Change and continuity : perceptions about childhood diseases among the Tumbuka of Northern Malawi

The objectives of this study were to determine what the Tumbuka people of northern Malawi consider to be the most dangerous childhood diseases, to explore their perceptions about the aetiology, prevention and treatment of these diseases, and to determine how such perceptions have changed over the years. The study was done in Chisinde and surrounding villages in western Rumphi District, northern Malawi. Although a household questionnaire was used to collect some quantitative data, the major data collection methods comprised participant observation, in-depth interviews with mothers with children under five and old men and women, and key informant interviews with traditional healers, traditional birth attendants, village headmen, health surveillance assistants and clinical officers. Informants in this study mentioned chikhoso chamoto, diarrhoea, malaria, measles, and conjunctivitis as the most dangerous childhood diseases in the area. Old men and women added that in the past smallpox was also a dangerous disease that affected both children and adults. Apart from measles and smallpox, community-based health workers and those at the local health centre also mentioned the same list of diseases as the most dangerous diseases prevalent among under-five children. Though health workers and informants mentioned the same diseases, the informants' perspectives about the aetiology and prevention of these diseases and the way they sought treatment during childhood illness episodes, in some cases, differed significantly from those of biomedicine. For example, while health workers said that the signs and symptoms presented by a child suffering from "chikhoso chamoto" were those of either kwashiorkor or marasmus, both young and elderly informants said that a child could contract this illness through contact with a person who had been involved in sexual intercourse. Biomedically, diarrhoea is caused by the ingestion of pathogenic agents, which are transmitted through, among other factors, drinking contaminated water and eating contaminated foods. While young men and women subscribed to this biomedical view, at the same time, just like old men and women, they also believed that if a breastfeeding mother has sexual intercourse, sperms will contaminate her breast milk and, once a child feeds on this milk, he or she will develop diarrhoea. They, in addition, associated diarrhoea with the process of teething and other infections, such as malaria and measles. In malaria-endemic areas such as Malawi, the occurrence of convulsions, splenomegaly and anaemia in children under five may be biomedically attributed to malaria. However, most informants in this study perceived these conditions as separate disease entities caused by, among other factors, witchcraft and the infringement of Tumbuka taboos relating to food, sexual intercourse and funerals. Splenomegaly and convulsions were also perceived as hereditary diseases. Such Tumbuka perceptions about the aetiology of childhood diseases also influenced their ideas about prevention and the seeking of therapy during illness episodes. Apart from measles, other childhood vaccine-preventable diseases (i.e. tetanus, diphtheria, tuberculosis, pertussis and poliomyelitis) were not mentioned, presumably because they are no longer occurring on a significant scale, which is an indication of the success of vaccination programmes. This study reveals that there is no outright rejection of vaccination services in the study area. Some mothers, though, felt pressured to go for vaccination services as they believed that non-vaccinated children were refused biomedical treatment at the local health centres when they fell ill. While young women with children under five mentioned vaccination as a preventative measure against diseases such as measles, they also mentioned other indigenous forms of 'vaccination', which included the adherence to societal taboos, the wearing of amulets, the rubbing of protective medicines into incisions, isolation of children under five (e.g. a newly born child is kept in the house, amongst other things, to protect him or her against people who are ritually considered hot because of sexual intercourse) who are susceptible to disease or those posing a threat to cause disease in children under five. For example, since diarrhoea is perceived to be caused by, among other things, a child feeding on breast milk contaminated with sperms, informants said that there is a strong need for couples to observe postpartum sexual intercourse. A couple with newly delivered twins is isolated from the village because of the belief that children will swell if they came into contact with them. Local methods of disease prevention seem therefore to depend on what is perceived to be the cause of the illness and the decision to adopt specific preventive measures depends on, among other factors, the diagnosis of the cause and of who is vulnerable. The therapy-seeking process is a hierarchical movement within and between aetiologies; at the same time, it is not a random process, but an ordered process of choices in response to negative feedback, and subject to a number of factors, such as the aetiology of the disease, distance, social costs, cost of the therapeutic intervention, availability of medicines, etc. The movement between systems (i.e. from traditional medicine to biomedicine and vice-versa) during illness episodes depends on a number of factors, including previous experiences of significant others (i.e. those close to the patient), perceptions about the chances of getting healed, the decisions of the therapy management group, etc. For example, febrile illness in children under five may be treated using herbs or antipyretics bought from the local grocery shops. When the situation worsens (e.g. accompanied by convulsions), a herbalist will be consulted or the child may be taken to the local health centre. The local health centre refers such cases to the district hospital for treatment. Because of the rapidity with which the condition worsens, informants said that sometimes such children are believed to be bewitched, hence while biomedical treatment is sought, at the same time diviners are also consulted. The therapeutic strategies people resort to during illness episodes are appropriate rational decisions, based on prevailing circumstances, knowledge, resources and outcomes. Boundaries between the different therapeutic options are not rigid, as people move from one form of therapy to another and from one mode of classification to another. Lastly, perceptions about childhood diseases have changed over the years. Old men and women mostly attribute childhood illnesses to the infringement of taboos (e.g. on . sexual intercourse), witchcraft and other supernatural forces. While young men and women also subscribe to these perceptions, they have at the same time also appropriated the biomedical disease explanatory models. These biomedical models were learnt at school, acquired during health education sessions conducted by health workers in the communities as well as during under-five clinics, and health education programmes conducted on the national radio station. Younger people, more frequently than older people, thus move within and between aetiological models in the manner described above

