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

Craig R Cohen, Rachel L Steinfeld, Elly Weke, Elizabeth A Bukusi, Abigail M Hatcher, Stephen Shiboski, Richard Rheingans, Kate M Scow, Lisa M Butler, Phelgona Otieno, Shari L Dworkin, Sheri D Weiser, Craig R Cohen, Rachel L Steinfeld, Elly Weke, Elizabeth A Bukusi, Abigail M Hatcher, Stephen Shiboski, Richard Rheingans, Kate M Scow, Lisa M Butler, Phelgona Otieno, Shari L Dworkin, Sheri D Weiser

Abstract

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.

Keywords: Agriculture; Food insecurity; HIV; Intervention; Livelihoods; Microfinance.

Figures

Figure 1
Figure 1
Shamba Maishacausal framework
Figure 2
Figure 2
Shamba Maishaintervention framework
Figure 3
Figure 3
Shamba Maishaconsort diagram

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