Philosophiae Doctor - PhD / This research explored the role of men in efforts by the Malawi Ministry of Health to promote women’s reproductive and maternal health in accordance with Millennium Development Goal (MDG) number five, i.e. to reduce the maternal mortality ratio by three quarters between 1990 and 2015. The study was conceptualised in 2011 in an effort to contribute to the national strategy to reduce maternal mortality in Malawi, and it was done in the particular cultural context of a matrilineal marriage and kinship system in Ntchisi district, Malawi. At the inception of this study, the highest prevalence of maternal deaths in the country was reported in seven districts, including Ntchisi. A common understanding in public health circles worldwide is that male involvement in reproductive and maternal health activities is an important factor in achieving the above MDG goal. But historically, research on maternal health in Malawi has focused mostly on women and children. Consequently there are only a small number of relevant previous studies or extant literature to draw on for the current investigation. Malawi’s reproductive and maternal health policies largely lack locally-informed research on men and masculinities. My study aimed to explore the relationship between local constructions of masculinity, fatherhood and reproductive health in Malawi among Chichewa speakers who live in Ntchisi. It was guided by the social constructionist theory which recognises the role of the impersonal features of the social world like cultural, personal and group influences in the construction of ideas, knowledge and facts. In this study I adopted an inductive approach to learning in which the participants were the main players in describing and explaining social phenomena as they are constructed and experienced in the research site. I conducted multiple in-depth interviews and focus group discussions with 53 married men, key informant interviews with eight local leaders and traditional birth attendants, as well as focus group discussions with 12 married women who had given birth multiple times. Data analysis involved intensive scrutiny of transcripts to determine prevailing themes. Listening to the tapes and re-reading these transcripts enabled me to detect patterns and categorise different practices and constructions, to find associations between these practices and constructions of concepts. Malawi’s men are considered to be the traditional gatekeepers of maternal and social ideals. Therefore, as elders in a clan or as husbands, their prompt decisions can facilitate the access of their spouses to maternal and reproductive health services. Men as heads of households and decision makers can also support and enable their wives to follow the recommended maternal health counsel. However, men’s “lack of involvement” is not the principal reason why there is increasing maternal challenges among child-bearing women in Ntchisi. Although men are not entirely free of the blame for contributing to the status quo, they already work hard towards ensuring positive pregnancy outcomes for their spouses. The study found that husbands in Ntchisi have long been involved in pregnancy and child care. The study shows that pregnancy is regarded as a liminal state or as a kind of “sickness”. Male involvement in pregnancy means the man should take over the routine household chores of drawing water, fetching firewood and cooking, among other things. However, men construct their involvement in reproductive and maternal health matters in the framework of masculinity and femininity as dictated by the commonly held beliefs of a matrilineal Chewa grouping. The study showed that masculinities are constructed within the context of a matrilineal system, which has nonetheless been changing largely due to the colonial impact of the United Kingdom, the related influences of Christian and westernised social ideals and an education system based on the British model. Men’s gendered practices in reproduction and parenting have foundations in the initiation rites of the secret Nyau societies where the masculine ideals of sexuality and secrecy are inculcated. This research cannot be generally extrapolated to the wider population in Malawi but it is a starting point for understanding the responses of matrilineal Chichewa speaking men to reproductive and maternal health matters. Further and broader research on the construction of fatherhood and masculinity is needed in Malawi to make it possible for public health policy on reproductive and maternal health to be more culturally informed.

The aim of this Bachelor thesis is to study the connection between literacy and development and poverty reduction in a third world country. The study is based on Mothers’ Union Literacy and Development Programme (MULDP) in Malawi, where it examines what difference literacy makes in the learners of MULDPs lives and what meaning literacy has for them. The results found in the study are analysed with a theoretical framework that is built on Freire’s theory of ‘conscientization’ and the concepts of functional literacy and functional illiteracy. The method chosen is unstructured focus group interviews with the learners of MULDP and the findings were classified into themes through meanings condensation and thereafter compared with the theoretical framework. The results show that the effects of literacy are visual in both the personal and public sphere, changing the lives of the individual, the family and the community. The findings illustrate that literacy is both a tool and a social practice. Literacy itself does not develop the learners; it is the knowledge that comes with the social practice that is the trigger to development. This study concludes that literacy is developing the learners as human beings. A connection can, however, not be made between literacy and poverty reduction; literacy cannot on its own take the learners out of poverty because other means are also needed.

