Intervention

Mlambe has been described elsewhere [41,42] but in brief, Mlambe consisted of ten monthly intervention sessions delivered by a pair of facilitators. The facilitators, one male and one female, had backgrounds in education and counseling and delivered the intervention sessions as a team. Prior to the first session, couples set up a joint banking account at a national bank in which they could start making deposits. Couples were incentivized with a 1:1 match for each Malawi Kwacha saved, up to $10 USD per month. Sessions took place in community-based locations equipped with a conference room or at a rented space at HIV clinics. A structured manual was followed and was divided into sessions on economic and relationship-strengthening activities, which included sessions on banking services, budgeting, savings and asset building, debt management, relationship and power dynamics, and couple communication skills. All sessions were group-based except for two one-on-one couples counselling sessions to learn and practice relationship skills. In the last session, community-based extension workers employed by the Malawian government were invited to meet the couples and advise them on best practices for their business goals (e.g., animal husbandry, growing vegetables for a produce stand) and continued to meet with couples as needed at their homes to offer support. To start their family-based income-generating activity (IGA), couples could access the combined savings and matched component and invest the money into the business of their choice.

Data collection

Trained, gender-matched interviewers with prior qualitative skills and experience discussing sensitive topics conducted the exit interviews in the local language of Chichewa. To improve comfort discussing sensitive topics, participants were interviewed by research staff that they were familiar with and with whom they had developed rapport. The research staff had already provided the intervention sessions and multiple rounds of surveys to the interview participants. Both partners were interviewed separately but simultaneously in private rooms to ensure confidentiality, to minimize bias, and to ensure that participants felt free to express their personal view independent from their partner. Interviews were conducted following the completion of all intervention sessions at 10 months post-intervention. Based on our a priori conceptual model of how Mlambe improves health and relationships, we followed a semi-structured interview guide that asked open-ended questions framed around the theories that the intervention was based on (Asset Theory and Interdependence Theory) [43–45]. Interview questions focused on overall experiences and perceptions (both positive and negative) of Mlambe, knowledge and skills gained, perceived impacts of Mlambe on relationship dynamics (including closeness, sexual life, arguments), household economics and food insecurity, adherence to medications and HIV care, mental health and well-being, and suggestions for how Mlambe could be improved. Similar questions were asked of both partners and interviews lasted approximately 60–90 minutes.

Analysis

The interviews were audio-recorded, transcribed, and translated from Chichewa to English by research assistants who are fluent in both languages. The research manager performed spot-checks to ensure that translations were through and accurate. We conducted an individual-level analysis and dyadic-level analysis using a framework analysis approach, which allows for comparative analysis of themes and cases by utilizing data matrices [51]. We read and reviewed the interview transcript pairs, created summary tables, and organized the data by couples and by the larger categories from the interview guide (e.g., perceived impacts on alcohol use). We then coded for patterns within each larger category by comparing responses within and between couples by examining raw quotes and noting any agreements or disagreements between partners (e.g., the husband reported that he quit consuming alcohol, but the wife said he only reduced alcohol use). A team of five coders, which included representation from Malawi and are included as authors, coded the full set of transcripts and met regularly to build consensus around definitions and applications of codes and to discuss the findings using the summary tables and the themes that emerged. Inter-coder reliability was not formally assessed but discrepancies in code application among the research team were discussed to reach consensus. Finally, we held community meetings with key stakeholders including couples who participated to present the findings and ensure our interpretations were correct.

Ethics statement

This study received ethical approval from the Human Research Protection Program at the University of California San Francisco and the National Health Science Research Committee in Malawi. The study was registered at ClinicalTrials.gov (NCT #04906616). Written informed consent was collected twice, once for enrollment into the trial and again for participation in the exit interviews.

Sample characteristics

Among the 40 individuals who completed an exit interview, mean age was 45 years and most (80%) had primary education or less. At baseline, 62.5% reported severe food insecurity. Couples had been together for a mean of 14 years and reports of IPV in the past 12 months were common, with 30% reporting emotional, 20% reporting physical, and 17.5% reporting sexual IPV. Most couples (74%) were sero-concordant positive and among all individuals on ART, 61% reported 95–100% adherence to treatment (Table 1).

