Ethics statement

Ethical approval for the study was obtained from the review boards of the University of California San Francisco and the Kenya Medical Research Institute. All participants provided written informed consent.

Research context

This is a qualitative research study located in Kisumu, Homa Bay, and Migori counties in western Kenya. This study is a sub-study of the Shamba Maisha cluster-randomized controlled trial (RCT) (NCT02815579): a 16-site study testing the effectiveness of an agricultural and finance intervention to improve health outcomes among farmers living with HIV. The Shamba Maisha intervention has been described in detail in other publications; intervention measures included provision of a non-electric water pump, a small loan for the purchase of farm supplies, and training on farming and financial management practices [43, 44]. Data collection for this study took place part-way through implementation of the Shamba Maisha study and included participants in both the control and intervention arms. Interviews were not designed to be evaluative of the impact of the intervention on mental health, but rather focused on the mechanisms through which climate change impacted mental health in a population highly vulnerable to adverse mental health outcomes. The impacts of the intervention on mental and physical health are presented in a separate publication of the Shamba Maisha RCT study results [45].

Research setting and population

The East Africa region, and Kenya, is a climate vulnerable region experiencing climatic changes such as warming temperatures and extreme rainfall events [46, 47]. Climate-related morbidity and mortality are also projected to increase [48]. Climate change is projected to significantly reduce yields of Kenya’s major staple crops, contributing to food insecurity and malnutrition [49, 50]. Food insecurity is a pathway by which climate change can impact mental health [22, 33, 51]. In rural Kenya, a large share of the population relies on agriculture as a primary source of food and income [52]. There are 1.5 million people living with HIV in Kenya [53], and HIV positive households face significantly higher rates of food insecurity [54]. Farmers [15] and people living with HIV [42] are distinctly susceptible to adverse mental health outcomes.

Study population

We purposively selected forty Shamba Maisha participants for enrollment in this study to include equal numbers of men and women, as well as control and intervention participants across the three study counties. Shamba Maisha project coordinators managed participant selection at study clinics; study research assistants conducted study enrollment and obtained written informed consent from all participants prior to participation. Eligibility criteria for the parent study included (a) living with HIV and receiving antiretroviral therapy (ART), (b) experiencing moderate to severe food insecurity or malnutrition at time of study enrollment (defined as BMI <18.5, and measured using the Household Food Insecurity Access Scale), (c) being 18 years or older, and (d) having access to farmland and surface water. Eligibility criteria for this study additionally included participation in the parent study for a minimum of one year.

Data collection

Two research assistants, trained by the study team in qualitative interviewing and use of the interview guides, conducted in-depth interviews with participants. Interviews, conducted in Luo or Swahili, took place in study clinics, participants’ homes, or participants’ farms, depending on participant preference. We piloted interview guides in July and August of 2018 and collected data from September 2018 to February 2019. Throughout the piloting and data collection phases, we held weekly meetings between the U.S. and Kenya-based researchers to discuss interview findings and modify interview guides to address emergent themes.

We developed semi-structured interview guides collaboratively with both the U.S.- and Kenya-based research teams. Interview guides covered the following topics: perceived climatic changes and their causes; experience with discrete weather events and long-term weather changes; perceived impact of climate change on agricultural practices and outputs, income and economic security, and health outcomes and behaviors; pathways through which climate change affects HIV and mental health; and gender differences in the experience of and response to climate change. Interviews lasted from 90–120 minutes. All individuals invited to participate participated in the interviews. Participants were paid approximately four USD and reimbursed for transportation if the interview took place outside of their home. Interviews were audio recorded, then simultaneously translated and transcribed into English by the research assistants.

Data analysis

We utilized a thematic analysis approach [55, 56] to analyze the interview data. Prior to coding the interviews, we read the transcripts to familiarize ourselves with the data and develop initial concepts for future coding. All coding in this analysis was based on emergent codes. For the early coding analysis, we applied an open coding approach with two researchers (NB, TN) independently creating and applying codes to each piece of transcript text. Subsequently, four researchers from both the U.S. and Kenya (NB, TN, GO, SJ) double coded a subset of interviews to jointly describe and discuss codes and code definitions, and to ensure the coding scheme accounted for and reflected the local context. Discrepancies in coding were resolved through discussion among all coders. We then developed a codebook through discussion of emerging concepts and themes, and used it to re-code interview transcripts in a more focused manner. In the final analysis, one author (NB) re-read and re-coded transcripts focusing on the themes of personal and communal mental health and wellbeing, to generate a deeper understanding of the themes that make up the focus of this paper. Given the potential for participation in the intervention arm to influence farmers’ experience of climate change, for instance through access to greater economic and agricultural resources, we considered participant characteristics including HIV status and participation in the farming intervention, in our analysis. Following our analysis, we consolidated our findings into a preliminary conceptual framework to highlight the key mechanisms through which climate impacts affected participant mental health and how these mechanisms interrelate.

