The bibliometric analysis of previous twenty- five years' literature: A microfinance review

The tremendous increase in publications in Microfinance since 2000 has highlighted need for and importance of innovative techniques to present big data in this field in a most informative, scientific, and summarized manner. The study highlights the trends and patterns of Microfinance literature by revealing what has been done and what could be done in future. The study comprises of 1429 microfinance publications extracted from the Scopus database. The authors adopt bibliometric analysis through open software application R and network analysis techniques using Gephi AND VOS viewer software. The study adds a valuable contribution to the field of Microfinance by distinctively summarizing the important literature. It identifies global academic research trends and provides insights about trending topics, highly cited literature, authors, countries, collaboration network, word cloud, citation analysis, etc. Finally based on extensive literature survey through bibliometric analysis. The study highlights about the scope of future research in Microfinance.

Engaging men in women's empowerment: impact of a complex gender transformative intervention on household socio-economic and health outcomes in the eastern democratic republic of the Congo using a longitudinal survey

BACKGROUND

In the Democratic Republic of the Congo, women in (peri-)urban areas are commonly engaged in small trade, which allows them to meet the basic needs of their families. Microsaving approaches are a low-risk option to obtain financing for economic activities. A project combining men's sensitization on gender equity and women's empowerment through village savings and loan associations were implemented in North and South Kivu to raise the household economic level.

OBJECTIVE

This study assessed how involving men in gender equity affects women's health and socio-economic outcomes, including food security.

METHODS

A cohort study was conducted with 1812 women at the baseline; out of them 1055 were retrieved at the follow-up. Baseline data collection took place from May to December 2017 and the follow-up from July 2018 to January 2019. To identify socio-economic changes and changes of gender relations, linear and logistic regressions were run.

RESULTS

Results showed that the household income improved with intervention (coefficient = 0.327; p = 0.002), while the capacity to pay high bills without contracting debts decreased (coefficient = 0.927; p = 0.001). We did not find enough statistically significant evidence of the influence of the intervention on skilled birth attendance (coefficient = 0.943; p = 0.135), or family planning use (coefficient = 0.216; p = 0.435) nor women's participation in the decision-making (coefficient = 0.033; p = 0.227) nor on couple's cohesion (coefficient = 0.024; p = 0.431). Food insecurity levels decreased over time regardless of being in the intervention or control area.

CONCLUSION

Empowering women while sensitizing men on gender aspects improves financial well-being (income). Time, security, and strong politics of government recognizing and framing the approach are still needed to maximize the benefit of such projects on social factors such as women's participation in decision-making and social cohesion.

Research into microfinance and ICTs: A bibliometric analysis

Information and communication technologies (ICTs) play an ever-increasing role in improving the efficiency, profitability, and sustainability of microfinance institutions. This paper aims to assess the role of ICTs in the microfinance industry by systematically reviewing the literature with bibliometric methods. In this research, a total of 347 samples (from 1998 to 2021) were selected from the Web of Science database according to the guideline of the systematic review. By performing descriptive statistical analysis, the contributing institutions, countries, journals, authors, as well as influential publications were identified. In the co-citation and co-word analysis section, three primary types of visualization-cluster views, timezone views and timeline viewswere all presented through CiteSpace. It turns out that crowdfunding, P2P lending and mobile banking have been the favorite topics. A central issue is the role of these platforms in entrepreneurship. We also proposed that applying fintech, especially blockchain and other emerging technologies, to promote financial inclusion is one of the future research trends. The findings of this study will be of interest to researchers, managers, policymakers, and evaluators and facilitate them to make well-informed decisions in their respective domains.

Integrating community-based HIV and non-communicable disease care with microfinance groups: a feasibility study in Western Kenya

BACKGROUND

The Harambee study is a cluster randomized trial in Western Kenya that tests the effect, mechanisms, and cost-effectiveness of integrating community-based HIV and non-communicable disease care within microfinance groups on chronic disease treatment outcomes. This paper documents the stages of our feasibility study conducted in preparation for the Harambee trial, which include (1) characterizing the target population and gauging recruitment capacity, (2) determining community acceptability of the integrated intervention and study procedures, and (3) identifying key implementation considerations prior to study start.

METHODS

Feasibility research took place between November 2019 and February 2020 in Western Kenya. Mixed methods data collection included surveys administered to 115 leaders of 105 community-based microfinance groups, 7 in-person meetings and two workshops with stakeholders from multiple sectors of the health system, and ascertainment of field notes and geographic coordinates for group meeting locations and HIV healthcare facilities. Quantitative survey data were analyzed using STATA IC/13. Longitude and latitude coordinates were mapped to county boundaries using Esri ArcMap. Qualitative data obtained from stakeholder meetings and field notes were analyzed thematically.

RESULTS

Of the 105 surveyed microfinance groups, 77 met eligibility criteria. Eligible groups had been in existence from 6 months to 18 years and had an average of 22 members. The majority (64%) of groups had at least one member who owned a smartphone. The definition of "active" membership and model of saving and lending differed across groups. Stakeholders perceived the community-based intervention and trial procedures to be acceptable given the minimal risks to participants and the potential to improve HIV treatment outcomes while facilitating care integration. Potential challenges identified by stakeholders included possible conflicts between the trial and existing community-based interventions, fear of group disintegration prior to trial end, clinicians' inability to draw blood for viral load testing in the community, and deviations from standard care protocols.

CONCLUSIONS

This study revealed that it was feasible to recruit the number of microfinance groups necessary to ensure that our clinical trial was sufficient powered. Elicitation of stakeholder feedback confirmed that the planned intervention was largely acceptable and was critical to identifying challenges prior to implementation.

TRIAL REGISTRATION

The original trial was prospectively registered with ClinicalTrials.gov (NCT04417127) on 4 June 2020.

Spatial analysis of the effect of microfinance on poverty and inequality in Ghana

Although microfinance is usually delivered with a spatial outlook, the literature is so far silent on the potential spatial effect of microfinance delivery. The aim of this study was, therefore, to examine the effect of microfinance intensity on spatial inequality and poverty in Ghana. Using the 6th (2012/2013) and 7th (2016/2017) rounds of data from a national survey on living standards in Ghana, the study first examined the pattern of district-level poverty and inequality in Ghana and then adopted spatial econometric techniques to explore the spatial correlation between microfinance, inequality, and poverty. The results revealed that microfinance has a significant negative impact on spatial inequality and poverty in Ghana. The spatial effect of microfinance intensity on poverty and inequality is characterized by both direct and spillover effects on neighbours. It was identified that the outreach of microfinance drives within-district disparity, whereas the disparity in microfinance credit distribution powers between-district disparity. Additionally, while there is evidence of an indirect effect, the indirect effect diffuses monotonically as the number of neighbours increases. The study's findings advocate for a complementary approach to microfinance delivery, as well as the elimination of institutional barriers that limit access, availability, and operational delivery of microfinance services in order to achieve spatially optimal microfinance delivery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40847-022-00210-3.