Lineage and land reforms in Malawi: do matrilinear and patrilinear landholding systems represent a problem for land reforms in Malawi?

This paper is about land tenure relations among the matrilineal and patrilineal cultures in Malawi. Data from the National Agricultural and Livestock Census are used to characterize marriage systems and settlement and landholding patterns for local communities. Marriage systems correspond to customary land tenure patterns of matrilineal or patrilineal land holding. The differences between the two major ways of land holding represent a particular challenge for land reforms intending to unify rules for land tenure and land devolution. The paper discusses the problems of formalisation and the idea of maintaining the diversity. If diversity is not respected there is a chance that some sections of society, especially communities with matrilineal land holding, might be victims of formalization. Based on analogy of the resilience of the patrilineal land holding system in Norway it is argued that a democratic system will have difficulty removing the preferential rights of linage members and it is recommended that the existing land rights are formally recognized and circumscribed by fair procedures. In a situation of diversity one goal of a well-designed land holding system should be to ease the transitions of the diverse customary tenure systems towards systems adapted to the requirements of a modern large scale society rather than to a unified national system

Using prospective methods to identify fieldwork locations favourable to understand divergences in health care accessibility

Central to this article is the issue of choosing sites for where a fieldwork could provide a better understanding of divergences in health care accessibility. Access to health care is critical to good health, but inhabitants may experience barriers to health care limiting their ability to obtain the care they need. Most inhabitants of low-income countries need to walk long distances along meandering paths to get to health care services. Individuals in Malawi responded to a survey with a battery of questions on perceived difficulties in accessing health care services. Using both vertical and horizontal impedance, we modelled walking time between household locations for the individuals in our sample and the health care centres they were using. The digital elevation model and Tobler’s hiking function were used to represent vertical impedance, while OpenStreetMap integrated with land cover map were used to represent horizontal impedance. Combining measures of walking time and perceived accessibility in Malawi, we used spatial statistics and found spatial clusters with substantial discrepancies in health care accessibility, which represented fieldwork locations favourable for providing a better understanding of barriers to health access.publishedVersio

Land Tenure and Social Relations in Matrilineal and Uxorilocal Societies in Malawi

