their ability to maintain their own wellbeing due to lack of finances and poor mental health. Nudges are a behavioural economics strategy used to influence healthcare decision-making by targeting behavioural barriers. Nudges such as cash incentives and SMS reminders are linked to improved health and wellbeing. There is a lack of evidence on whether these nudges could promote caregiver wellbeing during COVID-19.Objectives: To compare the feasibility, acceptability and preliminary effectiveness of an economic incentive nudge package (cash + motivational SMS) for improving caregiver wellbeing.Methods: We conducted a pilot individual-randomised controlled trial (November 2021-March 2022), with N=100 caregivers of ALHIV (10–19-year-olds), sampled from HIV clinics in Durban, KwaZulu-Natal. Participants were randomly assigned to the intervention or control arm. The intervention arm (n=50) received an unconditional cash incentive (~ $23 USD) via mobile banking services and a positive wellbeing SMS per month, over a three-month period. The control arm (n=50) received one standard SMS encouraging linkage to care. The intervention was co-designed with our caregiver advisory board. The nudge targeted three behavioural economic principles (aspiration framing, altruism, loss aversion), drawing on facilitators of wellbeing in this setting. Participants were interviewed at baseline and end-line (12 weeks) to collect socio-demographic, health, and wellbeing data. The primary outcome was change in wellbeing measured using the Mental Health Continuum Short-Form. Caregivers (n=8) in each arm underwent in-depth interviews to understand lived experiences and perceptions of the intervention. An intention-to-treat analysis was conducted. Qualitative data were analysed using the framework method. For more information on the trial, contact Dr Darshini Govindasamy ([e-mail]).