Microfinance loan officers before and during Covid-19: Evidence from India

The Microfinance industry has been severely affected by Covid-19. We provide detailed insights into how loan officers, the key personnel linking the lender to its borrowers, are affected in their performance and adapt their work to the pandemic. We use administrative records of an Indian Microfinance Institution and detailed panel survey data on performance, performed tasks, and work organization to document how the work environment became more challenging during the pandemic. Loan officers operate in a setting where work from home is hard to implement due to the nature of the tasks and technological constraints. The usual performance indicators appear to be mainly driven by external factors such as the nation-wide debt moratorium. Loan officers worked similar hours, but engaged less in planning activities and completed fewer of the usual tasks. Work perceptions and mental health of loan officers reflect these changes, and perceived stress was particularly high during the period of the debt moratorium.

Entrepreneurship, beekeeping, and health training to decrease community violence in Dar es Salaam, Tanzania: a pilot study for an intervention trial

Background

High unemployment rates and limited access to resources, services, and economic opportunities are associated with many types of violence. In Dar es Salaam, Tanzania, most violence is experienced by unemployed, poorly educated men between the ages of 20 and 35 years. It is expected that community violence will decrease as the incomes of those most at risk increase. However, economic opportunity through formal employment is rarely available to uneducated men in Dar es Salaam. Giving them access to economic independence through entrepreneurship training is therefore supported by the World Bank and the government of Tanzania. There has been little research on the effectiveness of programs to encourage entrepreneurship.

Methods

To evaluate the feasibility of providing entrepreneurial training programs to young men in Dar es Salaam, especially those without formal employment, a pretest-posttest pilot study was conducted drawing a sample of young men from neighborhood camps called vijiweni. There were four interventions, each implemented in a single camp: Health/Control, Entrepreneurship + Health, Beekeeping + Health, and Entrepreneurship + Beekeeping + Health. The four camps received 2, 6, 6, and 10 training sessions, respectively. No start-up capital was provided. The participants were interviewed at baseline and 3 months, 6 months, and 1 year after the sessions were completed. Data were collected on demographics, household assets, experience of violence, and income.

Results

Fifty-seven respondents attended the first session. At baseline, the camps were not meaningfully different from one another in educational attainment, number of dependents, daily income, assets, or individual members’ roles as victims, perpetrators, or witnesses of violence. Differences were found in age, occupation, and weekly income. Over a period of 2.25 years (from baseline to the end of the project), the weekly income of the Health/Control camp, which had been earning the most, decreased by 37% in a reflection of worsening economic conditions at the time. All three intervention camps increased their income: Beekeeping by 43%, All by 50%, and Entrepreneurship by 146%, with the latter almost reaching the minimum wage level. The most persistently reported constraint was insufficient start-up capital.

Conclusions

The feasibility and potential effectiveness of a short training program on entrepreneurship skills for unemployed, poorly educated young men in urban Tanzania were demonstrated in this study. It has set the stage for an intervention trial to test an updated hypothesis: A 5–7-day intervention about entrepreneurship and microfinance savings groups will lead to increased income and decreased violence.

Trial registration

ClinicalTrials.govNCT 04602416. Registered on 24 October 2020. Retrospectively registered.

Associations between hurricane exposure, food insecurity, and microfinance; a cross-sectional study in Haiti

Natural disaster and food insecurity are prevalent in Haiti. Natural disasters may cause long-term food insecurity. Microfinance programs may provide resilience against this outcome. The objectives of this study were 1) to assess the association between the impact of Hurricane Matthew and long-term food insecurity and 2) to understand whether this association varies by participants' membership in a microfinance program. In 2017-2018, we interviewed 304 Haitian female microfinance clients. We used log-binomial regression to evaluate the association between hurricane Matthew impact and long-term food insecurity, with evaluation of effect modification by timing of microfinance exposure. We found that one year after the hurricane, participants who were severely impacted by the hurricane were more likely to report poor dietary diversity and moderate to severe household hunger, compared to the less severely impacted participants. Both associations became insignificant among those who received their first microfinance loan before the hurricane. Natural disasters like hurricanes are associated with long-term food insecurity at individual and household levels. Microfinance programs might improve post-hurricane long-term food security.

The Relationship Between Household Microfinance Group Participation and Vaccine Adherence Among Children in Rural Western Kenya

INTRODUCTION

High childhood vaccine adherence is critical for disease prevention, and poverty is a key barrier to vaccine uptake. Interventions like microfinance programs that aim to lift individuals out of poverty could thus improve vaccine adherence of the children in the household. BIGPIC Family Program in rural Western Kenya provides group-based microfinance services while working to improve access to healthcare and health screenings for the local community. The aim of the present paper is to evaluate the association between household participation in BIGPIC's microfinance program and vaccine adherence among children in the household. We hypothesize that microfinance group participation will have a positive impact on vaccine adherence among children in the household.

METHODS

From 2018 to 2019, we surveyed a sample of 300 participants from two rural communities in Western Kenya, some of whom were participants in the BIGPIC Family's microfinance program. The primary outcome of interest was vaccine adherence of children in the household. Log-binomial models were used to estimate the relationship between microfinance group participation and vaccine adherence, adjusted for key covariates. We also assessed whether the relationship differed by gender of the adult respondent.

RESULTS

Microfinance group members were more likely to have all children in their households fully vaccinated [aPR (95% CI): 1.68 (1.20,2.35)] compared to non-microfinance group members. Further, the association was stronger when women were the microfinance members [PR (95% CI): 1.87 (1.27,2.76)] compared to men [PR (95% CI): 1.24 (0.81,1.90)].

CONCLUSIONS

Microfinance participation was associated with higher childhood vaccine adherence in rural Western Kenya. Microfinance interventions should be further explored as strategies to improve child health and well-being in low- and middle-income countries.

Dataset on the acceptance of islamic microfinance in Kano State, Nigeria

The present data from 194 customers of small and medium enterprises (SMEs) is about their acceptance of Islamic microfinance in Kano State, Nigeria. The dataset includes variables such as gender, age, marital status, duration as customer, account operate, annual income, type of business, service quality, perceived value, corporate image and religiosity of customers in Kano State. A survey from March to June 2019, self-administered questionnaires were used for data collection. This data may help scholars to understand how people of Kano State accept Islamic microfinance interacted with service quality, customer perceived value, corporate image and religiosity.

