Methods and protocol of a mixed method quasi-experiment to evaluate the effects of a structural economic and food security intervention on HIV vulnerability in rural Malawi: The SAGE4Health Study

Abstract

BackgroundPoverty and lack of a predictable, stable source of food are two fundamental determinants of ill health, including HIV/AIDS. Conversely, episodes of poor health and death from HIV can disrupt the ability to maintain economic stability in affected households, especially those that rely on subsistence farming. However, little empirical research has examined if, and how, improvements in people’s economic status and food security translate into changes in HIV vulnerability.MethodsIn this paper, we describe in detail the methods and protocol of an academic-NGO collaboration on a quasi-experimental, longitudinal study of the mechanisms and magnitude of the impact of a multilevel economic and food security program (Support to Able-Bodied Vulnerable Groups to Achieve Food Security; SAFE), as implemented by CARE. Primary outcomes include HIV vulnerability (i.e., HIV risk behaviors, HIV infection), economic status (i.e., income, household assets) and food security (including anthropometric measures). We recruited participants from two types of areas of rural central Malawi: traditional authorities (TA) selected by CARE to receive the SAFE program (intervention group) and TAs receiving other unrelated CARE programming (controls). In the intervention TAs, we recruited 598 program participants (398 women, 200 men) and interviewed them at baseline and 18- and 36-month follow-ups; we interviewed 301 control households. In addition, we conducted random surveys (n = 1002) in the intervention and control areas with a 36-month assessment interval, prior to and after implementation of SAFE. Thus, we are examining intervention outcomes both in direct SAFE program participants and their larger communities. We are using multilevel modeling to examine mediators and moderators of the effects of SAFE on HIV outcomes at the individual and community levels and determine the ways in which changes in HIV outcomes feed back into economic outcomes and food security at later interviews. Finally, we are conducting a qualitative end-of-program evaluation consisting of in-depth interviews with 90 SAFE participants.DiscussionIn addition to examining pathways linking structural factors to HIV vulnerability, this research will yield important information for understanding the impact of a multilevel environmental/structural intervention on HIV, with the potential for other sustainable long-term public health benefits.

A Qualitative Investigation of the Impact of a Livelihood Intervention on Gendered Power and Sexual Risk Behaviors Among HIV-Positive Adults in Rural Kenya

“…Furthermore, poverty has been found to have a complex relationship with HIV and to play a multidimensional role that is shaped by the broader social environment (Kim, Pronyk, Barnett, & Watts, 2008). Thus, researchers have increasingly called for multisectoral intervention packages that go beyond one structural factor to incorporate several that are appropriate to the local context, such as food security and property rights (Dworkin & Blankenship, 2009; Cohen et al, 2015; Dworkin et al, 2013; Kim et al, 2007; Weinhardt et al, 2009, 2014). …”

Mixed-Method Quasi-Experimental Study of Outcomes of a Large-Scale Multilevel Economic and Food Security Intervention on HIV Vulnerability in Rural Malawi

“…A comprehensive description of SAGE4Health methodology is described elsewhere [ 4 ]; a summary follows. SAGE4Health examines three interrelated samples designed to systematically evaluate the SAFE program, a community-based, structural, multilevel health and development intervention designed and implemented by CARE International-Malawi from January 2008–December 2010.…”

“…Interventions that break the cycle of poverty are of increasing interest to the development and public health communities given the potential for sustainable long-term impact. Our study [ 3 , 4 ] examines the effects of a structural multi-level HIV intervention, referred to as SAFE, designed and implemented by a large non-governmental organization (NGO), CARE International, in rural Malawi, which has high levels of poverty, food insecurity, and HIV prevalence.…”

Economic strengthening for HIV testing and linkage to care: a review of the evidence

“…The first found that individual savings, either alone or in combination with other HES and sexual health support, did not increase self-reported testing uptake among adolescent girls in Uganda (Austrian & Muthengi, 2014). In the other, participants in a multi-component intervention including group savings in Malawi were nearly twice as likely to report having undergone HTS compared to a control group, though the study did not measure the association between HTS uptake and the savings component independently (Galvao, 2015;Weinhardt et al, 2014). No savings studies assessed an outcome related to linkage to care.…”

“…Only one study assessed HTS uptake among participants in an integrated agricultural training, group savings, and HIV and gender education intervention in Malawi, finding that participants in the combined intervention had nearly double the odds of reporting HTS uptake compared to a control group (Galvao, 2015;Weinhardt (Table 6). No studies assessed vocational or entrepreneurial training and linkage to care.…”