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Table 1. Baseline characteristics of the Mlambe exit interview sample (N = 15 couples; 30 individuals).

https://doi.org/10.1371/journal.pone.0331202.t001

We highlight five themes that emerged regarding perceived changes of Mlambe on: 1) alcohol use patterns, 2) improvements in couple relationships, 3) improvements in sexual life and sexual satisfaction, 4) improvements in economic security, and 5) improvements in ART adherence.

Intervention couples reported that alcohol use caused many problems in the past, and that reducing or quitting alcohol use because of Mlambe brought about multiple improvements to their physical and emotional health, and the well-being of their marriages and households. While couples were asked about any negative feedback and how Mlambe could be improved in the future, the findings highlight largely positive perceptions of the intervention.

Changes in alcohol use patterns and underlying motivations for drinking

Many men and women believed that because of Mlambe, men’s alcohol use decreased or changed in other positive ways. While some men reported stopping drinking completely, others said they reduced their intake or switched to drinking alcoholic beverages with lower alcohol content like chibuku [a commercially manufactured sorghum beer with low alcohol content] instead of kachasu [a locally distilled spirit made from maize with a high alcohol content]. Some men also described changes to their drinking patterns, from consuming alcohol at formal drinking establishments (i.e., village bars) to drinking at home. Some wives viewed this as a positive change because they could monitor what and how much their partners drank.

I said, “my partner you should reduce your alcohol use” … Even if he was told [to reduce] he was not reducing his alcohol use but since Mlambe started he has improved, he has reduced his alcohol use. -Woman, 34 years old

After Mlambe I am now a changed man, by … 6:00 pm I’m already home, my partner even asks, “Are you back this time?” I would say yes, sometimes I take alcohol while at home, something I never used to do. -Man, 44 years old

Many women and men felt that since men had reduced alcohol use, they were now coming home earlier and contributing to family life. Participants reported that before Mlambe, men would often go out to drinking establishments and some would be so drunk that they would sleep at the bar and not come home. However, both women and men noted that because of Mlambe, some men spent fewer nights out drinking and sleeping outside the home.

My partner used to drink alcohol a lot and sometimes he was even sleeping at the bottle store, but now he stopped doing that since we started this program. -Woman, 41 years old

This increased presence of men at home often meant that men were now contributing to a family business or taking part in household chores, while also creating space for couples to spend more time together and communicate about family life.

He is not moving out as he used to, he has reduced. He was leaving for beer drinking places in the morning and was coming back in the evening, he was going back in the morning. So, I have noticed that he has reduced this, he can go to his friends to chat and come back in time, he is able to do household chores without any problem. -Woman, 34 years old

While most men and women reported a reduction in men’s alcohol use because of Mlambe, there were some discrepancies among couples about whether the men actually reduced their use. One woman reported that her husband had stopped drinking alcohol while he only reported reducing his alcohol intake. In addition, three men reported that they either reduced or stopped drinking alcohol while their wives reported that they had only reduced their consumption or had not altered their behavior at all, as seen in the quotes below from a husband and wife.

Sometimes I would take 4–5 drinks … so they asked me what I benefit when I take alcohol, so now I have reduced to a smaller number of drinks, maybe 3–4 … so that time I was a drunkard [local term referring to a person who is publicly intoxicated frequently], after Mlambe I am now a changed man. -Man, 44 years old

Imagine telling him to quit alcohol and then he replies, “ah I can’t stop alcohol, it’s better we should divorce”. You see that, so it’s difficult, because when you are telling one to stop something, it means it’s bad. Everything learned, he was leaving it behind at the exit door of the sessions. -Woman, 33 years old

