Comparing the effect of a multisectoral agricultural intervention on HIV-related health outcomes between widowed and married women

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Chapter 1

Abstract

Introduction: Widowed women make up eighteen to forty percent of the twelve million women living with HIV in eastern and southern Africa. Widowhood has also been associated with greater HIV morbidity and mortality. We compared the effectiveness of a multisectoral climate adaptive agricultural livelihood intervention (called Shamba Maisha) on food insecurity, and HIV related health outcomes among widowed and married women living with HIV in western Kenya.

Methods: We implemented Shamba Maisha using a cluster-randomized control trial design. The intervention arm received a one hundred seventy-five U.S. dollar in-kind loan to purchase a micro-irrigation pump, seeds, and fertilizer, and received eight training sessions on sustainable agriculture and financial management. Study outcomes were measured every six months over a twenty-four month follow-up period and trends in outcomes assessed using multilevel mixed-effects models.

Results: The trial enrolled two hundred thirty-two (sixty-one point five percent) married and one hundred forty-five (thirty-eight point five percent) widowed women. Widowed women (mean age forty-two point eight plus or minus eight point four years) were older than married women (thirty-five point eight plus or minus nine point zero years). Almost all widowed women (ninety-seven point two percent) self-identified as household heads compared to ten point eight percent of married women. Comparing widowed vs married women, reduction in food insecurity (negative three point one three, ninety-five percent confidence interval negative four point four two, negative one point eight four vs. negative three point zero eight, ninety-five percent confidence interval negative four point one five, negative two point zero two), depressive symptoms (negative zero point two one, ninety-five percent confidence interval negative zero point three six, negative zero point zero seven vs. negative zero point one nine, ninety-five percent confidence interval negative zero point two nine, negative zero point zero eight), internalized stigma (negative zero point three three, ninety-five percent confidence interval negative zero point five five, negative zero point one one vs. negative zero point three eight, ninety-five percent confidence interval negative zero point five seven, negative zero point one nine), and anticipated stigma (negative zero point four six, ninety-five percent confidence interval negative zero point six five, negative zero point two eight vs. negative zero point three five, ninety-five percent confidence interval negative zero point five zero, negative zero point two one) was similar for both groups. In contrast, improvements in social support (negative two point two two, ninety-five percent confidence interval negative three point eight five, negative zero point five nine vs. negative four point zero zero, ninety-five percent confidence interval negative five point one six, negative two point eight four; P equals zero point zero eight) and reduction in enacted stigma (zero point zero one, ninety-five percent confidence interval negative zero point zero six, zero point zero eight vs. negative zero point one four, ninety-five percent confidence interval negative zero point two zero, negative zero point zero nine; P is less than zero point zero one) were weaker for widowed than married women.

Conclusions: Our study is among the first comparing the effect of a livelihood intervention on HIV health outcomes among widowed and married women. Widowed women experienced similar benefits as married women on individual-level outcomes, but weaker benefit on outcomes dependent on their external environment like enacted stigma and social support. Future trials and programs targeting widowed women should bolster stigma reduction and social support.

One. Introduction

Among twelve million women living with HIV and AIDS in eastern and southern Africa, an estimated two point two to four point eight million are widows. Widowed women have between two and six times higher odds of living with HIV and AIDS than married women or women single unmarried. In Kenya, the HIV prevalence among widows in two thousand thirteen ranged between seventeen point zero and forty-four point two percent. Historically, widowhood has had a complex yet less scrutinized relationship with HIV and AIDS. In the ninety's, HIV and AIDS became known as a "widows' disease" due high AIDS-related mortality among men that left women both widowed and HIV infected. This view of widows as HIV carriers corrupted traditional socio-economic support systems for widows. Practices such as widow inheritance shifted from clan-based support system to a commercialized and exploitative system where non-relative widow inheritors have multiple and concurrent sexual relationships with widows, increasing the risk and burden of HIV among widows.

The social and economic effects of HIV and AIDS, including the collapse of traditional support systems for widows, has left widows living with HIV and AIDS with poorer health outcomes than their non-widowed counterparts. Widows living with HIV and AIDS are more likely to be accused of killing their husbands and as result experience social isolation, reduced social support and property disinheritance, all of which affect their mental health and limit their livelihoods and food security. Food insecurity exposes women living with HIV and AIDS to nutrient deficiencies, lowers their adherence to HIV treatment, and increases their depressive symptoms. This bidirectional relationship between food insecurity and HIV and AIDS increases HIV morbidity and mortality with widows reporting lower ART initiation, higher morbidity and higher depressive symptoms compared to married women.

Because of the association of food insecurity and HIV/AIDS, we developed a multisectoral agricultural livelihood intervention to improve food security and physical and mental health outcomes among people living with HIV/AIDS. Shamba Maisha, "farming for life", was an agriculture and finance intervention trial implemented in western Kenya, a region with a HIV prevalence that is thrice the national average. While there were no effects on HIV outcomes, the main Shamba Maisha study showed benefits on food security, depression, stigma, empowerment, and social support. This study is a sub-analysis of Shamba Maisha data, comparing HIV health and mental health outcomes between widowed and married women after the intervention.

Two. Methods

Two point two. Study design and population

Two point three. Outcome measures

Two point four. Statistical analysis

Three. Results

Three point two. Twenty-four-Month trends for widowed and married women

Three point three. Differences in intervention effects between widowed and married women

Four. Discussion

Five. Conclusion

Supplementary Material

Role of the funder/sponsor

Data availability

Overview

The research investigates how a multisectoral agricultural intervention impacts food insecurity and health outcomes in widowed versus married women living with HIV. It also emphasizes the need for tailored support for widowed women to improve their health outcomes in relation to external stigma and social support.

Key Points

1The study compares health outcomes between widowed and married women living with HIV in response to an agricultural intervention
2Widowed women experienced similar benefits as married women but had weaker improvements in social support and stigma reduction
3The intervention aimed to enhance food security, health, and well-being for women affected by HIV
4Findings suggest the need for programs specifically addressing stigma and social support for widowed women living with HIV

Details

Authors: Jackline A. Odhiambo, Sheri D. Weiser, Edward A. Frongillo, Rachel L. Burger, Elly Weke, Pauline Wekesa, Elizabeth A. Bukusi, Craig R. Cohen
Category: Health and Medicine

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