Community bylaws concerning sexual and reproductive health and rights in Machinga District, Malawi: to what extent are they responsive to young people's needs?

BACKGROUND: Community bylaws are commonly accepted mechanisms to influence behaviour change to achieve better health and development outcomes in sub-Saharan Africa. However, the uses, benefits, and potential downsides of community bylaws are largely unclear, especially regarding sexual and reproductive health and rights (SRHR) of young people. The objective of this study was to determine the extent to which community bylaws in Machinga District in southern Malawi are responsive to young people's realities and SRHR needs. METHODS: In Phase 1 of this qualitative study, 35 community members were interviewed, including 14 young people (15-24 years), five parents, five traditional leaders, and eleven key informants. Based on findings from Phase 1, eleven members from local youth groups co-created a drama performance that covered issues concerning bylaws and young people's SRHR (Phase 2). The drama was performed in the community, after which young women (18-24 years), young men (17-24 years), female and male parents discussed on what they saw in the drama, focusing on young people's SRHR, in four focus group discussions (Phase 3). All transcripts were coded and thematically analysed and narratives were written on main themes. RESULTS: Three community SRHR bylaws, related to teenage pregnancy, child marriage, and sexual harassment and rape were identified and commonly accepted in the community. While these bylaws intend to reduce SRHR-related issues among young people, they are often not involved in bylaw formulation. The bylaws were associated with protection of girls, and a good reputation for boys, young men and traditional leaders. Bylaw enforcement faced problems, as fines were not in line with national laws, and wealthy offenders could avoid them through bribes. Effects of bylaws on teenage pregnancy rates seemed limited, while some positive effects on school readmission, prevention of child marriage, and reporting sexual harassment were reported. CONCLUSIONS: The study revealed that community bylaws were accepted but not owned by young people, and had different effects on the rich versus the poor, and girls versus young men. Bylaws were associated with punishment in terms of money, which seemed to overpower their potential to promote rights and address social norms underlying SRHR issues of the youth.

Combining survey data, GIS and qualitative interviews in the analysis of health service access for persons with disabilities.

BACKGROUND: Equitable access to health services is a key ingredient in reaching health for persons with disabilities and other vulnerable groups. So far, research on access to health services in low- and middle-income countries has largely relied on self-reported survey data. Realizing that there may be substantial discrepancies between perceived and actual access, other methods are needed for more precise knowledge to guide health policy and planning. The objective of this article is to describe and discuss an innovative methodological triangulation where statistical and spatial analysis of perceived distance and objective measures of access is combined with qualitative evidence. METHODS: The data for the study was drawn from a large household and individual questionnaire based survey carried out in Namibia and Malawi. The survey data was combined with spatial data of respondents and health facilities, key informant interviews and focus group discussions. To analyse access and barriers to access, a model is developed that takes into account both measured and perceived access. The geo-referenced survey data is used to establish four outcome categories of perceived and measured access as either good or poor. Combined with analyses of the terrain and the actual distance from where the respondents live to the health facility they go to, the data allows for categorising areas and respondents according to the four outcome categories. The four groups are subsequently analysed with respect to variation in individual characteristics and vulnerability factors. The qualitative component includes participatory map drawing and is used to gain further insight into the mechanisms behind the different combinations of perceived and actual access. RESULTS: Preliminary results show that there are substantial discrepancies between perceived and actual access to health services and the qualitative study provides insight into mechanisms behind such divergences. CONCLUSION: The novel combination of survey data, geographical data and qualitative data will generate a model on access to health services in poor contexts that will feed into efforts to improve access for the most vulnerable people in underserved areas.

Paying for Happiness: Experimental Results from a Large Cash Transfer Program in Malawi.