Participants described several key sources of motivation that helped them to change alcohol use patterns in positive ways, including social support. First, men reported receiving consistent advice and reminders from their wives to reduce their alcohol use. Many men reported that these reminders, together with communication skills taught during Mlambe sessions, helped them to reduce or stop drinking alcohol. Second, men described feeling motivated to reduce their alcohol consumption because of support they received from other peers in the intervention, who advised them to reduce excessive drinking. Participants recalled how one of the lessons of Mlambe was to save money on alcohol to develop a small business. As a result, many men said they developed a desire to save their money or invest it in a business. Other men explained that the savings aspect of Mlambe and the business or income-generating activities they started kept them busy and as a result, they reported drinking less. Some men described how Mlambe helped them realize that spending money on alcohol was wasteful and caused them to use sparse resources on alcohol instead of on needed household items or food.

They enlightened me that you lose a lot of money with alcohol intake, such that when you want to make a budget you just be wasting. -Man, 40 years old

Perceived improvements to couple relationships

Most couples reported that their relationships improved because of Mlambe. Couples explained that some improvements in relationship quality were due to participation in the intervention and related to learning communication skills or learning to approach their partner with respect. Other improvements in the relationship were seen as being prompted by men’s reduction in alcohol use.

Men and women reported that quarrels and family conflicts about alcohol use were common prior to Mlambe. Couples also reported that, before Mlambe, talking about alcohol use within their relationship was rare. Many of the quarrels stemmed from men spending all their money or household funds on alcohol that could have been used for food or school fees for children. However, after the intervention, couples reported that they had learned about reducing alcohol use for the benefit of the entire family. Couples were usually in agreement on positive changes to their marriages and both men and women reported quarreling less because of Mlambe.

He went to drink alcohol and spent all the money. He came back home without any money. This is when we started arguing. We were arguing frequently. When someone did not speak well … we ended up quarrelling. But this stopped after we joined this project. -Woman, 34 years old

What happens is that you use that money for beer and [you] finish the money. So when you get home you find that there are arguments … sometimes I would speak roughly [to my wife]. But … we should be respecting each other as you have taught us. So I see that these days we are able to understand each other more. – Man, 70 years old

Men and women reported that communication skills that they learned as part of Mlambe helped to facilitate more open and respectful couple communication and other marital improvements, including more active listening and reports of increased trust. Couples felt that these skills helped to strengthen relationships and they felt more “free with each other”. Where in the past, discussing alcohol use or family finances had been off limits, couples reported that they could now openly discuss these topics, and they felt heard by each other. Couples discussed learning to approach each other with humility and respect, and to use “I statements” rather than casting blame with “you statements”. Men and women said these techniques helped to reduce fighting in the relationship and led more than one couple to say that Mlambe had brought peace to their family. As one husband and wife explained, the communication skills they learned helped to improve communication in their relationship.

We have benefited from this in our family, we understand each other and when speaking to each other, when I am angry with something, I start talking to her, “I am upset when…” And my partner listens and understands me … so because of this, since we started those sessions in our family, we have peace every time. -Man, 49 years old

On communicating with my spouse, we learnt that if I want to talk to him, I should not blame him like using ‘you,’ no I should say ‘I’ because if I say I … that the person who is listening is also interested that she has said ‘I’ and is not blaming me … the other thing is that when we are communicating, we must understand each other and be humble to each other. When one is speaking it is good that one listens to what the partner is speaking rather than both of us speaking at once, you end up quarrelling. – Woman, 39 years old

However, in some couples, it appeared that men were presenting a more positive view of improvements to communication since reports by their wives did not coincide with what they said.

Perceived improvements in sexual life and sexual satisfaction

While sexual satisfaction was not a primary focus of the Mlambe intervention, we anticipated that there could be spillover effects on sexual satisfaction through improvements in other relationship domains (e.g., communication, trust) and through reductions in alcohol use. While a few participants admitted that nothing changed with their sexual life, or that they already had a healthy sexual life to begin with, most intervention couples reported improvements in either the quality or quantity of sex. Improvements to sexual satisfaction were believed to be related to several shifts in the relationship that occurred through participation in Mlambe.