Background: Maternal common mental disorder (CMD), characterised by depression, anxiety and somatic symptoms of distress, is known to be an important health problem in low-and-middle-income countries, but had not been investigated in Malawi, Africa. In preliminary work, we adapted a CMD screening measure and showed that post-partum CMD was common and associated with child stunting. In the research presented here, we expanded the investigation of CMD in Malawi to include pregnant women and mothers of children with severe acute malnutrition (SAM). Using validated measures, we aimed to estimate the prevalence of antenatal CMD/depression and investigate its relationship to social support and intimate partner violence. Secondly, we sought to explore women’s lived experiences of the perinatal period. Finally, we investigated CMD amongst mothers of children admitted with SAM and other life-threatening illness and, in the former, we tested the hypothesis that maternal CMD would be associated with impaired child recovery. Method: In an antenatal clinic-based study, we validated and compared Chichewa and Chiyao versions of the Self Reporting Questionnaire (SRQ) and Edinburgh Postnatal Depression Scale (EPDS) using major depressive episode (MDE) as the criterion diagnosis. We adapted and validated the Multi-dimensional Scale of Perceived Social Support (MSPSS). We measured the prevalence of antenatal MDE and identified associated factors. We conducted focus group discussions with women and enquired about perinatal stressors and supports. We administered the SRQ to mothers of children with SAM during admission to a nutritional rehabilitation unit (NRU) and at 1-month post-discharge, and investigated whether CMD was a risk factor for lower child weight gain at follow-up. In a subsequent study, we compared levels of CMD symptoms between mothers of children admitted to a NRU, a high dependency unit and an oncology ward. Results: We found that the adapted EPDS and SRQ were both valid screening instruments for antenatal CMD/depression. The weighted prevalence of antenatal MDE was 10.7% (95% CI 6.9% - 14.5%). The adapted MSPSS showed adequate test characteristics and differentiated between sources of social support. MDE was associated with lack of support by a significant other; intimate partner violence moderated this association. We found that women in rural Malawi recognised depressive and anxious states in the perinatal period and identified lack of partner support as a key stressor. During admission with a severely malnourished child to a NRU, mothers had very high SRQ scores that greatly reduced post-discharge. There was no association between SRQ score and child weight gain at follow-up. We found no higher level of CMD symptoms amongst mothers of children admitted for treatment of SAM compared with those admitted to other wards. Conclusions: We demonstrated that measures of antenatal CMD and perceived social support can be adapted for use in Malawi. We found that maternal CMD is common and associated with lack of social support, intimate partner violence and child illness. We did not find evidence for a specific association between maternal CMD and child SAM but further prospective studies are required. Our findings suggest that treatment of CMD in mothers in Malawi will require attention to social support and partner behaviour.

Building resilient communities has emerged as a dominant agenda in the policy arena and in academia in the wake of recent disasters. However, there is a lack of clarity on the specific interventions required to build resilience. Current challenges associated with resilience include ambiguity, unclear measures, and problematized applicability. This thesis evaluates the determinants of resilience to drought in community food systems as a basis for contributing towards a more advanced understanding of resilience. A schematic model linking the key concepts associated with resilience was developed on the basis of literature review. This model was subsequently applied to a sample of 195 farm households, 16 community meetings and about 45 interviews with key informants across eight villages in Nsanje and Mzimba districts in Malawi interviewed between October 2010 and February 2011. Analysis at household level focused on exploring the causes of vulnerability, the role of livelihood assets and institutions in shaping coping and adaptation, and the implication of these to the meaning of resilience. The thesis concluded that vulnerability to food insecurity was produced by an interaction of slow and fast moving factors and processes, some of which were highly persistent. Access to livelihood assets and institutions increased short term coping and adaptive capacity but did not effectively predict resilience given unknowns regarding asset availability and liquidity over the long term. Different socio-economic groups associated different meanings with the concept of resilience, and in some cases, one group achieved ‘resilience’ at the expense of the larger community. In integrating vulnerability into resilience thinking, the analysis suggested that resilience could be analysed as existing in desirable and undesirable forms. Undesirable resiliencies reinforced the vulnerable state. By addressing the factors that sustain vulnerability, response capacity could be enhanced. This being the case, advanced by this thesis is a shift from focusing on resilience as a utopian goal, in favour of practices that enhance response capacity and letting communities learn for themselves and transform their value sets to ones that are more likely to ensure coping with adverse conditions. The study concludes that the concept of resilience in its current form is of more value as an organising framework within the re-engineering of food, agricultural, development and disaster management policy can be undertaken.

