Impact evaluation of PEPFAR’s DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women) Initiative in Nairobi (Round 3), DREAMS
As part of a partnership led by the London School of Hygiene and Tropical Medicine, the African Population and Health Research Center (APHRC) aims to evaluate the impact of the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women) Initiative in two urban informal settlements (Korogocho and Viwandani), where the Center has been running the Nairobi Urban and Health Demographic Surveillance System (NUHDSS) since 2002. The overall goal of the DREAMS Initiative is to reduce new HIV infections among the most vulnerable adolescent girls and young women (AGYW) aged 10-24 years in 10 subSaharan African countries including Kenya.
The specific objectives of the evaluation were to: measure whether HIV-related outcomes change due to DREAMS interventions at a population level; to explore the pathways of protection by which DREAMS interventions influence the lives of young women and ultimately their risk for HIV; and to assess the extent to which the DREAMS interventions were delivered as intended. The non-experimental impact evaluation, which was conducted over 3 years, adopted a mixed methods approach. used data from the NUHDSS and a new DREAMS module administered to all women and men aged 15 to 49 years to assess some of the key outcomes, including timing of first sex, number of sexual partners and condom use. The information collected from other age groups in the NUHDSS served to place findings from AGYW in context.
To explore the pathways of protection by which DREAMS interventions influence the lives of young women and ultimately their HIV status, we recruited a closed cohort of approximately 1500 AGYW aged 10-22 years evenly split by age group (10-14 years, 15-17 years, 18-22 years). The cohort was a random sample drawn from the NUHDSS database and stratified by age, area of residence, and schooling status. These young people completed a DREAMS survey at three time points—in 2017, 2018 and 2019—to assess changes in the key outcomes as well as key mediators such as empowerment, self-efficacy and social support.
Finally, we conducted in-depth interviews with a purposively selected group of AGYW and focus group discussions with a range of parents and young people to explore experiences with and perceived effects of the DREAMS initiative. We also conducted key informant interviews with DREAMS implementers within the study and observations of various DREAMS activities in order to assess: 1) whether components of the DREAMS intervention are implemented as scheduled and planned; 2) the barriers and facilitators to implementation; and 3) staff members’ and beneficiaries’ perceptions and value of the interventions. Quantitative data was collected on Android-based tablets using Survey-CTO software. Qualitative interviews were audio-recorded and directly transcribed.
This is the only version.
Unit of Analysis
The survey covered a random sample of women and men aged 15 to 49 years, and young girls aged 10-14 years.
Producers and sponsors
Authoring entity/Primary investigators
Sheru Wanyua Muuo
Bill and Melinda Gates Foundation
Provision of information.
We recruited a closed cohort of approixmately1200 AGYW aged 10-22 years (400 aged 10-14 years, 400 aged 15-17 years, and 400 aged 18-22 years). Within each age cohort, we sampled an additional 100 AGYW to account for attrition, meaning that the initial sample comprised 1500 AGYW. The cohort was a random sample of AGYW drawn from the Nairobi Urban Health and Demographic Surveillance Sites (NUHDSS) database stratified by age, area of residence (Viwandani and Korogocho), and schooling status for 15-22 year olds (in and out of school). These young people completed a DREAMS Cohort Survey at three time points: baseline, 12 months and 24 months, at time points closest aligned with periods before, during and after DREAMS implementation (specific timelines were determined by the NUHDSS activities planned within each site). Detailed contact information was collected at baseline to enhance follow-up of young people who migrate from the original households in the NUHDSS during the follow-up period.
For the GPC, a census approach was adopted with an aim of reaching all men and women aged 15-49 who were residents in the NUHDSS.
Deviations from the Sample Design
GEAS(10-14 years): At enrolment, we targeted a minimum sample of 500 girls aged 10-14 years. A random list of 1017 potentially eligible girls was generated from the most recent NUHDSS survey, and attempts were made to reach all girls in the list. Out of the random list of 1017 EAG, 333 (32.7%) were no longer eligible at the time of visit, due to reasons like out-migrations and age ineligibility. Of the remaining 684, 46 (6.7%) were absent from their residence for extended periods of time, 23 (3.4%) had their structures located but respondents' whereabouts were unknown, and 9 (1.5%) refused to participate either by self or their parents/guardians, leaving 606 (88.6%) who consented and completed the interviews in round 1 (2017).