The present paper is a revision of a paper that was submitted to Land Use Policy in 2009. The review from LUP from 2010 asked for a rewrite. Due to personal reasons this was not possible before other tasks took all available time. In connection with the lead authors work on an assessment of the fit of the Customary Land Act 2016 and its Amendments 2022 with rural lives and customary land management in Malawi, the discussion in the present paper was necessary as background. Hence we have updated the paper and present it as a report from the Centre for Land Tenure Studies at the Norwegian University of Life Sciences. Erling Berge, Ås, March 2023This paper is about social relations in customary lands for the matrilineal uxorilocal culture of the Lomwe, Nyanja and Yao tribes in Southern Malawi. The study was carried out in the districts of Chiradzulu and Phalombe. Qualitative methods were used to examine local histories and practices to identify the social and power relations between males and females in matrilineal groups and the roles of chiefs, extended families, and traditional practices in access to and control over customary land. By focusing on local histories the study documents that patterns of access to and control over customary lands are historical in nature and embedded in social ties and power relations. Male and female members of the household or family have equal use rights but unequal ownership rights. The land belongs to the extended family and not to the community or individuals. Instead of saying the land belongs to ‘me’ the people say the land belongs to ‘us’ even though the individuals may have user rights in perpetuity. The ‘us’ implies the extended family and not the community. The power and control over the land is located in the group of sisters and not in the head of family (mwini-mbumba) or the Chief. The patterns of control have to be understood for proper decisions to be made on how to organize access to and control over land, especially in a country where livelihoods are dependent on agriculture or are land based in nature.Denne artikkelen handlar om dei sosiale relasjonane i tradisjonelle jordbruksområde innan den matrilineale og uxorilokale kulturen hos Lomwe, Nyanja og Yao stammene i det sørlege Malawi. Studien vart gjort i distrikta Chiradzulu og Phalombe. Det vart nytta kvalitative metodar for å studere lokalhistorie og praksisar for å identifisere sosial- og makt-relasjonar mellom menn og kvinner i matrilineale grupper og kva roller høvdingar, stor-familiar og tradisjonelle praksisar har for tilgang til og kontroll over tradisjonelle jordbruksområde. Ved å fokusere på lokalhistorie dokumenterer studien at mønsteret i tilgang til og kontroll over tradisjonelle jordbruksområde er historisk i utgangspunktet og innbakt i sosiale band og makt relasjonar. Mannlege og kvinnelege medlemmer i hushaldet eller stor-familien har dei same bruksrettane, men ulike eigarrettar. Jorda tilhøyrer stor-familien og ikkje lokalsamfunnet eller individa. I staden for å seie at jorda tilhøyrer «meg» seier folk at jorda tilhøyrer «oss» sjølv om individet kan ha bruksrettar for all æve. «Oss» tyder stor-familien og ikkje lokalsamfunnet. Makt og kontroll over jorda er lokalisert i gruppa av søstrer og ikkje i sjefen for stor-familien (mwini-mbumba) eller høvdingen. Dette mønsteret for kontroll må ein skjøne for å kunne ta skikkelege avgjerder om korleis ein kan organisere tilgang til og kontroll over jorda, særleg i eit land der levebrødet er avhengig av jordbruk eller er grunnleggande arealbasert. [uxorilokal (= matrilokal) tyder at personane er busett på kvinna sin heimstad; matrilineal tyder at ein reknar slektslinjer gjennom mødrer; høvdingar og mwini-mumba-er kan like gjerne vere menn som kvinner; familie tyder stor-familien av mødrer, tanter, søstrer, søskenbarn, osv; menn har sjølvsagt sin plass i storfamilien, men dei er ikkje jordeigarar

The evil circle of poverty: a qualitative study of malaria and disability

<p>Abstract</p> <p>Background</p> <p>This article discusses the link between disability and malaria in a poor rural setting. Global malaria programmes and rehabilitation programmes are organized as vertical and separate programmes, and as such they focus on prevention, cure and control, and disability respectively. When looking at specific conditions and illnesses, the impairing long-term consequences of illness incidents during childhood are not questioned.</p> <p>Methods</p> <p>The study design was ethnographic with an open, exploratory approach. Data were collected in Mangochi District in Malawi through qualitative in-depth interviews and participant observation.</p> <p>Results</p> <p>Despite a local-based health service system, people living in poor rural areas are confronted with a multitude of barriers when accessing malaria prevention and treatment. Lack of skilled health personnel and equipment add to the general burden of poverty: insufficient knowledge about health care, problems connected to accessing the health facility in time, insufficient initiatives to prevent malaria attacks, and a general lack of attention to the long term disabling effects of a malaria attack.</p> <p>Conclusions</p> <p>This study points to the importance of building malaria programmes, research and statistics that take into consideration the consequences of permanent impairment after a malaria attack, as well as the context of poverty in which they often occur. In order to do so, one needs to develop methods for detecting people whose disabilities are a direct result of not having received health services after a malaria episode. This may be done through qualitative approaches in local communities and should also be supplemented by suitable surveys in order to estimate the problem on a larger scale.</p

Context matters: fostering, orphanhood and schooling in Sub-Saharan Africa

A growing body of research suggests that orphanhood and fostering might be (independently) associated with educational disadvantage in sub-Saharan Africa. However, literature on the impacts of orphanhood and fostering on school enrolment, attendance and progress produces equivocal, and often conflicting, results. This paper reports on quantitative and qualitative data from sixteen field-sites in Ghana and Malawi, highlighting the importance of historical and social context in shaping schooling outcomes for fostered and orphaned children. In Malawi, which has been particularly badly affected by AIDS, orphans were less likely to be enrolled in and attending school than other children. By contrast, in Ghana, with its long tradition of ‘kinship fostering’, orphans were not significantly educationally disadvantaged; instead, non-orphaned, purposively fostered children had lower school enrolment and attendance than their peers. Understanding the context of orphanhood and fostering in relation to schooling is crucial in achieving ‘Education for All’