Women's participation in microfinance: Effects on Women's agency, exposure to partner violence, and mental health

OBJECTIVES

The health and social effects of women's microfinance participation remain debated.

METHODS

Using propensity-score methods, we assessed effects of microfinance participation on novel measures of agency; intimate partner violence (IPV) exposure; and depressive symptoms in 930 wives in Matlab, Bangladesh interviewed 11/2018-01/2019.

RESULTS

Participants, versus non-participants, were married younger (16.7 vs. 17.4 years), more often Muslim (90.7% vs. 86.2%), less schooled (5.4 vs. 6.8 grades), and more often had husbands (27.0% vs. 19.6%) and mothers (63.2% vs. 50.5%) without schooling. Participants and non-participants had similar unadjusted mean scores for prior-week depressive symptoms, prior-year IPV, and intrinsic attitudinal agency (gender-equitable attitudes; non-justification of wife beating). Participants had higher unadjusted mean scores for intrinsic voice/mobility; instrumental agency (using financial services, voice with husband, voice/mobility outside home); and collective agency. Average adjusted treatment effects were non-significant for depressive symptoms, IPV, and attitudinal intrinsic agency, and significantly favorable for other agency outcomes.

CONCLUSIONS

Microfinance participation had no adverse health effects and favorable empowerment effects in Bangladeshi wives.

POLICY IMPLICATIONS

Microfinance can empower women without adverse health effects. Social-norms programming with men and women may be needed to change gendered expectations about the distribution of unpaid labor and the rights of women.

Microfinance towards micro-enterprises development in rural Malaysia through digital finance

Microfinance is critical for the development of micro-enterprises and alleviating poverty. However, micro-enterprises are able to get microfinance services, they would face a variety of obstacles, due to the misunderstandings among many stakeholders, microfinance has not acquired widespread acceptance. Therefore, the purpose of this study is to investigate microfinance's impact on the sustainable development of Malaysia's rural micro-enterprises. Besides, digital finance is integrated into the conceptual model to further investigate their mediating impact. Data was collected from 563 rural micro-enterprises using structured questionnaires, which were then statistically analyzed using AMOS-21. The findings of the study reveal that microfinance has a positive substantial influence on rural micro-enterprises development. Moreover, digital finance partially mediates the relationship. Thus, the study concludes that microfinance institutions are needed to adopt digital finance to enhance micro enterprises' productivity through low transaction costs. The findings of the study can be useful to policymakers in the micro-enterprise sector who have a long-term vision and expect the sector to develop steadily. The study also provides scope and space for future academics and scholars to conduct further research.

Examining the evidence of microfinance on non-communicable disease health indicators and outcomes: A systematic literature review

Microfinance has emerged as an effective approach to address health outcomes, particularly infectious diseases and maternal and child health. However, there remains a significant knowledge gap about microfinance and Non-Communicable Diseases (NCDs). This review synthesises current evidence on microfinance and NCDs, including NCD-specific modifiable risks, health-seeking behaviour, and financing mechanisms of adults using microfinance services. Studies were identified through a systematic search of seven electronic databases, extracted for full-text screening, and analysed using a narrative analysis. A total of twelve articles that covered thirteen countries and four global regions were included in the review. Variations in study designs and reporting in the articles limited the ability to draw strong conclusions about microfinance and NCDs. However, the review revealed that microfinance may reduce modifiable risk factors, promote health-seeking behaviour, and reduce out-of-pocket health expenditure and catastrophic health expenditure related to NCDs. One study, however, found microfinance to be associated with negative effects of higher waist circumference, BMI and obesity rates. Overall, the review helped to identify the current gaps in knowledge, and highlighted the need to focus future research and publication on the use of microfinance to target NCDs of the poor.

Compounding crises of social reproduction: Microfinance, over-indebtedness and the COVID-19 pandemic

The COVID-19 pandemic has hit at a time when microfinance is at its historical peak, with an estimated 139 million microfinance customers globally. Cambodia's microfinance sector is one of the fastest growing, and like others in the Global South has moved from offering entrepreneurial capital to everyday liquidity, and even disaster relief. In this Viewpoint, however, we argue that the promotion of microfinance as market-based relief and recovery from the pandemic should be a source of concern, not comfort. We firstly suggest that as a result of the health and economic impacts associated with COVID-19, credit-taking is likely to escalate further in terms of the number of borrowers and loan amounts. Second, we contend that a growing reliance on MFIs will leave households undernourished, and further vulnerable to its disciplining and extractive impulses. Third, we argue that the interplay between over-indebtedness, pre-existing malnutrition challenges, and the global public health crisis of COVID-19 represents a major challenge to gender equality and sustainable development. Coordination between the Cambodian government, microfinance lenders, international investors, and development partners is vital to offer debt relief. Furthermore, to reverse the reliance of so many households on the microfinance industry for survival, inclusive socio-economic policies and public welfare services must be prioritised.

The relationship between a microfinance-based healthcare delivery platform, health insurance coverage, health screenings, and disease management in rural Western Kenya

BACKGROUND

Structural barriers often prevent rural Kenyans from receiving healthcare and diagnostic testing. The Bridging Income Generation through grouP Integrated Care (BIGPIC) Family intervention facilitates microfinance groups, provides health screenings and treatment, and delivers education about health insurance coverage to address some of these barriers. This study evaluated the association between participation in BIGPIC microfinance groups and health screening/disease management outcomes.

METHODS

From November 2018 to March 2019, we interviewed a sample of 300 members of two rural communities in Western Kenya, 100 of whom were BIGPIC microfinance members. We queried participants about their experiences with health screening and disease management for HIV, diabetes, hypertension, tuberculosis, and cervical cancer. We used log-binomial regression models to estimate the association between microfinance membership and each health outcome, adjusting for key covariates.

RESULTS

Microfinance members were more likely to be screened for most of the health conditions we queried, including those provided by BIGPIC [e.g. diabetes: aPR (95% CI): 3.46 (2.60, 4.60)] and those not provided [e.g. cervical cancer: aPR (95% CI): 2.43 (1.21, 4.86)]. Microfinance membership was not significantly associated with health insurance uptake and disease management outcomes.

CONCLUSIONS

In rural Kenya, a microfinance program integrated with healthcare delivery may be effective at increasing health screening. Interventions designed to thoughtfully and sustainably address structural barriers to healthcare will be critical to improving the health of those living in low-resource settings.

Human-centered design as a guide to intervention planning for non-communicable diseases: the BIGPIC study from Western Kenya

BACKGROUND

Non-communicable disease (NCD) care in Sub-Saharan Africa is challenging due to barriers including poverty and insufficient health system resources. Local culture and context can impact the success of interventions and should be integrated early in intervention design. Human-centered design (HCD) is a methodology that can be used to engage stakeholders in intervention design and evaluation to tailor-make interventions to meet their specific needs.

