Microfinance and health interventions: Factors influencing loan repayment success with young men in Dar es Salaam, Tanzania

Economic outcomes among microfinance group members receiving community-based chronic disease care: Cluster randomized trial evidence from Kenya

BACKGROUND

Poverty can be a robust barrier to HIV care engagement. We assessed the extent to which delivering care for HIV, diabetes and hypertension within community-based microfinance groups increased savings and reduced loan defaults among microfinance members living with HIV.

METHODS

We analyzed cluster randomized trial data ascertained during November 2020-May 2023 from 57 self-formed microfinance groups in western Kenya. Groups were randomized 1:1 to receive care for HIV and non-communicable diseases in the community during regular microfinance meetings (intervention) or at a health facility during routine appointments (standard care). Community and facility care provided clinical evaluations, medications, and point-of-care testing. The trial enrolled 900 microfinance members, with data collected quarterly for 18-months. We used a two-part model to estimate intervention effects on microfinance shares purchased, and a negative binomial regression model to estimate differences in loan default rates between trial arms. We estimated effects overall and by participant characteristics.

RESULTS

Participants' median age and distance from a health facility was 52 years and 5.6 km, respectively, and 50% reported earning less than $50 per month. The probability of saving any amount (>$0) through purchasing microfinance shares was 2.7 percentage points higher among microfinance group members receiving community vs. facility care. Community care recipients and facility care patients saved $44.90 and $25.24 over 18-months, respectively, and the additional amount saved by community care recipients was statistically significant (p = 0.036). Overall and in stratified analyses, loan defaults rates were not statistically significantly different between community and facility care patients.

CONCLUSIONS

Receiving integrated care in the community was significantly associated with modest increases in savings. We did not find any significant association between community-delivered care and reductions in loan defaults among HIV-positive microfinance group members. Longer follow up examination and formal mediation analyses are warranted.

Development and implementation of a process evaluation for intervention quality improvement of a community-based behavioral HIV intervention trial in Tanzania

Aim

Process evaluations for social and behavioral interventions are increasingly important as interventions become more complex and multi-faceted. Conducting process evaluations in low-resource international settings can be challenging. Process evaluations in low-resource international settings can help inform and improve quality of ongoing intervention implementation. We conducted a process evaluation of a cluster-randomized controlled trial to assess the efficacy of a microfinance and health leadership program on sexually transmitted infections and intimate partner violence perpetration among young men in Tanzania.

Subject and Methods

Our trial included 1,491 participants and the intervention lasted two years. We collected process data on microfinance loan uptake and repayment, and health leaders' health conversations with peers to monitor intervention reach and dose received. We developed a database system that allowed offline data collection and synced to a central database when internet was accessible. Research staff in the U.S. accessed data from the central database to analyze and create regular implementation reports.

Results

Process graphical reports facilitated identification of implementation challenges and enabled us to resolve issues before they worsened. For example, from a group with low microfinance loan repayment we learned area participants perceived the loan to be a grant, and then we clarified the misinformation with participants.

Conclusions

The process evaluation helped inform ongoing intervention implementation, including approaches to improve reach and uptake of interventions. Field staff time was protected by systemizing the sharing of data processing and analyses across the global team.

A controlled pilot intervention on community violence prevention, financial and social capital generation in Dar Es Salaam, Tanzania

BACKGROUND

Community violence has been found to be highly prevalent in Dar es Salaam, Tanzania. Increasing socioeconomic inequality has been outlined as one of the main causes of community violence. This controlled pilot trial aimed at evaluating the impact of beekeeping and entrepreneurship training on community violence exposure, financial and social capital generation, and employment structure.

METHODS

Poisson regression was used to compare pre- and post-intervention risk ratios for community violence exposure. Linear regression was used to depict change in weekly income and utu scores. Employment rate structures were determined pre- and post-intervention.