Predictors of Utilisation of Skilled Maternal Healthcare in Lilongwe District, Malawi

Background: Despite numerous efforts to improve maternal and child health in Malawi, maternal and newborn mortality rates remain very high, with the country having one of the highest maternal mortality ratios globally. The aim of this study was to identify which individual factors best predict utilisation of skilled maternal healthcare in a sample of women residing in Lilongwe district of Malawi. Identifying which of these factors play a significant role in determining utilisation of skilled maternal healthcare is required to inform policies and programming in the interest of achieving increased utilisation of skilled maternal healthcare in Malawi.Methods: This study used secondary data from the Woman’s Questionnaire of the 2010 Malawi Demographic and Health Survey (MDHS). Data was analysed from 1126 women aged between 15 and 49 living in Lilongwe. Multivariate logistic regression was conducted to determine significant predictors of maternal healthcare utilisation. Results: Women’s residence (P = .006), education (P = .004), and wealth (P = .018) were significant predictors of utilisation of maternal healthcare provided by a skilled attendant. Urban women were less likely (odds ratio [OR] = 0.47, P = .006, 95% CI = 0.28–0.81) to utilise a continuum of maternal healthcare from a skilled health attendant compared to rural women. Similarly, women with less education (OR = 0.32, P = .001, 95% CI = 0.16–0.64), and poor women (OR = 0.50, P = .04, 95% CI = 0.26–0.97) were less likely to use a continuum of maternal healthcare from a skilled health attendant.Conclusion: Policies and programmes should aim to increase utilisation of skilled maternal healthcare for women with less education and low-income status. Specifically, emphasis should be placed on promoting education and economic empowerment initiatives, and creating awareness about use of maternal healthcare services among girls, women and their respective communities

Perceptions and experiences of community members on caring for preterm newborns in rural Mangochi, Malawi: a qualitative study

Background The number of preterm birth is increasing worldwide, especially in low income countries. Malawi has the highest incidence of preterm birth in the world, currently estimated at 18.1 percent. The aim of this study was to explore the perceived causes of preterm birth, care practices for preterm newborn babies and challenges associated with preterm birth among community members in Mangochi District, southern Malawi. Methods We conducted 14 focus group discussions with the following groups of participants: mothers (n = 4), fathers (n = 6) and grandmothers (n = 4) for 110 participants. We conducted 20 IDIs with mothers to preterm newborns (n = 10), TBAs (n = 6) and traditional healers (n = 4). A discussion guide was used to facilitate the focus group and in-depth interview sessions. Data collection took place between October 2012 and January 2013. We used content analysis to analyze data. Results Participants mentioned a number of perceptions of preterm birth and these included young and old maternal age, heredity, sexual impurity and maternal illness during pregnancy. Provision of warmth was the most commonly reported component of care for preterm newborns. Participants reported several challenges to caring for preterm newborns such as lack of knowledge on how to provide care, poverty, and the high time burden of care leading to neglect of household, farming and business duties. Women had the main responsibility for caring for preterm newborns. Conclusion In this community, the reported poor care practices for preterm newborns were associated with poverty and lack of knowledge of how to properly care for these babies at home. Action is needed to address the current care practices for preterm babies among the community members.BioMed Central open acces

Using locational data in a novel mixed-methods sequence design: Identifying critical health care barriers for people with disabilities in Malawi

The primary aim of this study was to determine which health care barriers were most important for people with disabilities in Malawi. To accomplish this, we devised a sequential mixed-methods research design that integrated locational survey data and qualitative data from field studies. Our secondary aim was to evaluate this research design not only as a design-solution to our particular research objective, but as a tool with more general applicability within social sciences. Malawi has one of the most underserved health service populations in the world with chronic resource shortages and long travel distances where people with disabilities are at a particular disadvantage. Nevertheless, our results show that even in a resource scarce society such as Malawi it is the interpersonal relationships between patients and health service providers that has the largest impact on the perception of access among patients. Our results also suggest that the sequential mixed-methods design is effective in guiding researchers towards models with strong specifications.publishedVersio