METHODS

We created a Design Team of health professionals, patients, microfinance officers, community health workers, and village leaders. Over 6 weeks, the Design Team utilized a four-step approach of synthesis, idea generation, prototyping, and creation to develop an integrated microfinance-group medical visit model for NCD. We tested the intervention with a 6-month pilot and conducted a feasibility evaluation using focus group discussions with pilot participants and community members.

RESULTS

Using human-centered design methodology, we designed a model for NCD delivery that consisted of microfinance coupled with monthly group medical visits led by a community health educator and a rural clinician. Benefits of the intervention included medication availability, financial resources, peer support, and reduced caregiver burden. Critical concerns elicited through iterative feedback informed subsequent modifications that resulted in an intervention model tailored to the local context.

CONCLUSIONS

Contextualized interventions are important in settings with multiple barriers to care. We demonstrate the use of HCD to guide the development and evaluation of an innovative care delivery model for NCDs in rural Kenya. HCD can be used as a framework to engage local stakeholders to optimize intervention design and implementation. This approach can facilitate the development of contextually relevant interventions in other low-resource settings.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02501746, registration date: July 17, 2015.

Promoting positive maternal, newborn, and child health behaviors through a group-based health education and microfinance program: a prospective matched cohort study in western Kenya

BACKGROUND

Chamas for Change (Chamas) is a group-based health education and microfinance program for pregnant and postpartum women that aims to address inequities contributing to high rates of maternal and infant mortality in rural western Kenya. In this prospective matched cohort study, we evaluated the association between Chamas participation and facility-based delivery. We additionally explored the effect of participation on promoting other positive maternal, newborn and child health (MNCH) behaviors.

METHODS

We prospectively compared outcomes between a cohort of Chamas participants and controls matched for age, parity, and prenatal care location. Between October-December 2012, government-sponsored community health volunteers (CHV) recruited pregnant women attending their first antenatal care (ANC) visits at rural health facilities in Busia County to participate in Chamas. Women enrolled in Chamas agreed to attend group-based health education and microfinance sessions for one year; controls received the standard of care. We used descriptive analyses, multivariable logistic regression models, and random effect models to compare outcomes across cohorts 12 months following enrollment, with α set to 0.05.

RESULTS

Compared to controls (n = 115), a significantly higher proportion of Chamas participants (n = 211) delivered in a health facility (84.4% vs. 50.4%, p < 0.001), attended at least four ANC visits (64.0% vs. 37.4%, p < 0·001), exclusively breastfed to six months (82.0% vs. 47.0%, p < 0·001), and received a CHV home visit within 48 h postpartum (75.8% vs. 38.3%, p < 0·001). In multivariable models, Chamas participants were over five times as likely as controls to deliver in a health facility (OR 5.49, 95% CI 3.12-9.64, p < 0.001). Though not significant, Chamas participants experienced a lower proportion of stillbirths (0.9% vs. 5.2%), miscarriages (5.2% vs. 7.8%), infant deaths (2.8% vs. 3.4%), and maternal deaths (0.9% vs. 1.7%) compared to controls.

CONCLUSIONS

Chamas participation was associated with increased odds of facility-based delivery compared to the standard of care in rural western Kenya. Larger proportions of program participants also practiced other positive MNCH behaviors. Our findings demonstrate Chamas' potential to achieve population-level MNCH benefits; however, a larger study is needed to validate this observed effect.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03188250 (retrospectively registered 31 May 2017).

Microfinance and violence prevention: A review of the evidence and adaptations for implementation in the U.S

Microfinance programs provide access to small amounts of capital in the form of credit, savings, or financial incentives. There is evidence that microfinance reduces financial strain and reduces violence making it a promising public health approach. However, most of this evidence was generated internationally in low-resource countries; thus, it is likely that adaptations are necessary for microfinance to be effective at preventing violence in the U.S. This article reviews the evidence base for microfinance interventions on violence outcomes; outlines the potential of microfinance to prevent violence in the U.S.; and offers some possible adaptations in order to increase the likelihood that microfinance will prevent violence in the U.S. Programs might consider providing matched savings instead of small loans to individuals and providing job skills training. Furthermore, it is important for U.S. microfinance programs to engage multiple sectors and to consider additional content, such as a gender equity component and safety planning to protect those who might be in violent relationships. It is also important that these adaptations be rigorously evaluated for impacts on multiple forms of violence.

Access and utilization of financial services among poor HIV-impacted children and families in Uganda

With high prevalence of both poverty and HIV, Sub-Saharan Africa (SSA) has one of the highest numbers of unbanked individuals and families. Although the use of savings products to promote financial inclusion among poor individuals and families has increasingly become more important to policy makers in SSA, limited research exists about the mechanisms and relative importance of institutional and individual-level factors associated with access and utilization of financial services. Using survey data and administrative bank records from a randomized controlled trial in southwestern Uganda, we find that given an opportunity, poor HIV-impacted families and individuals can engage with financial institutions and accumulate savings. Additionally, individual-level factors (e.g., household wealth, child poverty, child work, and attitudes towards savings) were significantly associated with three of the eight outcomes (i.e. saved any money, average monthly total savings, and total number of deposits). Furthermore, institutional-level factors (e.g., access and proximity to the bank, matching incentive rate, and financial education) were associated with all the eight outcomes included in the analysis. Our findings indicate that poor HIV-impacted families can engage with financial institutions and save for their children, if opportunities and institutional arrangements are in place. Findings have implications for financial inclusion policy and programming that target vulnerable youth and families to engage with financial institutions and accumulate savings.

Health Education Training Embedded in a Microfinance Platform Associated with Safer Sexual Behavior in Haitian Women

Sexual health education interventions have generally yielded modest impact, but may be more successful when integrated into programs designed to alleviate poverty and empower women. Between December 2017 and February 2018, we interviewed 304 Haitian female microfinance clients, 75 of whom had received health education training delivered within their regular meetings. Participants reported six key sexual health outcomes. We used log-binomial models to estimate the association between health education training and each outcome, and tested for interaction by age and literacy status. Women with health education training reported more condom use with unfaithful partners [PR (95% CI) 1.78 (1.04, 3.02)], more HIV testing [PR (95% CI) 1.56 (1.28, 1.90)], and fewer STI symptoms [PR (95% CI) 0.37 (0.19, 0.73)], compared to women with no training. Some of the associations were stronger among older women [e.g. HIV testing: PR (95% CI) 2.09 (1.49, 2.82)] and illiterate women [e.g. condom use: PR (95% CI) 3.46 (1.05, 11.38)]. These findings add to the growing body of evidence demonstrating the potential to use microfinance programs as platforms for health education delivery, and provide the first evidence for the association in Haiti.