Both men and women reported that before Mlambe when men were drinking, they often had extra-marital sexual partners and that these two behaviors went hand-in-hand. Women reported how their husbands were now spending less time “sleeping outside the house” (meaning having other sexual partners) and at drinking establishments, and more time at home. Some husbands admitted that they were having many sexual partners (referred to by the men as “womanizing”) because of their unhealthy drinking. After Mlambe, men reported less drinking, fewer sexual partners, and being more faithful to their wives. After taking part in Mlambe, one husband explained, “I had a secret lover but I ended the relationship after I noticed that I was not doing good to my partner because every time she was having stress.” Some women specifically explained that as their husbands decreased their drinking and were more likely to be sober, having sex was more enjoyable. Prior to Mlambe, women would either refuse to have sex when their husbands were drunk or sex would not happen because he was too tired or could not perform sexually. Husbands also acknowledged this was happening. For example, one husband admitted that:

When I have gone to drink alcohol, I might fail to do sex so she might be sad since I will be tired. So you just come back and lay on the bed, nothing happens as if you are sharing a bed with a fellow man. -Man, 40 years old

Couples also described how Mlambe taught them to communicate more openly and respectfully with their partner, which extended into the sexual realm. Communication around sex covered topics such as values around monogamy (e.g., addressing desires or temptations for other sexual partners), sexual desires and needs (e.g., how often sex should happen), and acceptable reasons for refusing sex (e.g., when sick). A husband described how he and his wife learned about the importance of verbal communication and learning to read each other’s signs for wanting sex:

Mlambe has helped us in this because in the past when we wanted to have sex, it was just happening as a surprise [laughing] and Mlambe has told us that when you want to have sex with your wife you need to show signs so that she is also aware what her husband wants. -Man, 60 years old

Finally, sexual life improved when sex was perceived as consensual and equally desired by both partners. This contrasted with the past, when one partner would pressure or force the other to have sex or refuse sex, often because the man was drinking. Two men explained that before Mlambe, they were forcing their wives to have sex with them, but since taking part in the intervention, they had stopped that behavior.

Perceived improvements in economic security

Both partners described how men would use household finances to buy alcohol before Mlambe, which left them unable to support basic family needs. Women and men both described situations where men spent money on alcohol that was being saved for buying food or for paying children’s school fees. Some men and women reported that their children were going hungry while the men used what money they had to buy alcohol. After Mlambe, men reduced spending on alcohol which led to more money being available to meet basic needs, such as buying more food, soap, clothing, fertilizer, or paying school fees for children. Couples were also able to save to plant vegetable gardens or make house improvements, such as buying iron sheets that could replace old roofs. When men were not using family funds to buy alcohol, this led to fewer conflicts, more “peace in the household”, a greater sense of economic security and reduced financial stress and led couples to have a more positive view of the future, with one participant saying that saving money helped to “transform” her household.

When he left to drink alcohol, he left home without giving me money to buy food, and he came back while he was drunk and then he asked for food. I told him that there was no food and then he blamed me for not preparing food yet he did not give me any money and he spent his money on alcohol. -Woman, 39 years old

Before Mlambe, I wasn’t able to save, I wasn’t able to take care of my family, but after I joined Mlambe I started saving because they taught us that, I am able to support my family, before when my wife tells me that flour is done, I was saying I cannot use this money, is meant for alcohol, but now that doesn’t happen. –Man, 44 years old

After Mlambe, women and men described how they were able to invest in small businesses such as rearing livestock (goats, pigs, and chickens), growing vegetables for sale, opening a small salon, or buying a motorbike that could be used as a local taxi. Prior to Mlambe, some men described being “idle” but after Mlambe, male drinkers described being more motivated to pursue income-generating opportunities such as rearing livestock.

He was saying that he was drinking alcohol because he doesn’t have things to do, when he found things to do [business] he was not going to drink alcohol because he was busy with the business. -Woman, 30 years old

Through the business we are able to find money and its different from just being idle then anything can come into mind like “I should go to the beer hall”. -Man, 69 years old

However, in some couples, even though men said they had reduced their alcohol use, women reported that they were “saving alone” and starting small businesses on their own without their partner’s support.

