improved household resilience to economic shocks:
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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.