Randomised controlled trial of a livestock productive asset transfer programme to improve economic and health outcomes and reduce intimate partner violence in a postconflict setting

Introduction

The eradication of poverty, ensuring health and well-being across the lifespan and achieving gender equity by 2030 are central to the Sustainable Development Goals (SDG).1 Meeting these goals require engaging the poorest families—those living on $1.25 daily and often the most marginalised within their communities—to move from insecure sources of income to more sustainable income-generating activities.1–3 Microcredit and productive assets programmes propose that the borrower or participant (eg, individual, household or group) operate an income-generating activity, which had previously been absent or limited by a lack of capital.4–7 Microcredit includes small loans ranging from $50 to $1000 and productive assets transfers are often livestock granted to households or groups serving as collateral for one another.8 ,9 These financial services have been promoted as supporting business development and increase in household wealth and economic well-being of the poor.5 ,8 ,10

van Rooyen et al8 conducted a systematic review of diverse microcredit studies implemented in sub-Saharan Africa and found evidence to question the positive impacts on financial outcomes for the poorest members of communities. As the investigators noted, there were only 15 rigorously evaluated programmes, those that included a comparison group, available to include in the review. Those studies judged rigorous enough to review provided mixed impacts, including a lack of benefits for the poorest in communities and not increasing household income.8 The review, however, did suggest that across diverse microcredit programmes, health outcomes were improved, primarily related to reduction in days missed from work due to sickness, the number of episodes of sickness, food security and nutrition.8 Gaining access to and control over income-generating activities may also improve mental health because of the participant's perceived ability to meet the needs of the household, including educating and feeding children.11–13 Further, the review provided mixed outcomes on women's empowerment.8 Two studies conducted in Uganda14 and South Africa15 ,16 showed evidence that microcredit contributes to women's decision-making power in the household and businesses. For example, the IMAGE trial in South Africa found a significant improvement in intervention, women's ability to negotiate safe sexual practices and a reduction in experiences of intimate partner violence (IPV).16 Although significant improvements were identified, the findings are limited by the inability to separate out the impact of the credit from gender programming, on the empowerment outcome. Although there is little evidence in conflict-affected settings, a group savings and loan intervention coupled with gender equity education in Cote d'Ivoire showed promise in preventing violence in intimate relationships and changing attitudes of men and women that favour or support a husband's use of violence to control or discipline his wife.17 Evaluating potential harms, such as increased violence in relationships, during economic development programmes is critical, given the potential of conflict related to shared decision-making over spending additional income or perceived threats to husband's authority in the household.4 ,16–18

Recent evidence from a multicountry evaluation has advanced the use of productive asset transfer for economic development with the poor.9 The Graduation Programme was designed by the Bangladesh Rural Advancement Committee (BRAC) to provide a comprehensive set of services, including a grant of a productive asset (eg, livestock or market-based business) to the poorest households in a defined community.9 The idea is to provide a ‘big push’ over a limited period to reduce extreme poverty. The investigators reported positive findings from the grant of a productive asset with comprehensive services increased consumption and income for participating households in all countries (Ethiopia, Peru, Pakistan, Ghana, Honduras and India).9 In addition to the productive asset, grant services include training and support for the asset, life skills coaching, regular consumption support for a defined period of time, access to savings accounts and health information or health services.9 These services plus regular home visits are designed to complement the households in a productive self-employment activity.9 Although the findings are impressive, the comprehensive nature of the programme and services is challenging to replicate in a humanitarian and conflict-affected settings, such as rural Eastern Democratic Republic of Congo (DRC), the study setting. More relevant to the DRC context is a Zambian livestock transfer programme implemented by Heifer International that included training for male and female participants. The physical transfer or ‘granting’ of livestock (cow or goats) with training on gender, nutrition, livestock health and care, sustainability, accountability resulted in increased cooperation and shared decision-making on the use of resources between men and women in participating households.19