Microfinance Interventions and HIV Treatment Outcomes: A Synthesizing Conceptual Framework and Systematic Review

BACKGROUND

Microfinance interventions have the potential to improve HIV treatment outcomes, but the mechanisms through which they operate are not entirely clear.

OBJECTIVES

To construct a synthesizing conceptual framework for the impact of microfinance interventions on HIV treatment outcomes using evidence from our systematic review.

METHODS

We conducted a systematic review by searching electronic databases and journals from 1996 to 2018 to assess the effects of microfinance interventions on HIV treatment outcomes, including adherence, retention, viral suppression, and CD4 cell count.

RESULTS

All studies in the review showed improved adherence, retention, and viral suppression, but varied in CD4 cell count following participation in microfinance interventions-overall supporting microfinance's positive role in improving HIV treatment outcomes. Our synthesizing conceptual framework identifies potential mechanisms through which microfinance impacts HIV treatment outcomes through hypothesized intermediate outcomes.

CONCLUSION

Greater emphasis should be placed on assessing the effect mechanisms and intermediate behaviors to generate a sound theoretical basis for microfinance interventions.

Project Nova: A Combination HIV Prevention and Microfinance Intervention for Women Who Engage in Sex Work and Use Drugs in Kazakhstan

Innovative combination HIV-prevention and microfinance interventions are needed to address the high incidence of HIV and other STIs among women who use drugs. Project Nova is a cluster-randomized, controlled trial for drug-using female sex workers in two cities in Kazakhstan. The intervention was adapted from prior interventions for women at high risk for HIV and tailored to meet the needs of female sex workers who use injection or noninjection drugs. We describe the development and implementation of the Nova intervention and detail its components: HIV-risk reduction, financial-literacy training, vocational training, and a matched-savings program. We discuss session-attendance rates, barriers to engagement, challenges that arose during the sessions, and the solutions implemented. Our findings show that it is feasible to implement a combination HIV-prevention and microfinance intervention with highly vulnerable women such as these, and to address implementation challenges successfully.

Expanding health coverage in India: role of microfinance-based self-help groups

To fulfil its commitment to universal health coverage, it will be necessary for the Indian government to expand access to appropriate and affordable health services. Through the mechanism of microfinance-based self-help groups (SHGs), poor women and their families are provided not only with access to finance to improve their livelihoods but also, in many cases, with a range of basic health services. Governments and non-governmental organisations in India have implemented large-scale programmes for the promotion of SHGs. With 93 million people organised nationally, the SHGs provide an established population base that can potentially be used to extend health coverage. However, the potential for working with SHGs to improve people’s access to health services has not been an active part of the national policy discourse.​

Linking gender, extramarital affairs, and HIV: a mixed methods study on contextual determinants of extramarital affairs in rural Tanzania

BACKGROUND

Extramarital sex is a potential driver of human immunodeficiency virus (HIV) transmission for long-term couples in sub-Saharan Africa. It is increasingly recognized that preventing sexual risk behaviours requires an understanding and adjustment of sexual relationship factors beyond the individual level. We investigated the association between extramarital affairs and HIV status, factors associated with extramarital affairs, and created insights in the context and pathways for married men and women in rural Tanzania who engage in extramarital affairs.

METHODS

A cross-sectional sequential explanatory mixed method design was employed. The WHO-Social determinants of health perspective guided the study. Using logistic regression, we analysed the MZIMA project community surveillance representative sample of 3884 married partners aged 15+ residing in Ifakara town, Tanzania (2012-2013). Multinomial logistic regression analysis established the relative risk ratio (RRR) of different social and economic factors with lifetime (proxy) and recent (12 months prior to survey) extramarital affairs. Logistic regression analysis determined the association between extramarital affairs and HIV status. Semi-structured interviews and focus group discussions explored the quantitative findings, capturing the experiences and norms regarding extramarital affairs.

RESULTS

We found a significant association between lifetime (proxy) extramarital affairs and HIV infection among women only. The RRR of having extramarital affairs (lifetime proxy) was significantly higher among Village Community Bank (VICOBA) members, the re-married, consumers of alcohol, those from southern regions, non-Muslims, and those with older age. In the case of recent extramarital affairs (12 months prior to survey), associations were significant for the same variables except for religion, having an income was also associated with the outcome. Qualitative narratives reflected that, desire to prove manhood (masculinity) supported by societal normative beliefs such as; 'it is not realistic for a man to stay without extramarital partner' and religious beliefs; 'a man shall dominate a woman' encouraged men's extramarital affairs. For women, striving for financial autonomy, obligations to pay back debts borrowed from several VICOBA, and limited support from their husbands encouraged their engagement in extramarital affairs. Low relationship quality (conflict and sexual dissatisfaction) were reported to encourage both men and women's extramarital affairs.

CONCLUSIONS

The findings show that the link between extramarital affairs and HIV has a gender dimension in which women are more likely to acquire HIV through extramarital affairs (case of recent extramarital affairs (12 months prior to survey). Future programs seeking to address risk sexual behaviors in Tanzanian marriages can consider context-sensitive interventions which address aspects beyond 'individual risk' and women's financial uncertainties, and include couple's relationship quality, excessive alcohol behaviors, normative masculinity ideology and societal norms, that encourage women's economic dependence and men's engagement in multiple sexual partnerships. Microfinance projects (e.g. VICOBA) could be a platform for gender-transformative approaches, combining economic empowerment and HIV risk protection strategies.

A cluster randomized controlled trial to assess the impact on intimate partner violence of a 10-session participatory gender training curriculum delivered to women taking part in a group-based microfinance loan scheme in Tanzania (MAISHA CRT01): study protocol

Background

Worldwide, almost one third (30%) of women who have been in a relationship have experienced physical and/or sexual violence from an intimate partner. Given the considerable negative impacts of intimate partner violence (IPV) on women’s physical health and well-being, there is an urgent need for rigorous evidence on violence prevention interventions.

Methods

The study, comprising a cluster randomized controlled trial (RCT) and in-depth qualitative study, will assess the impact on women’s past year experience of physical and/or sexual IPV of a participatory gender training curriculum (MAISHA curriculum) delivered to women participating in group-based microfinance in Tanzania. More broadly, the study aims to learn more about the factors that contribute to women’s vulnerability to violence and understand how the intervention impacts on the lives of women and their families. Sixty-six eligible microfinance loan groups are enrolled and randomly allocated to: the 10-session MAISHA curriculum, delivered over 20 weeks (n = 33); or, to no intervention (n = 33). Study participants are interviewed at baseline and at 24 months post-intervention about their: household; partner; income; health; attitudes and social norms; relationship (including experiences of different forms of violence); childhood; and community. For the qualitative study and process evaluation, focus group discussions are being conducted with study participants and MAISHA curriculum facilitators. In-depth interviews are being conducted with a purposive sample of 18 participants. The primary outcome, assessed at 24 months post-intervention, is a composite of women’s reported experience of physical and/or sexual IPV during the past 12 months. Secondary outcomes include: reported experience of physical, sexual and emotional/psychological IPV during the past 12 months, attitudes towards IPV and reported disclosure of IPV to others.