Direct impacts of climate change on the mental and emotional well-being of Kenyan farmers

Respondents nearly universally reported experiencing some level of climate change impact on their mental and emotional wellbeing. As one respondent commented, "Those of us who are farming are the ones likely to bear the brunt of climate change" (Man, 48 years, Migori). All study respondents reported direct experiences of changing weather, including higher temperatures; more drought, extreme rain events, and flooding; changes in the timing of the rainy season; and increasing weather unpredictability; though not all participants attributed these changes to the broader global phenomena of climate change. Participants described feeling “stressed”, “depressed”, “annoyed”, “demoralized”, “discouraged,” and “hopeless” because of these changes. One respondent explained that “the weather disoriented me completely" (Man, 38 years, Kisumu). Another described the stress of coping with unpredictability:

"You plant with so much hope of a better and food secure future…Then suddenly it rains, and everything is destroyed. You will be forced to start from zero. You get so affected mentally. Your thinking is distorted. You worry endlessly…You cannot know what happiness is at these times." (Man, 37 years, Kisumu)

Nearly all participants in the study described experiences of major damage to their homes and farms due to climate-related extreme weather events, losses that caused emotional distress and grief. One respondent described the loss of his farm as “equated to the death of a loved one. It was very painful” (Man, 53 years, Kisumu). Another participant reflected on how these emotional impacts affected his physical health:

“All my work had been drained just like that. I was deflated…My heart was bleeding, and my body became weak…Every time I would go to the farm, I would remember the loss…I lost appetite completely. I was so stressed up and worried.” (Man, 52 years, Kisumu)

Many participants described anger at the losses experienced. One participant reflected on the loss of her home and farm in a flood saying: “I could have jailed the rain if it was a human being” (Woman, 43 years, Kisumu). Other respondents spoke to the toll this took on their mental and economic well-being over time:

“I felt so devastated. I was depressed to the extent that I fainted. I couldn’t believe the loss I had just incurred and the damage the rain had done…I have never healed from that experience. I cannot do anything when it is raining because I get extremely scared…Weather has made me very angry and traumatized.” (Woman, 38 years, Kisumu)

In addition to these direct experiences of climate change, participants described anticipated future changes. Participants reported anticipating that future would be “difficult”, “rough” and “worse”, and that there was “no expectation for things to get better” (Woman, 27 years, Homa Bay). These negative expectations and fears about the future were a significant source of anxiety and worry.

Pathways through which climate change impacts mental wellbeing

In addition to the direct impacts of climate change on emotional wellbeing described above, we identified three social and economic pathways through which climate change contributed to participants’ emotional health and wellbeing. These included economic impacts, such as declining agricultural productivity and economic stability; impacts to community social cohesion, such as declining social support; and impacts to personal identity, such as changes in professional and family role.

Climate change erodes economic security of smallholder farmers

Economic insecurity was a major reported driver of participants’ mental and emotional distress. Participants described increasing economic insecurity resulting from direct climate impacts on agriculture, including declining agricultural productivity, property and crop losses. and the income unpredictability and instability that resulted. Climate disasters, such as unseasonable rain and flooding, destroyed farms and acutely impacted harvests. Participants “depend on farming” for their food and income; climate-related farm losses thus impacted their economic and food security. Many participants described experiencing significant declines in the productivity of their farms, sharing memories like this: “Floods came in April and all the maize, beans, and other cereals I had planted were swept away…There was nothing to harvest. The floods took all that we had worked for” (Man, 38 years, Kisumu).

Long-term climatic changes, such as drought and changing rainfall patterns also reduced farm productivity. As one participant described: “Droughts are more severe and frequent nowadays…We have no option but to sell our cattle at a throw away price. Nobody wants to be associated with such heavy losses" (Man, 27 years, Kisumu). Participants perceived these impacts to be widespread. One described: “There was a time when drought destroyed all the crops I had planted…This happens quite frequently, and to most farmers across this vast region” (Man, 23 years, Migori).