This study analyzes the short-term impact of an exogenous, positive income shock on caregivers' subjective well-being (SWB) in Malawi using panel data from 3,365 households targeted to receive Malawi's Social Cash Transfer Program that provides unconditional cash to ultra-poor, labor-constrained households. The study consists of a cluster-randomized, longitudinal design. After the baseline survey, half of these village clusters were randomly selected to receive the transfer and a follow-up was conducted 17 months later. We find that the short-term impact of household income increases from the cash transfer leads to substantial SWB gains among caregivers. After a year's worth of transfers, caregivers in beneficiary households have higher life satisfaction and are more likely to believe in a better future. We examine whether program impacts on consumption, food security, resilience, and hopefulness could explain the increase in SWB but do not find that any of these mechanisms individually mediate our results.

Short-term Impacts of an Unconditional Cash Transfer Program on Child Schooling: Experimental Evidence from Malawi.

This study analyzes the impact of a positive income shock on child schooling outcomes using experimental data from an unconditional cash transfer program in Malawi. Since households receive the cash and parents are responsible for making spending decisions, we also examine the intervening pathways between cash transfers and child schooling. Data comes from a cluster-randomized study of Malawi's Social Cash Transfer Program (SCTP). After a baseline survey, households in village clusters were randomly assigned to treatment and control arms with treatment villages receiving transfers immediately and control villages assigned a later entry. We test for treatment impacts on a panel of school-aged children (6-17) using a differences-in-differences model. After a years' worth of transfers, we find the Malawi SCTP both improves enrollment rates and decreases dropouts. The main intervening pathway between the program and schooling is education expenditures, suggesting that the cash improves the demand for education by reducing financial constraints.

Knowledge, attitudes and practices about HIV testing and counselling among adolescent girls in some selected secondary schools in Malawi.

The major objective of this study was to determine knowledge, attitudes and practices about HIV testing services and the uptake of this service amongst girls aged 15-19 in selected secondary schools in Malawi. A questionnaire was administered to 457 students and 18 focus group discussions and 45 in-depth interviews were conducted. The study found that almost every student knew about HTC but uptake was low as only about a third of the students reported having been tested. The uptake of this service also increased with age. Most of those tested wanted to know their sero-status. Others were tested because it was a requirement. Sixty nine per cent of the girls who did not go for the HIV test was mainly because either they were not sexually active or they felt they were not at risk. During FGDs some students did not test because they feared their parents would think they were sexually promiscuous. This study demonstrates the need for intensive campaigns among adolescent girls and their parents to create awareness about the importance of HIV testing as this is an entry point for all HIV and AIDS services.

Using Photo-Elicitation Methods to Understand Resilience Among Ultra-Poor Youth and Their Caregivers in Malawi.

Unconditional cash transfer programs are a form of structural intervention to address poverty, a "fundamental cause" of disease. Such programs increasingly aim to build resilience to sustain improved outcomes and provide a solid foundation for longer term transformations. As such, there is a need to understand what resilience means in specific contexts. The goal of this formative study was to explore local experiences of resilience and vulnerability among 11 youth-caregiver dyads ( n = 22) who were beneficiaries of the Malawi Social Cash Transfer Program in Balaka district. We used a photo-elicitation approach informed by the participatory, visual methodology photovoice to guide the study and conducted an iterative content analysis using thematic coding of transcripts and photos. Participants took pictures of their daily struggles and shocks and participated in audio-recorded discussions to reflect on the photos using an adapted version of the SHOWeD method. We found that participants characterized resilience as a tireless process of using all available individual, family, and community resources at all times in pursuit of survival and well-being. In the context of daily struggles, resilience was an essential part of survival. Shocks, mostly health-related, were depicted through staged images candidly highlighting individual and environmental vulnerabilities. Community support was an essential component of resilience for both daily struggles and shocks. Using photo-elicitation methods facilitated an intergenerational, community-driven reflection on the meaning of resilience and the multilevel determinants of health in a context of extreme poverty. Findings can inform the design of resilience-focused cash transfer programs to improve health equity.

Social networks, social participation, and health among youth living in extreme poverty in rural Malawi.