Discussion

The study forms part of a wider programme of research (MAISHA) that includes: a complementary cluster RCT evaluating the impact of delivering the MAISHA curriculum to women not receiving formal group-based microfinance; an economic evaluation; and a cross-sectional survey of men to explore male risk factors associated with IPV. MAISHA will generate rigorous evidence on violence prevention interventions, as well as further insights into the different forms and consequences of violence and drivers of violence perpetration.

Trial registration

ClinicalTrials.gov ID: NCT02592252, registered retrospectively on 13 August 2015.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0546-8) contains supplementary material, which is available to authorized users.

Microfinance for women at high risk for HIV in Kazakhstan: study protocol for a cluster-randomized controlled trial

BACKGROUND

Among women at high risk for HIV and other sexually transmitted diseases (STIs), gender and economic issues limit the impact of behavioral prevention strategies. Women in Kazakhstan with dual risks of sex trading and drug use face elevated risk for HIV and STIs and may benefit from an economic empowerment intervention which combines HIV-risk reduction (HIVRR) education with financial skills-building and asset-building to promote reduced reliance on sex trading for income.

METHODS/DESIGN

The study employs a two-arm, cluster-randomized controlled trial (c-RCT) design. We will use cluster randomization to assign 350 women in approximately 50 cohorts to a traditional four-session HIV-risk-reduction intervention combined with a six-session financial literacy intervention, enrollment in a 24-session vocational training program and receipt of matched savings (HIVRR+MF); or to the four-session HIV-risk-reduction intervention alone (HIVRR). Repeated behavioral and biological assessments will be conducted at baseline, then at 6, 9, and 15 months post randomization/session 1.

DISCUSSION

This study responds to an identified need in the academic literature for rigorous testing of structural interventions, including combination microfinance and HIV-prevention interventions.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02406482 . Registered on 30 March 2015.

Cost-Effectiveness of a Savings-Led Economic Empowerment Intervention for AIDS-Affected Adolescents in Uganda: Implications for Scale-up in Low-Resource Communities

PURPOSE

Nearly 12 million children and adolescents in sub-Saharan Africa have lost one or both parents to AIDS. Within sub-Saharan Africa, Uganda has been greatly impacted, with an estimated 1.2 million orphaned children, nearly half of which have experienced parental loss due to the epidemic. Cost-effective and scalable interventions are needed to improve developmental outcomes for these children, most of whom are growing up in poverty. This article examines the direct impacts and cost-effectiveness of a savings-led family economic empowerment intervention, Bridges to the Future, that employed varying matched savings incentives to encourage investment in Ugandan children orphaned by AIDS.

METHODS

Using data from 48 primary schools in southwestern Uganda, we calculate per-person costs in each of the two treatment arms-Bridges (1:1 match savings) versus Bridges PLUS (1:2 match savings); estimate program effectiveness across outcomes of interest; and provide the ratios of per-person costs to their corresponding effectiveness.

RESULTS

At the 24-month postintervention initiation, children in the two treatment arms showed better results in health, mental health, and education when compared to the usual care condition; however, no statistically significant differences were found between treatment arms with the exception of school attendance rates which were higher for those in Bridges PLUS. Owing to the minimal cost difference between the Bridges and Bridges PLUS arms, we did not find substantial cost-effectiveness differences across the two treatment arms.

CONCLUSION

After 24 months, an economic intervention that incorporated matched savings yielded positive results on critical development outcomes for adolescents orphaned by AIDS in Uganda. The 1:1 and 1:2 match rates did not demonstrate variable levels of cost-effectiveness at 24-month follow-up, suggesting that governments intending to incorporate savings-led interventions within their social protection frameworks may not need to select a higher match rate to see positive developmental outcomes in the short term. Further research is required to understand intervention impacts and cost-effectiveness after a longer follow-up period.

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

Despite the recognized links between food insecurity, poverty, and the risk of HIV/AIDS, few randomized trials have evaluated the impact of livelihood interventions on HIV risk behaviors. The current study draws upon data collected from a qualitative process evaluation that was embedded into a pilot randomized controlled trial that tested whether a multisectoral agricultural intervention (Shamba Maisha) affected the HIV-related health of HIV-positive adults in rural Kenya. In the current study, we drew upon longitudinal, in-depth interviews with 45 intervention participants and nine control participants (N = 54) in order to examine the impacts of the intervention on gendered power and sexual risk reduction among both women and men. Female and male participants in the intervention described positive changes in sexual practices and gendered power dynamics as a result of intervention participation. Changes included reduced sexual risk behaviors, improved gender-related power dynamics, and enhanced quality of intimate relationships. These findings illuminate how a multisectoral agricultural intervention may affect inequitable gender relations and secondary transmission risk. Further research is needed to explore how to best leverage agricultural interventions to address the important intersections between poverty and inequitable gender relations that shape HIV risks.

Adult and adolescent livestock productive asset transfer programmes to improve mental health, economic stability and family and community relationships in rural South Kivu Province, Democratic Republic of Congo: a protocol of a randomised controlled trial

INTRODUCTION

People living in poverty have limited access to traditional financial institutions. Microfinance programmes are designed to meet this gap and show promise in improving income, economic productivity and health. Our Congolese-US community academic research partnership developed two livestock productive asset transfer programmes, Pigs for Peace (PFP) and Rabbits for Resilience (RFR), to address the interlinked health, social and economic well-being of individuals, their families and communities. The community-based randomised controlled trials examine the effectiveness of PFP and RFR to improve health, economic stability, and family and community relationships among male and female adults and adolescents living in 10 rural, postconflict villages of eastern Democratic Republic of Congo.

METHODS AND ANALYSIS

PFP participants include adult permanent residents of rural villages; adolescent participants in RFR include male and female adolescents 10-15 years old living in the selected rural villages. Participants were randomised to intervention or delayed control group. Participants in PFP completed baseline interview prior to intervention and follow-up interview at 6, 12 and 18 months postintervention. In RFR, participants completed baseline interview prior to intervention and follow-up interview at 6, 12 and 18 months postbaseline. The primary outcome of both trials, the change in baseline mental health distress at 18 months in the intervention group (adults, adolescents) compared to control group, is used to calculate sample size.