At baseline we targeted a minimum sample of 1000 AGYW aged 15-22 years. A random list of 2599 AGYW was generated. Of these, 829 (31.9%) were no longer eligible at the time of visit. Of the remaining 1770, 6 (0.34%) had incomplete interviews, 241 (13.62%) were absent from their residence for extended period of time, 283 (16%) refused to participate either by self or their parents/guardians, and 159 (9%) had their structures located but respondents' whereabouts were unkown, leaving 1081 (61.1%) with successful interviews.
Dates of Data Collection (YYYY/MM/DD)
Mode of data collection
Field interviewers completed tracking sheets which helped them account for all the respondents that were assigned to them.
Team leaders carried out mirror interviews, spot-checks, sit-ins and actual interviews as a way of data quality control and assurance.
Type of Research Instrument
General Population Component (GPC) and closed cohort of AGYW aged 15-22 years
This survey was administered to all women and men aged 15-49 years who were considered eligible, competent and willing to participate in the study. Eligible respondents were determined by the pattern of their residency i. e if they were usual members of the households, if they had lived in the study area and qualified as permanent NUHDSS residents. The tool was made up of 5 sections;
· Socio-demographic data
· Measuring exposure to dreams
· Questions to measure mediating variables
· Questions on sexual behavior outcomes
· Measuring biological pathways of protection
Global Early Adolescent Survey (GEAS) - Borrowed modules
This survey was administered to adolescent girls aged 10-14 years. It sought to explore healthy sexuality in early adolescents and understand normative expressions of masculinity and femininity. It was made up of 6 sections:
· Socio-demographic data
· DREAMS exposure matrix
· Gender norms
· Health literacy
· Sexual behavior
Weekly meetings were held by the team to check and revise inconsistencies with the data.
Data cleaning was conucted which included duplicates checks, consistency checks, missingness etc
Variables were recoded during analysis.
Estimates of Sampling Error
Director of Research
The data from the study will be made available in compliance with the Bill and Melinda Gates Foundation’s and APHRC’s data sharing policy. The final data will be made available to the scientific and research community as de-identified data sets. A detailed analysis of risk of data disclosure will be performed prior to data disclosure to protect both the privacy of the participants and the confidentiality of the data. Timelines for distribution of data will vary depending on any required restrictions. In addition to communication channels such as speaking engagements and publications, these data also may be distributed by a number of electronic methods, including datasets via electronic media such as CDs, DVDs, and tape. All data users will sign appropriate confidentiality agreements. Documents will be developed allowing the public to view a description of the available data that can be requested. The process for requesting the data and a copy of the data-sharing agreement will also be available by email. This process and the documents will be developed by the investigators of the project with the input and guidance from the Bill and Melinda Gates Foundation and APHRC’s Statistics and Surveys Unit. All documents will be Health Insurance Portability and Accountability Act (HIPAA) compliant and meet all the requirements of the local IRBs. Even though final datasets will be stripped of identifiers prior to release for sharing, there may remain the possibility of deductive disclosure of participants with unusual characteristics. Therefore, we will make the data and associated documentation available to users only under a data sharing agreement that provides for 1) a commitment to using the data only for research purposes and not to identify any individual participant; 2) a commitment to securing the data using appropriate computer technology; and 3) a commitment to destroying the data.
Use of the dataset must be acknowledged using a citation which would include:
- the Identification of the Primary Investigator
- the title of the survey (including country, acronym and year of implementation)
- the survey reference number
- the source and date of download
Disclaimer and copyrights
The user of the data acknowledges that the original collector of the data, the authorized distributor of the data, and the relevant funding agency bear no responsibility for use of the data or for interpretations or inferences based upon such uses.