Improved Household Resilience to Economic Shocks:

1. 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

2. 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 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

4. Background MALAWI • Heavy HIV burden • 10.8% HIV prevalence • life expectancy 54.8 yrs. • Among the poorest nations • 74% live in extreme poverty (< US $1.25 per day) • inflation at 24% • Agricultural economy • 84% rural • smallholder, rain-fed maize production • vulnerable to climatic shocks (e.g., drought) • limited roads & transport • restricted access to financial services

5. Background Intervening at the Structural Level • Poverty, food insecurity, gender disparity are structural determinants of HIV/AIDS • Few controlled investigations of structural intervention effects on HIV vulnerability • Leverage Model • NGO - Academic Partnership • Enables detailed controlled study of real-world structural interventions • Leverages strengths • NGO capacity for large-scale, sustainable development work • Academic researchers’ expertise in rigorous scientific evaluation

6. SAGE4Health Study Purpose 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

8. SAGE4Health Evaluation Timeline

9. Integration of Qualitative & Quantitative Data Analytic Steps • Understand intervention impact on household resilience from participants’ point of view Qualitativefocus groups and interviews (sub-sample of intervention group N=90) • thematic analysis • hypotheses generation • Examine intervention effects on household resilience outcomes across condition & time Quantitative longitudinal surveys (intervention group N=600 & controls N=300) • cross-tabulation • Chi-Square • Generalized Estimating Equations with repeated measures logistic regressions

10. Qualitative Findings

11. Farmer Field School Fewer Economic Shocks Success across growing seasons Increased food security Less reliance on “ganyu” More attention to own farm plot

12. Village Savings and Loans Fewer Economic Shocks Emergency loans Collective saving Small business loans Annual dividends

13. Perceived Intervention Impact on Household Resilience Farmer Field School Village Savings & Loans

14. Agricultural Day Labor “Ganyu” as Emergency Livelihood in a Subsistence Environment Participant Perspectives on “ganyu” least desirable livelihood response to acute need double-edged sword oppressive & health threatening

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

16. 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) * * 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.

17. 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) *

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

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

20. As a result of a structural intervention combining sustainable agriculture & local micro-financerural Malawian households may have been…. Conclusion “We can stop harvesting hunger.”

21. 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.

22. Recommendations • Integrate food security and microfinance components into HIV prevention and treatment to address structural inequalities driving the pandemic in subsistence environments. • Collaborate across sectors to understand health impacts of economic development by leveraging NGO capabilities on-the-ground, and academics’ research expertise. • 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.

23. “Zikomo” Thank you.