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Background: Food insecurity remains a major obstacle to achieving health and well-being for individuals living with HIV in western Kenya. Studies have shown that pregnant women are vulnerable to experiencing food insecurity worldwide, with significant consequences for both maternal and child health. The Shamba Maisha cluster randomized controlled trial in western Kenya (which means “farming for life” in Swahili) tested the effects of a multisectoral livelihood intervention consisting of agricultural and finance trainings, farm inputs, and a loan on health and food security among 746 farmers living with HIV in Kisumu, Homa Bay, and Migori Counties. Objectives: We conducted a qualitative substudy within the Shamba Maisha trial to understand the experiences and perspectives of pregnant women living with HIV enrolled in the trial. Methods: Thirty women who had experienced a pregnancy during the Shamba Maisha study period, comprising 20 women in the intervention arm and 10 women in the control arm, completed in-depth interviews using a semistructured interview guide. Results: Intervention participants interviewed noted improvements in maternal nutrition compared with previous pregnancies, which they attributed to the livelihood intervention. Key identified pathways to improved nutrition included improved access to vegetables, increased variety of diet through vegetable sales, and improved nutritional awareness. Women in the intervention arm also perceived increased weight gain compared with prior pregnancies and increased strength and energy throughout pregnancy. Conclusions: Livelihood interventions represent a promising solution to alleviate food insecurity for pregnant women in order to improve maternal and child health outcomes. This trial was registered at clinicaltrials.gov as NCT02815579.
We conducted a qualitative substudy nested within the Shamba Maisha RCT ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT02815579″,”term_id”:”NCT02815579″}}NCT02815579). For Shamba Maisha, 746 men and women living with HIV and on ART aged 18–60 y who met criteria for malnutrition or food insecurity at baseline were enrolled at 16 paired facilities in Kisumu, Homa Bay, and Migori Counties in western Kenya. Participants at 8 intervention sites received the Shamba Maisha intervention consisting of the following components: a series of group trainings on sustainable farming practices and financial management; the “MoneyMaker Max” pump, a low-cost treadle micro-irrigation pump; and a commodity loan of ∼$175 in value, issued upon completion of a down payment, that was used to purchase the pump and other farming implements including seeds, fertilizers, and pesticides. Data were collected at home and the clinic every 6 mo for 2 y after enrollment. Data collection was completed in December 2019. To assess the experiences of pregnant and recently pregnant women enrolled in the trial and the impact of the intervention on maternal health, we conducted a qualitative substudy with recently and currently pregnant female index participants (n = 30). All women interviewed were enrolled in the trial and, if in the intervention group, had paid the down payment and received the components of the commodity loan. Research assistants at all 16 study facilities identified currently and recently pregnant women through record review and subsequently recruited participants through phone calls or discussions during scheduled study visits. All 30 participants who met the inclusion criteria and were approached agreed to be interviewed. For currently pregnant women, we recruited them at ≥20 weeks of gestation at time of interview, as confirmed by clinic chart records or self-reported estimated date of delivery, to ensure that women could speak in detail about their pregnancy thus far and any potential impact of the study intervention. For recently pregnant women, we recruited women who had given birth within approximately the last year from the date of interview, as confirmed by chart records or self-reported delivery date, to promote accurate recall of events and ensure that their participation in the Shamba Maisha trial coincided with their pregnancy. Similarly, we excluded women whose most recent pregnancy did not result in a live birth, in order to capture pregnancies of longer duration and thus maximize the detail that participants were able to provide about any changes experienced throughout pregnancy. We chose to interview both intervention (n = 20) and control (n = 10) participants in order to compare perceptions and themes between the 2 groups, and to determine whether impacts and mechanisms described by intervention participants were related to the intervention or to study participation more broadly. Interviews were conducted in local languages (Dholuo, Swahili, and English) by a team of 3 female qualitative interviewers who are fluent in these languages. They were further trained on qualitative interviewing technique during a 2-d training workshop that included both observed mock and pilot interviews. Each interviewer met with a study investigator (AM) for an in-depth feedback session after completion of the pilot interview, and study investigators (AM, SDW) provided regular feedback based on detailed review of transcripts throughout the interview process. A semistructured guide was developed by members of our study team before the interviews. The guide contained a list of main questions organized by topic, as well as suggested follow-up questions and probes beneath each main question. It was tailored to explore experiences and perceptions related to health, farming, and pregnancy, and included sections such as “nutrition and weight gain,” “labor and agricultural practices,” and “antenatal care.” In addition, questions were developed to explore the pathways through which the Shamba Maisha intervention may exert its impact on health outcomes; the guide therefore included sections on mental health, empowerment, and relationship power. The questions were developed based on previous literature, including our prior qualitative research conducted during the Shamba Maisha pilot study (29–31). Intervention participants were asked additional questions about their experiences and perceptions of the intervention; therefore, interviewers were not blinded to the intervention or control status of interviewees. The guide was modified and further developed through an iterative process based on interviewer feedback and review of early transcripts. All interviews took place in a private location at or near a study facility and lasted between 45 min and 2 h. Only the interviewer and participant were present in the room during each interview. Interviews were audio recorded and subsequently transcribed and translated by the original interviewer verbatim into English; field notes and contextual information were incorporated into these documents. All transcripts were reviewed and any questions were discussed with the interviewer in order to ensure accuracy of translation. Transcripts were managed using Dedoose qualitative analysis software (SocioCultural Research Consultants). An a priori broad coding framework was established using thematic analysis methods based on the interview guide, and additional inductive codes were subsequently added after a subset of interviews had been reviewed. Two members of the research team coded the interviews using broad codes. One-half of the interviews were double-coded and reviewed through phone discussions to ensure intercoder reliability. Subsequently, 2 investigators developed fine codes for a subset of the broad codes based on emergent themes. We created an analytic report including main findings and contradicting viewpoints for each major theme and included illustrative quotes to support the findings. All participants provided written informed consent before participating in an interview, and participants were reimbursed 400 Kenyan shillings (Ksh) (∼$4.00) for their time and up to 400 Ksh for transport to the interview location, consistent with ethical research protocols in Kenya. Ethics approval for this study was obtained from the Kenya Medical Research Institute and the University of California, San Francisco.
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