Couples also described that prior to Mlambe, men oversaw finances in the household and women had little say when men spent their savings on drinking. As one woman described, before Mlambe, her husband, “took all the money and ruled over it”. Another man described that when his wife asked him for money, he would scoff at her and say, “I am the one who earns money, and you do not have any right to tell me what to do”. However, Mlambe included a session on balancing power dynamics including economic power, and after Mlambe, women reported decisions about how to spend household finances became more equitable. Men often brought home their earnings and either developed a budget with their wives or discussed how to spend or save the money with their wives.

The other skill I learnt is on finances, because previously, every one of us was keeping their money alone and that also meant spending, but now, we are able to discuss expenditure. –Man, control arm, 46 years old

Perceived improvements in adherence to ART

Men and women both described how prior to Mlambe, men experienced ART adherence challenges because of alcohol use. For many men, they forgot to take medications altogether or took them late because of drinking. Women confirmed that alcohol intake was affecting the medication adherence of their partners. Couples also noted that at times it was hard to get to facilities for appointments and to collect medications because they were busy. As a result of Mlambe sessions, however, men and their wives reported that they started to reduce their alcohol use, and this led to greater medication adherence and men feeling healthier. Couples reported that they learned in counselling sessions that medication adherence can help them live longer, improve their immunity, and their overall health. Many men identified that skipping their medications was a direct result of drinking too much. As one man explained, “[I] no longer skip taking medication because I stopped drinking alcohol. The skipping of medication was as a result of alcohol intake.”

Before Mlambe, he was drinking heavily, he was spending carelessly. I would advise him but he wouldn’t listen … but he reduced all that after Mlambe, and also right now he is complying with medication prescriptions … we were arguing because he was declining taking medication but now, he is taking medication well. -Woman, 35 years old

In addition to providing general support for medication adherence, an important way that couples supported each other was through reminders to take their ART on time and to not miss doses. Both men and women reported that they now remind their partners to attend clinic appointments and many reported that they collect medications for each other if one person is sick or busy. Many couples also talked about creating daily reminders whereby their partners reminded them to take their medications every morning before leaving for work, or right after they eat breakfast. Women also reminded their partners that taking medications and alcohol at the same time was not good for their health. The Mlambe sessions helped couples to see each other as “guardians” or each other’s health. Many participants also felt that improved communication skills led them to support each other to take their ART after Mlambe.

When I wake up in the morning, immediately after taking let’s say porridge, she comes and give me the medicine, then I take the medicine with water. When I forget she reminds me, so I don’t skip taking medicine. -Man, 44 years old

If someone forgets to take the ARVs the other one should remind him. So we help each other, asking each other if he has taken the ARVs. If you have not yet taken them you give thanks for the reminder and then go and take them. -Woman, 72 years old

Limitations

This study has some limitations. As with all research, it is possible that participants were overly positive in their interviews about intervention satisfaction given their relationship with the Mlambe study, their desire to maintain a good relationship with the study, and the hope to access future opportunities. However, we had checks in place to overcome this potential bias. During the exit interviews, the interviewers highlighted the importance of hearing both positive and negative feedback and focused on the importance of improving the intervention in the future. However, the positive qualitative findings are consistent with the quantitative results which also showed very positive experiences with Mlambe [96]. Therefore, while we had intended to include results in these analyses from those reporting low satisfaction and those reporting negative experiences, everyone reported being satisfied or very satisfied with the intervention. Social desirability bias is also a concern. Participants may have under-reported or misreported details about alcohol use or changes in alcohol use, behavior change related to extra-marital sexual partnerships, changes in relationship quality, or changes in their financial behavior. In this case, having the accounts of both partners is critical as sometimes one partner reported changes while the other reported some or no change. The inclusion of the wives’ voices in the findings also helps to offset overly positive portrayals of behavior change among the men—who were the primary target of the alcohol intervention.