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Vulnerability of Adolescents to HIV/AIDS in Malawi

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Vulnerability of Adolescents to HIV/AIDS in Malawi Western University Scholarship@Western Electronic Thesis and Dissertation Repository November 2011 Vulnerability of Adolescents to HIV/AIDS in Malawi Paul Mkandawire The University of Western Ontario Supervisor Dr. Isaac Luginaah The University of Western Ontario Graduate Program in Geography A thesis submitted in partial fulfillment of the equirr ements for the degree in Doctor of Philosophy © Paul Mkandawire 2011 Follow this and additional works at: https://ir.lib.uwo.ca/etd Part of the Human Geography Commons Recommended Citation Mkandawire, Paul, "Vulnerability of Adolescents to HIV/AIDS in Malawi" (2011). Electronic Thesis and Dissertation Repository. 304. https://ir.lib.uwo.ca/etd/304 This Dissertation/Thesis is brought to you for free and open access by Scholarship@Western. It has been accepted for inclusion in Electronic Thesis and Dissertation Repository by an authorized administrator of Scholarship@Western. For more information, please contact [email protected]. VULNERABILITY OF ADOLESCENTS TO HIV/AIDS IN MALAWI (Thesis Format: Integrated-Article) By PAUL MKANDAWIRE Graduate Program in Geography A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy The School of Graduate and Postdoctoral Studies The University of Western Ontario London, Ontario, Canada © Paul Mkandawire 2011 THE UNIVERSITY OF WESTERN ONTARIO SCHOOL OF GRADUATE AND POSTDOCTORAL STUDIES CERTIFICATE OF EXAMINATION Supervisor Examiners _____________________________ ________________________________ Dr. Isaac N. Luginaah Dr. Joseph R. Oppong Supervisory Committee ________________________________ Dr. Godwin Arku _________________________ ________________________________ Dr. Rachel Bezner-Kerr Dr. Jamie W. Baxter ________________________________ Dr. Douglass Drozdow-St Christian Thesis by Paul Mkandawire entitled: VULNERABILITY OF ADOLESCENTS TO HIV/AIDS IN MALAWI is accepted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Date: ________________________ ___________________________________ Dr. James C. Lacefield Chair of the Thesis Examination Board ii ABSTRACT This thesis aims at examining vulnerability to HIV/AIDS among adolescents in Malawi. The study uses mixed methods that combine quantitative and qualitative techniques in order to better understand whether there are significant variations in the pattern of sexual behaviour between adolescent orphans and non-orphans. Results of a quantitative analysis (n=1214) revealed that orphans are less likely to undertake voluntary counseling and testing (VCT) for HIV/AIDS, that they tend to experience their first sexual intercourse earlier in life, and that they are generally more likely to engage in high risk sexual behavior than non-orphans. In addition, female orphans in particularly are less likely to abstain from sex or to use a condom. The qualitative analysis (n=82) revealed that female orphans’ high risk sexual behaviour is closely linked to a well-established inter-household casual labour relation locally known as ganyu. While providing an escape from extreme poverty, ganyu is increasingly associated with a practice of sexual exchange between those who offer it and those who perform it. This study makes important contributions to theory, methodology and policy. Theoretically, the study shows that orphans’ heightened vulnerability to HIV/AIDS in Malawi is in part rooted in their socioeconomic disadvantage and the lack of social support, but in ways that markedly differ between male and female orphans. Building on survey findings in order to examine the role played by the social and spatial environment in shaping vulnerability to HIV/AIDS also demonstrates the value of combining quantitative and qualitative methods. The presence of a large and highly vulnerable orphan population in a country already overburdened with one of the worst HIV/AIDS iii prevalence rates in the world raises searching questions regarding new fault lines of the epidemic, and unravels complex policy challenges. Key words: vulnerability, Northern Malawi, orphans, HIV/AIDS, policy, VCT, ganyu, gender. iv THE CO-AUTHORSHIP STATEMENT This thesis is made up of a collection of papers which have been submitted for publication and are currently under peer review. The study problem, objectives and the relationship among the various manuscripts are outlined in the introductory chapter, while the study context is described in Chapter 2. The research manuscripts are as follows: Chapter 3: Mkandawire, P. and Luginaah, I., Voluntary testing and counseling (VCT) for HIV in adolescents in Northern Malawi: Is Orphanhood a factor? Submitted: AIDS Care Chapter 4: Mkandawire, P., Tenkorang, E. and Luginaah, I., Orphanhood and time to