Proponents of socially and culturally oriented mathematics education have argued that teaching approaches which value and connect with the learner's prior knowledge and everyday experience are more likely to promote active, meaningful, relevant and liberatory learning than approaches which rely on transmission and abstract presentation of mathematical content. In Malawi, proposals to reform the outdated secondary mathematics curriculum have been made with the aim of aligning mathematics instruction with the social and political changes in the current Malawian society. Using a case study approach, this study investigated the extent to which everyday experiences could be used as a vehicle for changing the learning and teaching of secondary mathematics in Malawi. The study was collaborative, taking place over a period of five months in severely overcrowded and poorly resourced classes in two schools. It involved three mathematics teachers in a cycle of planning and teaching mathematics lessons based on the use of everyday experiences, and observation of and reflection on these lessons, in order to document the effects of using everyday experiences on student learning and teachers' teaching practices. The data was collected through student questionnaires; classroom observations and fieldnotes; interviews and reflective meetings with teachers; and informal meetings with key education officials in Malawi. Mathematics examination results from students involved in this study and a corresponding group from the previous year were collected. A reflective and critical approach was adopted in the interpretation and discussion of the data. Teachers' participation in this study resulted in heightened awareness of their teaching roles and the value of linking school mathematics with everyday experience. The study also shows that students found mathematics interesting and important to learn despite their lack of success in it. In addition, the study documented a number of constraints to change in mathematics instruction such as teachers' focus on mathematics content and examination requirements, and students' resistance to inquiry learning. It also recorded possibilities and barriers to collaboration both between teachers and researchers, and teachers themselves. The findings of this study are timely since they could serve to inform the reform of the Malawian secondary mathematics curriculum currently being undertaken, which began without a critical examination of the classroom conditions necessary to accommodate a socio-politically relevant mathematics education.

Best international health practice requires that all people benefit equally from health care services regardless of their socio-economic status and that healthcare payments be based on ability to pay. Although recent household surveys in Malawi show progress in a number of health indicators population averages, many inequalities in health outcomes still exist or are widening among households stratified by socioeconomic and geographical location variables. Inequalities in out-of-pocket expenditures (OOPEs) for healthcare and how they influence utilization of healthcare services are of particular interest to policy makers as they ultimately affect overall health of households. The rationale for this study is that analysis of inequities in healthcare between socioeconomic groups can help to unmask intra-group and between groups' inequities hidden in national population averages. The study's three main papers examined equity in households' out-of-pocket healthcare payments and utilization of medical care. The study adopted the widely used economic frameworks and techniques developed by O'Donnell et al (2008) for analyzing health equity using household data. These economic frameworks focus on the notion of equal treatment for equal need and that payment for healthcare should be according to ability to pay. The Malawi Integrated Household Survey 2(2005) (MIHS2) was the main dataset used in the analysis. The MIHS2 is currently the only dataset that presents inequalities in healthcare expenditures at the household level in Malawi. However, the MIHS2 report does not examine the extent to which these inequalities are inequities. It is in this context that the first study focused on assessing, first, the progressivity of OOPEs for healthcare and second, the redistributive effect of OOPEs for healthcare as a source of finance in the Malawi health system. The progressivity results indicate that OOPEs for healthcare are relatively regressive in Malawi with the poor shouldering the highest financial burden relative to their ability to pay. The study found no evidence of redistributive effect of OOPEs on income inequalities in Malawi. The second study focused on linking OOPEs to use of healthcare using the recommended two-part model (Probit and OLS). The concentration indices were decomposed into contributing factors after standardizing for health need factors, which include age, sex, self-assessed health, chronic illness and disabilities. Probability of use of healthcare and OOPEs were both found to be concentrated among the non-poor while the poor who have higher health need have less use of healthcare. The last study assessed the socioeconomic factors associated with horizontal equity in use of medical facilities and predicted use using logistic regression. General medical facilities use was found to be more concentrated among the non-poor despite the poor having a higher health need. The results showed no significant inequalities in use of public medical facilities and self-treatment between the poor and the non-poor. Overall, inequalities in healthcare utilization and out-of-pocket healthcare expenditures in Malawi are mainly influenced by socioeconomic factors, which are non-need factors than health need factors. Inequalities due to non-need factors suggest presence of inequities, which are avoidable and unjust. This study can help policy makers have a better understanding of the possible effects of OOPEs and help in explaining the factors contributing to inequities in medical care utilization in Malawi. Such information is necessary so that highest priority should be given to the health problems or challenges disproportionately affecting households with varying levels of socioeconomic privilege. / Graduation date: 2012