RESULTS

This study reports that compared to the Control arm beekeeping and entrepreneurship training appears to have protected young men in Dar es Salaam from exposure to community violence (All = 0.62 (0.40-0.96), Beekeeping = 0.57 (0.30-1.08), Entrepreneurship = 0.62 (0.33-1.17)), while increasing financial (All = 23,145 (- 27,155 - 73,444), Beekeeping = 29,310 (- 26,079 - 84,698), Entrepreneurship = 82,334 (12,274 - 152,293)) and partially also social capital (All = - 0.24 (- 1.35-0.87), Beekeeping = 0.85 (- 0.26-1.96), Entrepreneurship = 0.30 (- 1.16-1.77)). Financial dependency across all arms was reduced from 29.1 to 2.2%.

CONCLUSIONS

Our study reports that beekeeping training and entrepreneurship seminars appear to have a protective effect against exposure to community violence among young men in Dar es Salaam, while partially also increasing financial and social capital, as well as reducing financial dependency. We recommend that these results should lay the foundation for an adequately powered randomized trial to confirm the study's efficacy.

TRIAL REGISTRATION

retrospectively registered at ClinicalTrials.gov (Identifier: NCT04602416; October 26, 2020).

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.

A review of prospective pathways and impacts of COVID-19 on the accessibility, safety, quality, and affordability of essential medicines and vaccines for universal health coverage in Africa

Background

The ongoing pandemic of coronavirus disease 2019 (COVID-19) has the potential to reverse progress towards global targets. This study examines the risks that the COVID-19 pandemic poses to equitable access to essential medicines and vaccines (EMV) for universal health coverage in Africa.

Methods

We searched medical databases and grey literature up to 2 October 2020 for studies reporting data on prospective pathways and innovative strategies relevant for the assessment and management of the emerging risks in accessibility, safety, quality, and affordability of EMV in the context of the COVID-19 pandemic. We used the resulting pool of evidence to support our analysis and to draw policy recommendations to mitigate the emerging risks and improve preparedness for future crises.

Results

Of the 310 records screened, 134 were included in the analysis. We found that the disruption of the international system affects more immediately the capability of low- and middle-income countries to acquire the basket of EMV. The COVID-19 pandemic may facilitate dishonesty and fraud, increasing the propensity of patients to take substandard and falsified drugs. Strategic regional cooperation in the form of joint tenders and contract awarding, joint price negotiation and supplier selection, as well as joint market research, monitoring, and evaluation could improve the supply, affordability, quality, and safety of EMV. Sustainable health financing along with international technology transfer and substantial investment in research and development are needed to minimize the vulnerability of African countries arising from their dependence on imported EMV. To ensure equitable access, community-based strategies such as mobile clinics as well as fees exemptions for vulnerable and under-served segments of society might need to be considered. Strategies such as task delegation and telephone triage could help reduce physician workload. This coupled with payments of risk allowance to frontline healthcare workers and health-literate healthcare organization might improve the appropriate use of EMV.

Conclusions

Innovative and sustainable strategies informed by comparative risk assessment are increasingly needed to ensure that local economic, social, demographic, and epidemiological risks and potentials are accounted for in the national COVID-19 responses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00666-8.

Social innovation in sexual health: a scoping review towards ending the HIV epidemic

As donor financial support decreases, ending the HIV epidemic in Asia will require novel and sustainable approaches. Social innovation, a community-engaged process that links social change and health improvement, may be useful for helping to end the HIV epidemic in Asia. A scoping review to examine social innovation strategies in sexual health for the Asian region was conducted. The research identified focused on three types of social innovation: (1) microfinance; (2) social entrepreneurship; and (3) social enterprise. Microfinance provides financial opportunities (e.g. banking services, job opportunities) to spur local entrepreneurship and healthier behaviours. Social entrepreneurship uses business principles and tools (e.g. crowdsourcing, human-centred design) to improve health. Social enterprise is a business with a social mission. Further research is needed to measure the efficacy and cost-effectiveness of social innovation strategies in improving HIV services.