ETHICS AND DISSEMINATION

The Johns Hopkins Medical Institute Internal Review Board approved this protocol. A committee of respected Congolese educators and community members (due to lack of local ethics review board) approved the study. The findings will provide important information on the potential for community-led sustainable development initiatives to build on traditional livelihood (livestock raising, agriculture) to have a sustained health, economic and social impact on the individual, family and community.

TRIAL REGISTRATION NUMBER

NCT02008708, NCT02008695.

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

The objective of the Savings, Agriculture, Governance, and Empowerment for Health (SAGE4Health) study was to evaluate the impact of a large-scale multi-level economic and food security intervention on health outcomes and HIV vulnerability in rural Malawi. The study employed a quasi-experimental non-equivalent control group design to compare intervention participants (n = 598) with people participating in unrelated programs in distinct but similar geographical areas (control, n = 301). We conducted participant interviews at baseline, 18–, and 36–months on HIV vulnerability and related health outcomes, food security, and economic vulnerability. Randomly selected households (n = 1002) were interviewed in the intervention and control areas at baseline and 36 months. Compared to the control group, the intervention led to increased HIV testing (OR 1.90; 95 % CI 1.29–2.78) and HIV case finding (OR = 2.13; 95 % CI 1.07–4.22); decreased food insecurity (OR = 0.74; 95 % CI 0.63–0.87), increased nutritional diversity, and improved economic resilience to shocks. Most effects were sustained over a 3-year period. Further, no significant differences in change were found over the 3-year study period on surveys of randomly selected households in the intervention and control areas. Although there were general trends toward improvement in the study area, only intervention participants’ outcomes were significantly better. Results indicate the intervention can improve economic and food security and HIV vulnerability through increased testing and case finding. Leveraging the resources of economic development NGOs to deliver locally-developed programs with scientific funding to conduct controlled evaluations has the potential to accelerate the scientific evidence base for the effects of economic development programs on health.

Untangling the role of diverse social dimensions in the diffusion of microfinance

Ties between individuals on a social network can represent different dimensions of interactions, and the spreading of information and innovations on these networks could potentially be driven by some dimensions more than by others. In this paper we investigate this issue by studying the diffusion of microfinance within rural India villages and accounting for the whole multilayer structure of the underlying social networks. We define a new measure of node centrality, diffusion versatility, and show that this is a better predictor of microfinance participation rate than previously introduced measures defined on aggregated single-layer social networks. Moreover, we untangle the role played by each social dimension and find that the most prominent role is played by the nodes that are central on layers concerned with trust, shedding new light on the key triggers of the diffusion of microfinance.

The impact of a microsavings intervention on reducing violence against women engaged in sex work: a randomized controlled study

Background

Women who engage in sex work are at risk for experiencing violence from numerous perpetrators, including paying partners. Empirical evidence has shown mixed results regarding the impact of participation in microfinance interventions on women’s experiences of violence, with some studies demonstrating reductions in intimate partner violence (IPV) and others showing heightened risk for IPV. The current study reports on the impact of participation in a microsavings intervention on experiences of paying partner violence among women engaged in sex work in Mongolia.

Methods

Between 2011 and 2013, we conducted a two-arm, non-blinded randomized controlled trial (RCT) comparing an HIV/STI risk reduction intervention (HIVSRR) (control condition) to a combined microsavings and HIVSRR intervention (treatment condition). Eligible women (aged 18 or older, reported having engaged in unprotected sex with paying partner in past 90 days, expressed interest in microsavings intervention) were invited to participate. One hundred seven were randomized, including 50 in the control and 57 in the treatment condition. Participants completed assessments at baseline, immediate post-test following HIVSRR, and at 3-months and 6-months after completion of the treatment group intervention. Outcomes for the current study include any violence (physical and/or sexual), sexual violence, and physical violence from paying partners in the past 90 days.

Results

An intention-to-treat approach was utilized. Linear growth models revealed significant reductions over time in both conditions for any violence (β = −0.867, p < 0.001), physical violence (β = −0.0923, p < 0.001), and sexual violence (β = −1.639, p = 0.001) from paying partners. No significant differences between groups were found for any violence (β = 0.118, p = 0.389), physical violence (β = 0.091, p = 0.792), or sexual violence (β = 0.379, p = 0.114) from paying partners.

Conclusions

Microsavings participation did not significantly impact women’s risk for paying partner violence. Qualitative research is recommended to understand the cause for reductions in paying partner violence in both study conditions.

Trial registration

Evaluating a Microfinance Intervention for High Risk Women in Mongolia; NCT01861431; May 20, 2013.

Men's response to their wives' participation in microfinance: perpetration and justification of intimate partner violence in Bangladesh

OBJECTIVE

The present study adds to extant literature on the association between microfinance participation and intimate partner violence (IPV) by assessing a national sample of men married to microfinance participants. The key objective was to assess whether there was a positive association between wives' microfinance participation and men's perpetration and justification of IPV in urban areas of Bangladesh.

STUDY DESIGN

This study is based on a population-based secondary data analysis.

METHODS

In this cross-sectional study, data from a national sample of men from the 2007 Bangladesh Demographic and Health Survey were analysed using logistic regression analyses. IPV perpetration was measured using a modified Conflict Tactics Scale and justification of IPV was measured based on 'justification of wife beating' statements with which men agreed or disagreed.

RESULTS

Men married to microfinance participants were not significantly different from men married to non-participants of microfinance in terms of IPV perpetration in both urban and rural areas. However, the interaction effect of wives' microfinance participation and urban living on men's justification of IPV revealed a significant and positive beta coefficient. Specifically, wives' participation in microfinance was positively associated with men's justification of IPV in urban areas (β = 0.51, P < 0.05).

CONCLUSION

Microfinance organizations in urban areas should bundle microfinancial services with IPV screening and intervention geared toward men and women.

Microfinance participation and contraceptive decision-making: results from a national sample of women in Bangladesh

OBJECTIVES

Our objective was to assess whether microfinance participation affords greater contraceptive decision-making power to women.

STUDY DESIGN

Population based secondary data analysis.

METHODS

In this cross-sectional study using nationally representative data from the Bangladesh Demographic and Health Survey 2011 we conducted multinomial logistic regression to estimate the odds of contraceptive decision-making by respondents and their husbands based on microfinance participation. Microfinance participation was measured as a dichotomous variable and contraceptive decision-making was conceptualized based on who made decisions about contraceptive use: respondents only; their partners or husbands only; or both.

RESULTS

The odds of decision-making by the respondent, with the reference case being joint decision-making, were higher for microfinance participants, but they were not significant. The odds of decision-making by the husband, with the reference case again being joint decision-making, were significantly lower among men who were partnered with women who participated in microfinance (RRR = 0.70, P < 0.01).