The devastating consequences of HIV/AIDS have caused untold harm and human suffering globally. Over 33 million people worldwide are estimated to be living with HIV and AIDS and a majority of these are in sub-Saharan Africa. Women and children are more infected particularly in sub-Saharan countries. Globally, an estimated number of 370 000 children were newly infected in 2007, mainly through mother to child transmission (MTCT). Implementation of prevention of mother to child transmission (PMTCT) programmes has been introduced in many sub-Saharan countries during the last years. Operational research was conducted to study the demand and adherence of key components within a PMTCT Programme among women in rural Malawi. This study was carried out at Malamulo SDA Hospital in rural Malawi and employed a mixture of both quantitative and qualitative approaches. Data sources included antenatal care (ANC), PMTCT and delivery registers, structured questionnaires, in-depth interviews with HIV positive women in the programme and focus group discussions with community members, health care workers and traditional birth attendants. Over the three year period of the study (January 2005 to December 2007), three interventions were introduced in the antenatal care (ANC) at the hospital at different times. These were HIV testing integrated in the ANC clinic in March 2005, opt-out testing in January 2006 and free maternal services in October 2006. A steady increase of the service uptake as interventions were being introduced was observed over time. HIV testing was generally accepted by the community and women within the programme. However, positive HIV tests among pregnant women were also experienced to cause conflicts and fear within the family. Although hospital deliveries were recognised to be safe and clean, home deliveries were common. Lack of transport, spouse support and negative attitudes among staff were some of the underlying factors. Further study on the quality of care offered in the presence of increased service uptake is required. Community sensitisation on free maternal care and male involvement should be strengthened to enable full utilisation of services. Additionally, service providers at facility and community levels, policy makers at all levels and the communities should see themselves as co-workers in development to reduce preventable maternal and infant mortality including MTCT of HIV.

Lake Malawi is a great lake not only because of its size (30,800 km2) but also because of its unique fish diversity. The lake contains the highest number of freshwater fish species in the world. The fish species are hypothesized to have radiated within the lake, which is 1-2 million years old. The collapse of the capture fishery in Lake Malawi between the 1970s and 1990s led to the launch of cage culture of indigenous fish species in 2004 in the south east arm of the lake. While cage culture has been practiced for many years in temperate lakes and seas, the fish farm in Lake Malawi is the first in the African Great Lakes and, therefore, not much information currently exists that is relevant to the impact of cage culture on such a large, species-rich tropical lake. Consequently, a study was done between January and December, 2007, at the fish farm in Lake Malawi to determine potential impacts of cage wastes on the environment. The study found that, just like in temperate systems where 70-87% of C, N and P added through feed get dispersed into the environment, discharges from fish cages in Lake Malawi were between 71-88% of the nutrients added through feed. The discharges were proportional to the amount of feed added so that as production and feed supply increase over time, more cage wastes would be generated and released into the environment. The discharges were exacerbated by poor stocking and feeding regimes. Production periods were longer (mean of 376±42 days) than if recommended stocking and feeding rates were followed. Feed quality may also have affected production performance and waste generation in the cages, but was not studied. The cage wastes were incorporated into the food web and support the wild fishes in the vicinity of the fish farm. Impacts of the cage wastes on the water column and sediments in the vicinity of the cages were minimal during the study period, probably because of rapid and efficient dispersion of the wastes by strong water currents, that averaged 9.3 cm s-1, through the cages and high consumption of the cage wastes by large numbers of wild fishes which aggregated around the cages. The wild fishes also helped to disperse the cage wastes over a larger area through consumption, translocation and defecation. However, as production increases, the amount of cage wastes generated may overwhelm mitigation by dispersion by water currents and consumption by wild fishes, particularly if many cages are deployed close together and interfere with current flows. Based on my observations, a fish farm that produces 15,000 tonnes fish/yr in Lake Malawi would generate 1249, 113 and 21 megamoles/yr of C, N and P, respectively, that are comparable or higher than DOC, TDN and TDP loadings observed in the most disturbed large river systems draining into Lake Malawi. The impacts of these river systems in Lake Malawi have been well documented, particularly around river mouths and in the more densely populated and shallower southern portion of the lake, where algal communities and their sedimentation rates have begun to change. Cage culture discharges may accelerate these changes.