DRC provides an exemplar of the ways in which prolonged conflict, human rights violations and the related negative health, economic and social consequences can impact communities.20–24 Violence against civilians is used as a ‘deliberate and strategic tactic in war’,25 to destroy or expel populations and pillage land and livestock. The rural territory targeted for the study reported the loss of land and essential tools for farming, resulting in limited agricultural productivity.26 ,27 The looting or loss of animals has also limited the household's ability to pay for health needs, school fees and economic shocks (eg, death of a family member) or opportunities (eg, marriages, births).26 ,28 As agricultural production and animal husbandry has decreased in rural Eastern DRC in the past two decades of conflict,26 ,29 a cycle of food insecurity,30 poor health and extreme poverty29 ,31 has likely been further aggravated by exposure to multiple traumatic events with limited access to quality financial and support services.32 The daily economic, health and resource constraints on rural populations in addition to the trauma of violence and forced displacement due to conflict add stress to family and social relationships33 and may result in conflict and violence of wives by husbands.34 The study authors previously reported on the potential of livestock/animal assets to moderate mental health symptoms for women multiple conflict-related traumatic events.13 As the household livestock/animal assets increased, the impact of conflict-related traumatic events on symptoms consistent with post-traumatic stress disorder (PTSD) and depression was reduced. Livestock/animal assets extend beyond its association with household wealth, as other measures of wealth (eg, durable housing, savings, regular work) did not buffer the effect of conflict-related traumatic events on mental health symptoms. Women reported using the funds gained through the livestock/animal asset to pay for school fees, purchase land and materials to build/repair homes, thus potentially strengthening self and household perception of productivity and status and advancing well-being.13

In 2010, Programme d'Appui aux Initiatives Economiques (PAIDEK), a Congolese microfinance organisation and the Johns Hopkins School of Nursing (JHSON) joined in collaboration to improve household economic stability, health and safety in rural Eastern DRC.27 The partners adapted their experience in microcredit, knowledge of productive asset transfer programmes, health and women's empowerment to the DRC context and developed Pigs for Peace (PFP). PFP is a hybrid programme that integrates microcredit and productive asset transfer principles. In rural DRC, animal husbandry continues to be one of the few opportunities for economic stability as livestock are assets to accumulate to rebuild household wealth and social status.35 Pigs are traditional productive assets, therefore, not intended for regular food consumption but rather serve as a ‘savings account’ for economic opportunities and crises.26 ,28 ,29 The purpose of this study is to rigorously evaluate the effectiveness of PFP on financial and non-financial outcomes in a rural, conflict-affected setting.

Methods

Results

Sample description

The majority of the 833 household participants were women, 25 years or older, married, had on average 3–4 children in the home and had never attended school. Most participants reported living in homes with non-durable walls (N=740, 89%) and roofs (N=487, 59%). Very few (N=38, 5%) had savings; the vast majority (N=680, 82%) described their household wealth as being the same or worse off than most people in the village. The intervention and control groups were not significantly different on any of these variables at baseline (table 1). The two groups were not significantly different on any of the outcome variables at baseline, with the exception of anxiety. The control group had significantly higher anxiety than the intervention group. Lost to 18-month follow-up was not significantly different between the groups; 13.0% (N=68) of the control group and 16.2% (N=50) of the intervention group did not complete the interview (figure 1). Men (N=36, 27.7%) were more likely than women (N=82, 11.7%, p<0.00001) to not complete the 18-month interview. Completers and non-completers did not differ on age, marital status, schooling, perceived wealth, subjective health, PTSD, IPV, livestock/animal assets or having loans at baseline. Those who were lost to follow-up had significantly lower anxiety (p<0.001) and depression (p=0.015). In addition, there were no differences between the intervention and control group non-completers on the baseline characteristics.

Table 1

View inline|View popup

Demographics by condition

Request permission

Figure 1

Trial profile.

Table 2 summarises the baseline and 18-month outcomes by group.