Extensive research documents that social network characteristics affect health, but knowledge of peer networks of youth in Malawi and sub-Saharan Africa is limited. We examine the networks and social participation of youth living in extreme poverty in rural Malawi, using in-depth interviews with 32 youth and caregivers. We describe youth's peer networks and assess how gender and the context of extreme poverty influence their networks and participation, and how their networks influence health. In-school youth had larger, more interactive, and more supportive networks than out-of-school youth, and girls described less social participation and more isolation than boys. Youth exchanged social support and influence within their networks that helped cope with poverty-induced stress and sadness, and encouraged protective sexual health practices. However, poverty hampered their involvement in school, religious schools, and community organizations, directly by denying them required material means, and indirectly by reducing time and emotional resources and creating shame and stigma. Poverty alleviation policy holds promise for improving youth's social wellbeing and mental and physical health by increasing their opportunities to form networks, receive social support, and experience positive influence.

Early childhood development: the role of community based childcare centres in Malawi.

BACKGROUND: Somatic changes including growth and development of the brain of a human being occur very early in life. Programmes that enhance early childhood development (ECD) therefore should be part of the national agenda. Cognizant of this fact, the Malawi Government together with development partners facilitated the establishment of community-based child care centres (CBCCs) which are owned and managed by community members. This study was aimed at understanding how CBCCs operated and their core functions. METHODS: Using information from databases kept by the District Social Welfare Officers from all the 28 districts in Malawi, coupled with snowballing, all functioning CBCCs were enumerated. A questionnaire was administered to the head of the CBCC or a care giver. Highly trained Research Assistants also carried our observations of the structures around the centres and the activities that actually happened. Data was analysed using a Statistical Package for Social Sciences. RESULTS: Communities provide structures, support for care givers, food, utensils, labour and play materials for the children in CBCCs. The first ECD centre was established in 1966 but the real surge in establishing these happened towards the end of the 1990s and by 2007 there were 5,665 CBCCs in Malawi caring for 407,468 children aged between 3 and 5 years. CBCCs were established to provide pre-primary school learning, and in some cases provide special care to orphans and other vulnerable. CONCLUSIONS: Despite the fact that most CBCC premises and structures fell short of the standards laid down by the CBCC profile, the activities and services provided were mostly to the book. Children were provided with nutritious foods and subjected to play that stimulated their cognitive and mental development. Despite the fact that some members of the community do not realize the value of the CBCCs, the existence of these institutions is an opportunity for the community to take care of their children communally, a task that has become imperative as a result of the upsurge in the number of orphans as a result of the HIV and AIDS epidemic. The study recommends that Malawi should take investments in ECD programmes as a priority.

"Condoms make you lose both the child and pleasure": perceptions on contraceptives use in Malawi.

A qualitative study comprising 91 focus group discussions (FGDs) of adult married men and women and 21 key informant interviews (Klls) was conducted in Malawi in 2008. The purpose of the study was to explore the knowledge, perceptions and practices towards contraceptives and family planning. Data were analyzed using content analysis. The perceived effectiveness, physical health gains and socio-economic benefits of contraceptives and/or family planning were well recognized by the study participants. Covert use of contraceptives by women was despised by both men and women and considered a punishable offence. Women reported men as less likely to provide support for contraceptive use. A woman's own relatives were reported to be more likely to support contraceptive use, while her in-laws and friends identified as not as supportive. Concerns regarding adverse health effects of hormonal contraceptive use included vaginal bleeding and delayed return to fertility. Unwanted social or personal consequences were that vaginal bleeding or spotting as a consequence of hormonal contraceptive use limited women's availability to their male partners for sex, that a woman who was using contraceptives was not fulfilling her childbearing responsibilities and that contraceptive use promoted extramarital sex as there was no more fear of pregnancy. Having a wide range of contraceptives in health facilities or community sources, a supportive healthcare and supportive social network could improve contraceptive uptake.