The aim and purpose of this report is to describe how the domestic tobacco industry is affectingsustainable development in Malawi. This is done by describing the environmental and socio-economic effects ofthe cultivation and selling of tobacco leaves. Together with an outlook on the future developments of the industry,this information is used to describe how the Malawian tobacco industry corresponds to sustainable developmentand how it can be changed to improve sustainability in the country. The report is based on a literature study andtwo interviews. Theories on sustainable development and developmental concepts form the theoreticalbackground for the report. The conclusion of the report is that the situation regarding the Malawian tobaccoindustry is a complex one, where direct economic benefits are the main motive, but various socio-economic andenvironmental effects combine to make the situation unsustainable in a number of aspects. The suggestion of thisreport is to turn away from the current high dependence on tobacco to a more diversified agriculture, wheredifferent types of food crops substitute tobacco as the main source of income, while at the same time providingmore food in a country where poverty and malnutrition are problematic issues.

Lake Malawi is a great lake not only because of its size (30,800 km2) but also because of its unique fish diversity. The lake contains the highest number of freshwater fish species in the world. The fish species are hypothesized to have radiated within the lake, which is 1-2 million years old. The collapse of the capture fishery in Lake Malawi between the 1970s and 1990s led to the launch of cage culture of indigenous fish species in 2004 in the south east arm of the lake. While cage culture has been practiced for many years in temperate lakes and seas, the fish farm in Lake Malawi is the first in the African Great Lakes and, therefore, not much information currently exists that is relevant to the impact of cage culture on such a large, species-rich tropical lake. Consequently, a study was done between January and December, 2007, at the fish farm in Lake Malawi to determine potential impacts of cage wastes on the environment. The study found that, just like in temperate systems where 70-87% of C, N and P added through feed get dispersed into the environment, discharges from fish cages in Lake Malawi were between 71-88% of the nutrients added through feed. The discharges were proportional to the amount of feed added so that as production and feed supply increase over time, more cage wastes would be generated and released into the environment. The discharges were exacerbated by poor stocking and feeding regimes. Production periods were longer (mean of 376±42 days) than if recommended stocking and feeding rates were followed. Feed quality may also have affected production performance and waste generation in the cages, but was not studied. The cage wastes were incorporated into the food web and support the wild fishes in the vicinity of the fish farm. Impacts of the cage wastes on the water column and sediments in the vicinity of the cages were minimal during the study period, probably because of rapid and efficient dispersion of the wastes by strong water currents, that averaged 9.3 cm s-1, through the cages and high consumption of the cage wastes by large numbers of wild fishes which aggregated around the cages. The wild fishes also helped to disperse the cage wastes over a larger area through consumption, translocation and defecation. However, as production increases, the amount of cage wastes generated may overwhelm mitigation by dispersion by water currents and consumption by wild fishes, particularly if many cages are deployed close together and interfere with current flows. Based on my observations, a fish farm that produces 15,000 tonnes fish/yr in Lake Malawi would generate 1249, 113 and 21 megamoles/yr of C, N and P, respectively, that are comparable or higher than DOC, TDN and TDP loadings observed in the most disturbed large river systems draining into Lake Malawi. The impacts of these river systems in Lake Malawi have been well documented, particularly around river mouths and in the more densely populated and shallower southern portion of the lake, where algal communities and their sedimentation rates have begun to change. Cage culture discharges may accelerate these changes.