Improved Household Resilience to Economic Shocks:Findings from SAGE4Health, a Mixed-methods, Quasi-experimental, Non-

equivalent Control Group Effectiveness Study of a Combined Structural Intervention in Rural Central Malawi Improved Household Resilience to Economic Shocks:Findings from SAGE4Health, a Mixed-methods, Quasi-experimental, Non-

equivalent Control Group Effectiveness Study of a Combined Structural Intervention

Improved Household Resilience to Economic Shocks:

Findings from SAGE4Health, a Mixed-methods, Quasi-experimental, Non-equivalent Control Group Effectiveness Study of a Combined

Structural Intervention in Rural Central Malawi

1University of Wisconsin-Milwaukee, College of Nursing, USA

2University of Wisconsin-Milwaukee, Joseph J. Zilber School of Public Health, USA

3University of Wisconsin-Milwaukee, Center for Global Health Equity, USA

4CARE International-Malawi, Lilongwe, Malawi;

We THANK…Study Participants from Malawi’s Kasungu District

National Institutes of Health Eunice K. Shriver National Institute of Child Health and Human Development Grant R01-HD055868 (2008 – 2014) P.I. Lance S. Weinhardt

P. E. Stevens1 A. F. Yan2 L. W. Galvao1,3 T. Mwenyekonde4 L. Mkandawire-Valhmu1

K. M. Grande2 T. Saka4 C. Manda4 G. Kosamu4 C. Depete4 E. M. Ngui2 L. Emer2 & L. S. Weinhardt2

Background

• Heavy HIV burden o 10.8% HIV prevalenceo life expectancy 54.8 yrs.

• Among the poorest nationso 74% live in extreme poverty (< US $1.25 per day)o inflation at 24%

• Agricultural economyo 84% rural o smallholder, rain-fed maize production o vulnerable to climatic shocks (e.g., drought)o limited roads & transporto restricted access to financial services

MALAWI

Background

• Poverty, food insecurity, gender disparity are structural determinants of HIV/AIDS

• Few controlled investigations of structural intervention effects on HIV vulnerability

Leverage ModelNGO - Academic Partnership

• Enables detailed controlled study of real-world structural interventions

• Leverages strengthso NGO capacity for large-scale, sustainable development worko Academic researchers’ expertise in rigorous scientific evaluation

Intervening at the Structural Level

SAGE4Health Study

Evaluate a large-scale economic development program implemented by CARE-Malawi to examine mechanisms and magnitude of impact on economic livelihoods, food security, and health.

Specific Aim

Examine how socioeconomic changes may affect vulnerability to HIV and other risks that can overwhelm rural households in subsistence environments

Purpose

SAGE4Health Evaluation Timeline

2009 2010 2011 2012

SAFE Intervention XXXXXXX XXXXXXX

Longitudinal Quantitative

Baseline Survey X

18-mon Follow-up Survey X

36-mon Follow-up Survey X

End-of-Program Qualitative

Focus Groups & Interviews X

Integration of Qualitative & Quantitative Data

Analytic Steps

1. Understand intervention impact on household resilience from participants’ point of view

Qualitative focus groups and interviews (sub-sample of intervention group N=90)o thematic analysiso hypotheses generation

2. Examine intervention effects on household resilience outcomes across condition & time

Quantitative longitudinal surveys (intervention group N=600 & controls N=300)o cross-tabulationo Chi-Squareo Generalized Estimating Equations with repeated measures logistic regressions

Qualitative Findings

Fewer Economic ShocksSuccess across growing seasonsIncreased food securityLess reliance on “ganyu”More attention to own farm plot

Farmer Field School

Village Savings and Loans

Fewer Economic ShocksEmergency loansCollective savingSmall business loansAnnual dividends

Perceived Intervention Impact on Household Resilience

Successful growing

seasons using sustainable

farming

Emergency loans &

cumulative savings

Enhanced capacity to cope with sudden adversity

& Decreased reliance on

“ganyu” in times of economic shock

“ganyu” = agricultural day labor

Farmer Field School

Village Savings & Loans

Agricultural Day Labor “Ganyu” as Emergency Livelihood in a Subsistence Environment

least desirable livelihood response to acute need

double-edged sword

Economic shock

Agricultural day labor for emergency cash / food

Unable to manage own subsistence

farm

Food insecurity &

economic ruin

Participant Perspectives on “ganyu”

oppressive & health threatening

Quantitative Findings

Outcome variables: • Economic crises due to unpredictable events• Emergency livelihood strategies in response to food shortages