Many described immediate economic hardship following climate events. One participant described how a single night of heavy rainfall destroyed her home and crops and “took me back to poverty” (Woman, 38 years, Kisumu). Other respondents described how longer-term declines in farm yields led to long-term economic stress; “Income from the farm has greatly reduced, and this is because of the direct effect of the weather. We have suffered so much in our farming journeys” (Man, 45 years, Kisumu).

Economic losses led to extreme stress as a result both of the experienced disruptions to their livelihoods, and the anticipation that these experiences would continue or worsen in the future. As one respondent said "I had so many worries because I depended on the returns from my farm…Where was I going to get school fees? How was I going to feed my family?” (Woman, 47 years, Migori). Another stated: “Famine and poverty have pushed us to the wall” (Man, 58 years, Kisumu). Thus, not only did immediate economic stress and insecurity undermine emotional wellbeing, but also worry and fear about their expected economic prospects and their ability to provide for their families contributed to emotional distress independent of direct economic losses. In the words of one participant: “Being wealthy as a result of hard work is no longer a working narrative” (Man, 58 years, Kisumu).

Participants universally reported adapting their farming practices to respond to experienced and expected weather changes and to mitigate future losses. Participants described that climate change caused new farming challenges including pests and plant diseases, declining soil quality, and declining productivity of traditional crops. This necessitated a transition from “the practice our grandmothers taught us” (Man, 37 years, Kisumu) to more input-intensive farming techniques. Many respondents reported expanding the use of pesticides, fertilizers, and non-indigenous hybrid seeds.

However, participants described varying success in managing climatic changes and buffering economic stability. For some, these strategies made farming “more costly” and at times reinforced participants’ financial precarity and thus economic stress–and thus were actually maladaptive from a health perspective. As one participant said: “The amount of money we use in farming has tremendously increased…In the past you could farm and have plenty of harvest at zero costs. Now, I must buy fertilizer and seeds" (Man, 37 years, Migori). Often, as a result of adaptive strategies being insufficient to mitigate climate-related farm losses, those same strategies amplified economic insecurity. One participant described: "The capital we invest in the farm is much more than what we get from our farms" (Man, 42 years, Kisumu).

At the same time, as participants perceived climate change to make farming a less stable livelihood, some participants additionally perceived that broader land use and economic changes were making it harder for smallholder farmers to cope with climate change and deepened economic insecurity. For instance, several participants reported that the growth of large-scale commercial agriculture reduced access to land, leaving "very small pieces of land that cannot produce enough food" (Man, 37 years, Migori). Participants perceived this to affect economic and food security, as related by one: "All those commercial rice fields you saw were places where sorghum and millet were grown…So, there is a lot of famine” (Man, 58 years, Kisumu). Some participants also reported that changes in agricultural policies and markets were affecting their ability to earn income from farm products. Several respondents described local markets “over-flooded” with imported products, such that even when their harvests were strong, “the market was bad” and “prices fell greatly” (Man, 53 years, Kisumu). Another participant remarked: “The [local] market is flooded with imported rice…It outstrips demand…we sell [our] rice at a throwaway price" (Man, 58 years, Kisumu). Participants perceived these policy decisions as further straining their economic security, intersecting with and compounding the impacts of climate change on their agricultural practices, and consequently contributing to the emotional distress arising from economic factors.

Economic insecurity undermines community support systems

Participants described how the economic impacts of climate change also affected the social drivers of emotional health at the community level. The widespread economic insecurity experienced by participants, together with an increase in perceived economic and food scarcity, disrupted community social cohesion by interrupting systems of communal support and mutual aid that historically buffered individual economic losses. This was an additional driver of worsening mental and emotional outcomes for some participants. Participants noted that those smaller harvests reduced community food availability: "In the past we had so much yield that we had to store in large granaries that were built outside our houses. Right now, you can walk for thousands of miles before seeing just one such granary." (Man, 37 years, Kisumu). As food insecurity grew, respondents described a shift in the culture of food sharing; "in earlier days you would walk into someone’s granary and take grains enough for your use, for free. Nowadays no one has harvest" (Man, 52 years, Kisumu). Another respondent said: “Nobody is giving out food for free. There is scarcity everywhere” (Man, 45 years, Kisumu).