Table 2

View inline|View popup

Baseline and 18-month means (SD), parameter estimate from the residualised change analyses and associated effect sizes

Economic status. At 18 months postbaseline, the participants in PFP reported significantly greater increase in household livestock/animal assets than the control group (p=0.00004), controlling for assets at baseline. Participants in PFP were significantly less likely to have one or more loans (received as cash loan or inkind) (p=0.028) than control group participants, controlling for whether or not they had one or more loans at baseline. The same pattern of results was found with completers only. Participants reported that loans were typically received from family members or friends, health centres or small businesses in the village, only 1% of participants reported having credit with a traditional microfinance organisation.

Physical and mental health. PFP participants had significantly greater improvement in subjective health (p=0.035), controlling for their baseline subjective health. The intervention group also had greater improvement in symptoms of anxiety (p=0.023) and post-traumatic stress (p=0.0004), but did not differ on change in symptoms of depression (p=0.089). The same pattern of results was found with completers only.

Intimate partner violence. Among men and women who were partnered at baseline and 18 months (N=311 control, N=162 intervention), the groups differed on experiencing/perpetrating psychological abuse (35.1% control, 27.2% intervention; p=0.080) at 18 months although not statistically significant. Further, partnered women and men in the intervention and delayed control groups reported a decrease in experienced/perpetrated physical and sexual violence, the groups did not differ significantly on physical (p=0.340) or sexual violence (p=0.503) at 18 months. Importantly, the study was powered for the main outcomes using the entire sample (N=833); therefore, the analyses for IPV among those married at baseline and 18 months (N=473) are underpowered.

Discussion

The study findings confirm the hypotheses that participants in PFP households would have increased economic stability and improved subjective health and mental health compared with participants in delayed control households in rural, conflict-affected villages. In rural DRC, like rural communities globally, animal husbandry continues to be one of the few opportunities for economic stability as livestock are productive assets to accumulate to rebuild household wealth and social status.29 ,35 Livestock is a visible symbol of wealth, productivity and social status to the extended family and larger community. Livestock possession and productivity influences the owners' positive perception of self and household wealth.13 ,28 ,29 The local implementing partner, PAIDEK, was essential in identifying the productive asset that would result in improved economic stability and engaging men and women in the programme, as cooperation and shared decision-making was viewed as critical to success.29 ,46 ,47 For example, cows and goats were not selected as the productive asset because women cannot sell cows or goats without consent from the husband or male member of the household, as these animals are tied to the dowry system. As is tradition among the Shi people, the majority tribe in the study area, the future husband's family provides one cow to the future wives family. In recent years, with the loss of livestock wealth in rural areas, goats are often used for the dowry. Further, important in selecting the productive asset is that the vast majority of residents in the target area are either Catholic or Protestant and pork/pork products are produced and regularly consumed. Thus, the pig was the productive asset that represented a gender-neutral intervention to bring husbands and wives and other family members together in income-generating activities to improve economic stability for the household.

The findings demonstrated improved subjective health and a reduction in symptoms associated with poor mental health. Women and men in this area of Eastern DRC have experienced significant trauma over a prolonged period, resulting in symptoms of PTSD, depression and anxiety that can negatively impact productivity and family relationships.23 ,48–50 PFP may have reduced these negative mental health symptoms by limiting stress through increased livestock/animals assets and less cash or inkind credit with family, friends and others.13 There have been other successful and innovative efforts to address unmet mental health needs through skilled healthcare. For example, Bass et al48 conducted a study with female sexual violence survivors in Eastern DRC to examine the effectiveness of an adaptation of group cognitive processing therapy (CPT) provided by community-based psychosocial assistants supervised by psychosocial staff at an international NGO and US-based clinical experts. The findings indicate that psychosocial assistants with appropriate training and supervision can implement psychotherapeutic treatments such as CPT and improve mental health for women. Our findings build on this work by demonstrating positive mental health outcomes, reduced symptoms of PTSD and anxiety for men and women participants. This is an important finding as the intervention is effective with male and female participants that had experienced multiple and diverse forms of traumatic events, beyond sexual violence. Further, it provides an example of a potentially sustainable economic programme led by village associations that has the added benefit of reducing mental health symptoms in settings that have extremely limited infrastructure and capacity to provide mental healthcare. In Eastern DRC, as in many low-resource countries, there is a lack of government-funded health centres with a workforce that has training in mental healthcare. It is estimated that DRC has 0.07 psychiatrists working in the mental health sector per 100 000 population.51