CONCLUSION

Microfinance participation by women allowed men to share decision-making power with their wives that resulted in higher odds of joint decision-making.

A systematic review of microfinance and women's health literature: Directions for future research

While growing evidence suggests that microfinance is an effective approach for improved women's health, a significant gap remains in our understanding. The objective of this review is to synthesise the findings from published literature focused on microfinance and health issues particularly affecting women, including HIV/AIDS, reproductive health, mental health, and violence. Forty-one articles that examine the impact of microfinance participation on women's health were identified through a systematic search of electronic databases, coded using a structured abstraction form, and synthesised. Review results indicate that the impact of microfinance on women's health is an area in great need of research and publication attention. Varied quality and reporting in the identified articles restricted the ability to draw concrete conclusions regarding the relationship between microfinance participation and women's health, but led to the identification of current gaps in existing published research. Future research should work to address the recommendations provided in order to offer additional evidence to better understand the use of microfinance programming as a structural intervention to improve women's health.

Effect of combining a health program with a microfinance-based self-help group on health behaviors and outcomes

Objectives

Women's participation in microfinance-based self-help groups (SHGs) and the resultant social capital may provide a basis to address the gap in health attainment for poor women and their children. We investigated the effect of combining a health program designed to improve health behaviours and outcomes with a microfinance-based SHG program.

Design

A mixed method study was conducted among 34 villages selected from three blocks or district subdivisions of India; one in Gujarat, two in Karnataka.

Methods

A set of 17 villages representing new health program areas were pair-matched with 17 comparison villages. Two rounds of surveys were conducted with a total of 472 respondents, followed by 17 key informant interviews and 17 focus group discussions.

Results

Compared to a matched comparison group, women in SHGs that received the health program had higher odds of delivering their babies in an institution (OR: 5.08, 95% CI 1.21–21.35), feeding colostrum to their newborn (OR: 2.83, 95% CI 1.02–5.57), and having a toilet at home (OR: 1.53, 95% CI 0.76–3.09). However, while the change was in the expected direction, there was no statistically significant reduction in diarrhoea among children in the intervention community (OR: 0.86, 95% CI 0.42–1.76), and the hypothesis that the health program would result in decreased out-pocket expenditures on treatment was not supported.

Conclusion

Our study found evidence that health programs implemented with microfinance-based SHGs is associated with improved health behaviours. With broad population coverage of SHGs and the social capital produced by their activities, microfinance-based SHGs may provide an avenue for addressing the health needs of poor women.

•

Combining a health program with SHGs is associated with an improvement in key health behaviours in the study population.

•

However, the program led to no significant improvement in diarrhoea among children, and no effect on spending on treatment.

•

The structure of SHGs and duration of association played a role in promoting trust between members and the host organization.

•

Working with SHGs provides a basis for addressing the gap in health attainment for women and their children.

Shamba Maisha: Pilot agricultural intervention for food security and HIV health outcomes in Kenya: design, methods, baseline results and process evaluation of a cluster-randomized controlled trial

BACKGROUND

Despite advances in treatment of people living with HIV, morbidity and mortality remains unacceptably high in sub-Saharan Africa, largely due to parallel epidemics of poverty and food insecurity.

METHODS/DESIGN

We conducted a pilot cluster randomized controlled trial (RCT) of a multisectoral agricultural and microfinance intervention (entitled Shamba Maisha) designed to improve food security, household wealth, HIV clinical outcomes and women's empowerment. The intervention was carried out at two HIV clinics in Kenya, one randomized to the intervention arm and one to the control arm. HIV-infected patients >18 years, on antiretroviral therapy, with moderate/severe food insecurity and/or body mass index (BMI) <18.5, and access to land and surface water were eligible for enrollment. The intervention included: 1) a microfinance loan (~$150) to purchase the farming commodities, 2) a micro-irrigation pump, seeds, and fertilizer, and 3) trainings in sustainable agricultural practices and financial literacy. Enrollment of 140 participants took four months, and the screening-to-enrollment ratio was similar between arms. We followed participants for 12 months and conducted structured questionnaires. We also conducted a process evaluation with participants and stakeholders 3-5 months after study start and at study end.

DISCUSSION

Baseline results revealed that participants at the two sites were similar in age, gender and marital status. A greater proportion of participants at the intervention site had a low BMI in comparison to participants at the control site (18% vs. 7%, p = 0.054). While median CD4 count was similar between arms, a greater proportion of participants enrolled at the intervention arm had a detectable HIV viral load compared with control participants (49% vs. 28%, respectively, p < 0.010). Process evaluation findings suggested that Shamba Maisha had high acceptability in recruitment, delivered strong agricultural and financial training, and led to labor saving due to use of the water pump. Implementation challenges included participant concerns about repaying loans, agricultural challenges due to weather patterns, and a challenging partnership with the microfinance institution. We expect the results from this pilot study to provide useful data on the impacts of livelihood interventions and will help in the design of a definitive cluster RCT.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov, NCT01548599.

Providing primary health care through integrated microfinance and health services in Latin America

The simultaneous burdens of communicable and chronic non-communicable diseases cause significant morbidity and mortality in middle-income countries. The poor are at particular risk, with lower access to health care and higher rates of avoidable mortality. Integrating health-related services with microfinance has been shown to improve health knowledge, behaviors, and access to appropriate health care. However, limited evidence is available on effects of fully integrating clinical health service delivery alongside microfinance services through large scale and sustained long-term programs. Using a conceptual model of health services access, we examine supply- and demand-side factors in a microfinance client population receiving integrated services. We conduct a case study using data from 2010 to 2012 of the design of a universal screening program and primary care services provided in conjunction with microfinance loans by Pro Mujer, a women's development organization in Latin America. The program operates in Argentina, Bolivia, Mexico, Nicaragua, and Peru. We analyze descriptive reports and administrative data for measures related to improving access to primary health services and management of chronic diseases. We find provision of preventive care is substantial, with an average of 13% of Pro Mujer clients being screened for cervical cancer each year, 21% receiving breast exams, 16% having a blood glucose measurement, 39% receiving a blood pressure measurement, and 46% having their body mass index calculated. This population, with more than half of those screened being overweight or obese and 9% of those screened having elevated glucose measures, has major risk factors for diabetes, high blood pressure, and cardiovascular disease without intervention. The components of the Pro Mujer health program address four dimensions of healthcare access: geographic accessibility, availability, affordability, and acceptability. Significant progress has been made to meet basic health needs, but challenges remain to ensure that health care provided is of reliable quality to predictably improve health outcomes over time.

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

Background

Poverty 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.

Methods

In 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.

Discussion

In 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.