Figure 1. Percentage of households that reported experiencing an economic crisis in past 12-months due to

major illness or hospitalization (n=827) time X group (p<.001) *

Baseline 18-month 36-month0

102030405060708090

100

45.6

6258.2

61

57.3 46.4 Control Intervention

% h

ad to

cope

with

eco

-no

mic

cris

es in

the

past

12

mon

th

Baseline to 18-month 18-month to 36-month Baseline to 36-month

OR (95% CI) P value OR (95% CI) P value OR (95% CI) P value

Intervention .99 (.741 - 1.311) 0.922 .78 (.579 - 1.062) 0.784 .77 (.581 - 1.028) 0.077Control 1.76 (1.20 - 2.58) 0.004 1.03 (.65 - 1.633) 0.9 1.81 (1.155 - 2.835) 0.01

* All GEE logistic models adjusted for corresponding baseline measure for each outcome and other covariates (age, gender, marital status, head of household literacy, and highest level of school) to obtain adjusted ORs.

Figure 2. Percentage of households that reported experiencing an economic crisis in past 12-months due to environmental disaster (e.g.,

drought, flood, hail, fire) (n=827) time X group (p=.003) *

Baseline to 18-month 18-month to 36-month Baseline to 36-monthOR (95% CI) P value OR (95% CI) P value OR (95% CI) P value

Intervention .09 (.041 - .205) <.001 1.15 (.435 - 3.023) 0.782 .11 (.048 - .229) <.001Control .24 (.049 - 1.169) 0.077 4.17 (.856 - 20.375) 0.077 1.00 (.379 - 2.639) >.05

Baseline 18-month 36-month0

102030405060708090

100

4.62.7 4.2

15.7

2.8 3.6

Control Intervention

% h

ad to

cope

with

eco

-no

mic

cris

es in

the

past

12

mon

th

Figure 3. Percentage of households in which adults did “ganyu” (agricultural day labor) in past 12-months (n=827) time X group (p<.001) *

Baseline 18-month 36-month0

10

20

30

40

50

60

70

80

42.2

60.562.7

51.4

61.359.9

Control Intervention

% d

id g

anyu

/cas

ual

labo

r/pi

ecew

ork

for p

ay

Baseline to 18-month 18-month to 36-month Baseline to 36-month

OR (95% CI) P value OR (95% CI) P value OR (95% CI) P value

Intervention 1.16 (.884 - 1.511) 0.291 0.92 (.722 - 1.163) 0.473 1.06 (.787 - 1.425) 0.705Control 3.0 (2.047 - 4.323) <.001 1.07 (.72 - 1.583) 0.746 3.18 (2.055 - 4.908) <.001

Figure 4. Percentage of households in which children did “ganyu” (agricultural day labor) in past 12-months (n=827) time X group (p=.014)

*

Baseline 18-month 36-month05

101520253035404550

1521.1

27.1

15.4 17.6 17.8

Control Intervention

% d

id g

anyu

/cas

ual

labo

r/pi

ecew

ork

for p

ay

Baseline to 18-month 18-month to 36-month Baseline to 36-monthOR (95% CI) P value OR (95% CI) P value OR (95% CI) P value

Intervention 1.14 (.842 - 1.531) 0.404 0.98 (.709 - 1.356) 0.904 1.11 (.781 - 1.587) 0.554Control 2.26 (1.365 - 3.751 0.002 1.22 (.783 - 1.910) 0.376 2.77 (1.631 - 4.695) <.001

As a result of a structural intervention combining sustainable agriculture & local micro-finance rural Malawian households may have been….

better able to absorb shocks without falling

further into poverty.

less likely to respond to

emergencies by resorting to agricultural day

labor.

“We can stop harvesting hunger.”

Conclusion

Discussion

• Intervening to improve household resilience to shocks may reduce vulnerability to HIV and other hazards in subsistence environments.

• Variation in local economic conditions has been shown to shape the spread of HIV by such mechanisms as shock-induced increases in transactional sex. In one study (Burke, Gong, & Jones, 2013) researchers found that economic shocks explained up to 20% of variation in HIV prevalence across African countries.

• Further analysis of SAGE4Health data is planned to determine specific pathways linking economic shocks to HIV.

Burke, M., Gong, E., Jones, K. (2011) Income Shocks and HIV in Sub-Saharan Africa.Washington, DC: International Food Policy Research Institute.

Recommendations

1. Integrate food security and microfinance components into HIV prevention and treatment to address structural inequalities driving the pandemic in subsistence environments.

2. Collaborate across sectors to understand health impacts of economic development by leveraging NGO capabilities on-the-ground, and academics’ research expertise.

3. Consider creative models for evaluating interventions done by economic development organizations to identify those with the greatest potential to increase household resilience. Randomized controlled trials (RCT) may not always be the most feasible or appropriate design to this purpose.

“Zikomo” Thank you.