As with economic impacts, both experienced and expected changes in social cohesion affected mental health. Some respondents perceived a reduced willingness among community members to support each other, reporting that people were “more individualistic”, “selfish”, and “concentrate only on [their] family”. One participant reflected: “Climate change and hard economic times have barred people from being as generous as they would want” (Man, 34 years, Migori), while others highlighted tension in balancing their desire to support others with the reality of scarcity:”The urge to give you some small tin will be there, yes, but I will have to reflect on how this might affect me and my family and then definitely I will tell you ‘No’” (Man, 50 years, Kisumu). The loss of social support systems contributed to emotional distress, as participants felt they had to rely on themselves even in times of need. Perceived lack of community support affected emotional health even when that support was not tested. As one woman described: “I would rather sleep hungry than beg my neighbors…I do not want that kind of shame” (Woman, 45 years, Migori).

Economic insecurity affects personal identity

Finally, economic loss and insecurity also impacted emotional wellbeing by threatening participants’ personal expectations and sense of identity as caregivers and farmers, affecting individual level social drivers of poor mental health. This pathway to emotional stress was primarily discussed by men. Some participants reported a high degree of emotional distress when they were unable to provide for their family, challenging expectations they had for themselves as family head and primary household earner. As one participant described:

“[My] children wanted food which I couldn’t afford…It appeared to them that I hated them and did not want to provide as I should. This brought me a lot of mental torture. I wanted to give them the very best, but I couldn’t afford it…As a father, when you cannot provide for your children, it degenerates into a mental case.” (Man, 36 years, Kisumu)

Emotional distress from the inability to meet one’s personal expectations of their role as a caregiver could result from the direct experience of being unable to provide, as described above, or from the anticipated fear of future failure or declining social status. For instance, one participant described: "Your kids will constantly view you as a failure…You feel you cannot provide…The respect I expect from my wife and children won’t be given. I am almost useless " (Man, 52 years, Kisumu). These real and awaited changes in family cohesion created another potential stressor on participants’ emotional wellbeing.

A second disruption to participants’ sense of identity resulted from changes in agricultural work that affected the experience of farming, sense of control over their labor, and level of satisfaction in the profession. These changes could result in direct challenges to their farming identity, and consequently emotional distress. Some respondents reported taking on other jobs to supplement their income. This was another source of emotional stress, particularly for men, as having to work for others was viewed as demeaning: “I had gotten used to being my own boss. Now I had to start working at the mercy of other people…They deal with you the way they want. You are scolded like a kid in front of people” (Man, 26 years, Kisumu). Several men described embarrassment, disappointment, or loss of dignity at not being able to farm. One said: “You can’t even call me a farmer. I am a consumer. I live hand to mouth” (Man, 58 years, Kisumu). Others described how farming itself was increasingly viewed as a profession that could not sustain a person economically; in the words of a respondent: "[Farming] has been left to…those perceived to be poor" (Man, 45 years, Kisumu). The redefinition of farmers’ perceived role and position economically and socially was a source of emotional distress for these participants.

Distress could also result from anticipated threats to identity. As one respondent described: “You may have the [farming] knowledge, but the unpredictable weather pattern renders you useless” (Woman, 31 years, Migori). Unpredictability and repeated losses led some participants to feel a sense of futility about the future of agriculture. As one respondent asked: "Why plant crops only for the sun to scorch? Why plant crops for the floods to wash away? You cannot predict the weather, it either rains too much or there is too much drought" (Man, 42 years, Kisumu).

Proposed conceptual framework

Based on our analysis presented above, we consolidated our findings into a preliminary conceptual framework to capture the economic and social pathways by which climate change can shape mental and emotional wellbeing, and how these pathways are interrelated (Fig 1). This framework highlights the primary mechanisms through which we found climate change to affect emotional wellbeing. Climate impacts directly affect emotional health through experienced disruption, such as loss of a farm, and worry about the future. Climate impacts also drive economic shocks directly and shape economic security through the responses adopted by farmers, which can be either adaptive (improve resilience) or maladaptive (create further strain). Economic insecurity is a predominant mechanism of emotional distress. Finally, economic disruption creates social disruption both at the individual and community level, which in turn can each contribute to worsening emotional health. Across each of these domains, the arrows depicted in the figure, as described in the text above, can represent both directly experienced and anticipated or perceived potential impacts.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Simplified conceptual model of social and economic pathways linking climate change to emotional wellbeing.

https://doi.org/10.1371/journal.pgph.0002152.g001