first sex among adolescents in Malawi, Submitted: AIDS & Behaviour Chapter 5: Mkandawire, P. and Luginaah, I., Lost in the shuffle: Female orphans’ vulnerability to HIV/AIDS in Malawi, Submitted: Environment and Planning C Chapter 6: Mkandawire, P., Luginaah, I. and Baxter, J., Growing up alone: Vulnerability of adolescent orphans to HIV/AIDS in Northern Malawi, Submitted: Transactions of the Institute of British Geographers While all the papers are co-authored with my thesis supervisor and others, as the first author I conducted the actual research which involved problem identification, literature review, data analysis, and writing. The bibliographies of the individual chapters are consistent with The University of Western Ontario Graduate and Postdoctoral Thesis requirements. v ACKNOWLEDGEMENTS Many people and organizations need to be thanked for the production of this thesis. First I am deeply thankful to my supervisor, Dr. Isaac Luginaah, who has been very supportive, helpful, thoughtful and wise in his guidance from the very first day I met him. I am extremely grateful for making himself available, for his mentorship and willingness to attend to my needs at the oddest times. I also would like to express my thanks to Dr. Rachel Bezner-Kerr and Dr. Baxter for their unrelenting support. Many thanks also to Drs. Arku, Tenkorang, Richmond, Weis, and Smart for guidance and direction over the course of my doctorate. I would like to especially thank IDRC for proving the funds to carry out this study. Additional funding was provided by UWO through International Research Grant award and by Dr. Joy Parr. My profound thanks also go to all my research assistants. The many hours they spent walking long distances conducting surveys have been much appreciated. My gratitude to all my research participants and my heart especially goes out to all orphans who volunteered to take part in this study. Thanks to wonderful members of the EHHL; my sister Jenna, Tor, Yvonne, Chad, May, Vincent, Ellena, Frederick and VicTOria. To those who came before – Odwa, Abel, Leith, and Rachel – thanks for your encouragement. Many thanks also to Joe, Corinne, Lori, Angelica, Caroline and Karen for your tireless behind-the-scene efforts. To my friends Jo (and mom Pat), Liam, Nuno, Denver, Jim, Jodi, Peter, Wayne, Carmen, Buddy Mimi, Joanne, David and Liz - thanks so much. vi Finally, I would like to thank my late brother Caeser and rest of the Mkandawires: Fannie, Wiza and Chawa. They have been my greatest source of inspiration. vii TABLE OF CONTENTS ABSTRACT .................................................................................................................................... iii THE CO-AUTHORSHIP STATEMENT ........................................................................................ v ACKNOWLEDGEMENTS .............................................................................................................vi LIST OF TABLES ........................................................................................................................... xi CHAPTER ONE .............................................................................................................................. 1 INTRODUCTION ........................................................................................................................... 1 1.1 Background ........................................................................................................................ 1 1.2 Study Objectives ................................................................................................................ 5 1.3 Geographies of health ........................................................................................................ 5 1.4 Study Design ...................................................................................................................... 9 1.5 Organization of the thesis ................................................................................................ 12 References .............................................................................................................................. 15 CHAPTER TWO ........................................................................................................................... 19 RESEARCH CONTEXT ........................................................................................................... 19 2.1 Introduction ...................................................................................................................... 19 2.2 Malawi’s Historical Background ..................................................................................... 19 2.3 Current situation ..............................................................................................................
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