Although PFP does not include a women's empowerment component, our staff emphasised the importance of communication and shared decision-making between husbands and wives in the programme. Analyses of IPV are based on those who were partnered at baseline and 18 months (56.8% of the total sample) and do not have adequate statistical power; however, the pattern of reduction of IPV is clear. At 18 months postbaseline, fewer participants in the intervention group reported experiencing/perpetrating psychological abuse than the control group (27.2% intervention, 35.1% control; p=0.080). Further, reductions in physical (3.5%) and sexual (10.6%) IPV were reported by partnered women and men in the intervention group; however, the reduction was not significantly different between intervention and control group participants. Research has suggested that in conflict-affected populations, men express a need to recover their authority and role as head of household, despite the severe economic and health stress on the family.34 ,52 With the DRC national prevalence of past year frequent (sometimes or often) physical, sexual and/or psychological IPV of 43.9%,53 identifying effective approaches to IPV prevention is critical to sustained development. Women's report of decreased IPV by their husband/partner was consistent with men's report of reduced use of IPV over the 18-month period. Indepth qualitative interviews were conducted at ∼6–9 months postbaseline with married/partnered male and female PFP participants that reported IPV perpetration or victimisation at baseline. The indepth interviews added to our understanding of risk factors associated with IPV in participating households. Men and women described financial stress including lack of work for men outside the home, alcohol use, male peer group sanctions use of IPV and social norms that support a husband's role in disciplining his wife as risk factors for husband's use of IPV.54 Future PFP programming will include primary prevention of IPV through engaging men and women in changing social norms that sustain gender inequality and reducing the multiple risk factors identified in our work and others that may provide additional reductions in IPV and enhance women's empowerment outcomes.

PFP prioritised the focus on transitioning from humanitarian ‘granting’ to household ‘investing’ for sustainable development. The success of PFP provides support for the importance of indigenous expertise in sustainable development programmes to improve economic stability, subjective health and mental health and reduce IPV in rural households. Our implementing partner had the expertise and access to engage traditional and administrative village leaders in productive and culturally appropriate economic activities that supported the participation of men and women.27 Partnerships have the benefit of also building local capacity to provide economic and other development initiatives, which is a critical step to ending a dependence on humanitarian aid and progress to sustainable development that will advance wealth, health and gender equality. It is certain that credit and productive asset transfer programmes alone will not solve the multiple challenges facing families in conflict-affected settings. However, a collaboratively developed and culturally relevant economic development programme that has the benefit of improved health and women's empowerment has potential for advancing SDG.

This study has limitations. The study was conducted in 10 conflict-affected rural villages in 1 province in Eastern DRC. Therefore, the experiences of the male and female participants are not generalisable to all rural households experiencing conflict. Participants reported exposure to multiple traumatic events within the past 10 years, representing at least two periods of conflict; therefore, some of the reported traumatic experiences were likely in the recent past and others several years prior to the baseline interview, so recall bias is an issue. Further, given the limitations of resources, our PFP programme staff was also trained as research assistants and participated in data collection and supervised interns that conducted interviews with participants across the 18 months. We also acknowledge the potential for contamination between the groups, as the delayed control group households were in the same villages as the intervention households.

Conclusions

PFP has important implications for achieving the SDGs with positive findings that intersect areas critical to sustainable development—economic stability, improved subjective health and mental health and reduced violence against women. PFP has potential for scalability, given that it was successful in a challenging rural and conflict-affected setting where residents have extremely limited access to financial institutions or credit programmes, health or social services and where social norms that sustain gender inequality are strong.