Microfinance and Peer Health Leadership Intervention Implementation for Men in Dar es Salaam, Tanzania: A Qualitative Assessment of Perceived Economic and Health Outcomes

Men in sub-Saharan Africa continue to experience health disparities that are exacerbated by low employment. This study qualitatively assessed men's perceptions of the economic and health-care-seeking effects of participation in an integrated microfinance and peer health leadership intervention on violence and HIV risk reduction in Tanzania. Three focus group discussions with 27 men, aged 20 to 44 years, examined the perceived effects on income generation, employability, mental health, and uptake of HIV and related health services. All discussions were recorded, transcribed, and analyzed using deductive and inductive coding methods. Men reported that the benefits of the intervention included increased employability and income-earning activities due to greater access to entrepreneurial training, low-interest microfinancing, and male-oriented group supports to start or strengthen their businesses. Increased wages through business or other forms of employment were also attributed to men's lower anxiety and distress as financial providers for their families. However, men indicated that apart from the uptake of free HIV testing services, there was limited change in overall health-care-seeking behavior given the high clinic fees and lost time to earn income when attending routine health visits. Men recommended that future microfinance and health promotion interventions provide larger loan amounts, less frequent repayment intervals, and access to health and social insurance. Microfinance and peer health leadership interventions may help to address economic and health disparities in poor, urban men. Efforts are needed to assist lower income men in accessing financial tools as well as fee-based preventive and health-care services.

Results from a cluster-randomized trial to evaluate a microfinance and peer health leadership intervention to prevent HIV and intimate partner violence among social networks of Tanzanian men

Despite calls to engage men in HIV and intimate partner violence (IPV) prevention efforts, effective approaches to reach and engage men in low-resource, high-HIV prevalence settings are limited. We identified and engaged social networks of mostly young men in a study designed to evaluate the efficacy of a combined microfinance and peer health leadership intervention to prevent HIV and IPV. We conducted a cluster-randomized trial among 60 social networks locally referred to as "camps" within Dar es Salaam, Tanzania. Camps were randomly assigned (1:1) to a microfinance and peer health leadership intervention or a control condition that received a brief delayed intervention after the study's conclusion. Allocation was not masked to participants or researchers. Behavioral assessments were conducted at baseline and 30-months post-intervention launch, with biological samples drawn at 30-months to test for sexually-transmitted infections (STIs). Primary outcomes included prevalence of STIs and past-year IPV perpetration. Secondary outcomes included STI sexual risk behaviors and past-year HIV testing. Proximal intervention targets included inequitable gender norm attitudes and hope. A modified Poisson regression approach was used to estimate intention-to-treat intervention effects on outcomes assessed at the 30-month follow-up. We enrolled 1,258 men within 60 camps. Of these men, 1,029 (81.8%) completed the 30-month follow-up. There were no differences by condition in STI prevalence, IPV perpetration, or sexual risk behaviors at the 30-month follow-up. Intervention participants reported greater levels of past-year HIV testing, controlling for baseline testing (aRR 1.13 95% CI 1.005-1.28). They also reported significantly lower levels of inequitable gender norm attitudes (adjusted effect -0.11, 95% CI -0.21-0.003). We successfully engaged and retained social networks of men in this multilevel intervention study. While we did not see an effect on the primary outcomes, our intervention successfully improved HIV testing and reduced inequitable gender norm attitudes.

Decision-making and cash spending patterns of adolescent girls and young women participating in a cash-transfer intervention in Tanzania: Implications for sexual health

Although cash transfers (CT) have been recommended as a strategy to address structural drivers of HIV, the evidence of the effects of CT on sexual risk and HIV outcomes is mixed. This could partly be due to CT implementation dynamics and beneficiary interpersonal factors. We conducted an assessment of CT component of the DREAMS programme in Tanzania. We explored how AGYW spent their CT over time, to whom they disclosed cash receipt, and where they sought advice on CT use. The study employed qualitative research methods including: 20 longitudinal in-depth interviews (IDIs) and 60 cross-sectional IDIs with AGYW in the CT programme. Data were analysed thematically. AGYW use of CT fell into five categories: business development, survival, self-care, helping family, and savings. The primary uses of CT funds were investment in businesses and livestock for savings. AGYW use of cash changed over instalments. AGYW consulted a variety of sources when deciding on how to use the cash, primarily mothers, programme personnel, and long-term partners/husbands. CT programmes that give cash directly to AGYW and have a strong entrepreneurial mentorship component could have implications for HIV prevention, SRH, and overall social and economic development.