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Older Adults' Experiences of Ageing, Sex and HIV Infection in Rural Malawi

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Older Adults' Experiences of Ageing, Sex and HIV Infection in Rural Malawi Older adults’ experiences of ageing, sex and HIV infection in rural Malawi Emily Freeman The London School of Economics and Political Science Thesis submitted to the Department of Social Policy of the London School of Economics for the degree of Doctor of Philosophy October 2012 1 Declaration I certify that the thesis I have presented for examination for the PhD degree of the London School of Economics and Political Science is solely my own work other than where I have clearly indicated that it is the work of others (in which case the extent of any work carried out jointly by me and any other person is clearly identified in it). The copyright of this thesis rests with the author. Quotation from it is permitted, provided that full acknowledgement is made. This thesis may not be reproduced without my prior written consent. I warrant that this authorisation does not, to the best of my belief, infringe the rights of any third party. I declare that my thesis consists of 97,035 words. I can confirm that parts of thesis were copy edited for conventions of language, spelling and grammar by John Freeman, Paul Bouanchaud, Melody Mohebi, Shaffa Hameed, Nicola McMahon and Eve Gordon. Emily Freeman 2 Abstract This thesis contributes to understanding two demographically important phenomena: African ageing, and the ageing of the African HIV epidemic. Building on the body of interpretivist demography that privileges context and meanings, it explores older adults’ experiences of becoming old, sexuality and living with HIV in rural Malawi. The research uses a constructivist grounded theory framework. It is based primarily on data produced using repeat dependent interviews (N=135) with older men and women (N=43). These are supplemented by fieldwork observations, as well as data from a three-month multi-site pilot study, interviews with HIV support groups (N=3), and key informant interviews (N=19) and policy documents. The thesis identified sets of meanings surrounding old age and ways of discussing ageing that, taken together, formed an analytical framework. The framework is focused on the importance of maintaining an ‘adult’ identity and draws insights from sociological and psychological identity theories. The adult identity was aligned with personhood. It was situated within the body-centred livelihood system of rural Malawi, and associated with physical production. Old age was understood to limit productivity and thereby an individual’s adult identity. This thesis argues that ostensibly contradictory narratives about ageing experiences can be understood as rhetorical strategies respondents employed to maintain their adult identities. A central tenet of the thesis is that the adult identity (and its childlike counter identity) influenced older adults’ broader experiences and behaviours. This framework is used to explore ageing, as well as sex and HIV infection. The grounded understandings of older adults’ experiences developed in the thesis are presented against dominant understandings of the situation of older adults documented by the academe and in policy and programmatic arena emerging in Malawi. The findings highlight the centrality of wider experiences of ageing for older adults’ experiences of sex and HIV, as well as the broader importance of identity for understanding demographic behaviours and processes. In addition, they demonstrate how grounded theory and repeat dependent interviewing can be used within demographic studies to produce nuanced analytical accounts of the experiences that are most salient for the population of interest. 3 For my parents, who have given me everything. 4 Acknowledgements Every thesis is the work of many, despite the declaration. Without the patience and support of so many people this one would not have been possible. I gratefully acknowledge the older men and women in Malawi who gave me so much of their time, their hospitality, and their trust. I offer this thesis in honour of that trust, and hope it will generate thoughtful responses their needs. I am also indebted to the policy makers and influencers who helped me to construct a potted history of the policy context developing in Malawi between 2006 and 2010. The logistical and intellectual support of those working on the Malawi Longitudinal Studies of Families and Health in the collection of data used in this thesis is very gratefully acknowledged. I extend particular thanks to Susan Watkins, who welcomed me to Malawi and has continued to provide unparalleled and unexpected support, interest and confidence in my work. The collaborative and collegial environments fostered among those who have worked with the MLSFH stand in testament to her. The research would not have been possible without the help of my Malawian research assistants: Jonathan Kandodo, Aminah Wadi, Pretorius Halidi and Tommy Navilembo of whom I asked so much; as well as Violet Boillo, Francis Kadzula, Memory Phiri, Peter Paswell Sanna, Esnat Sanudi, Joyce Kephas, Harry Mnyenyembe and Kondwani Mwenda. Particular thanks are given to Jonathan Kandodo for his on-going interest in the project, our many discussions, and most of all, his efforts to improve the lives of older adults living in rural Malawi based on this study. In addition, fieldwork would have been a very different experience without the support, friendship and cakes of Erin Mitchell. Ernestina Coast has been a truly inspirational supervisor and has led by example. I will endeavour to be the kind of academic she is. In addition, I would like to thank Rebecca Sear for her encouragement and support during the first years of my study, and Tiziana Leone for her insightful comments on a draft of this thesis, and moreover, a hearty dose of reassurance, just when it was needed. I gratefully 5 acknowledge the support of John Macnicol and his advice regarding preindustrial ageing. To do a PhD surrounded by such generous and brilliant minds is a privilege I cannot measure. There are no words to thank Alice Goisis, Melody Mohebi, Paul Bouanchaud, Dwan Kaoukji, Victoria de Menil, Louise Caffrey, Eleri Jones, Ben Wilson and Daniel Bear enough. My work is better because of them. I would like to extend a special thank you to Ellie Hukin and Shaffa Hameed for making ‘cohort’ my favourite word in demography, and making every day easier. The research was funded by the Economic and Social Research Council, UK (ES/F022174/1) and subsequently the London School of Economics. The financial contribution to my fieldwork costs provided by my Grandmother, Muriel Freeman, were much needed, and much appreciated. Margaret, John and Hannah Freeman deserve all the thanks in the world. They have supported me throughout this process in more ways than I can detail here. (Although the piles of letters given to me at Heathrow to be opened one each week of fieldwork should certainly be mentioned!) I hope I have produced something that can make them proud. Finally I thank Eve Gordon, Nicola McMahon and Amandeep Lafferty. They are my tripod. 6 Contents Glossary, translations, acronyms and abbreviations ............................................ 11 Chapter 1| Introduction ........................................................................................... 13 1.1 African Ageing ............................................................................................... 13 1.2 Ageing of the African HIV epidemic ............................................................. 16 1.3 Situating the thesis ......................................................................................... 21 1.4 Outline of the thesis ....................................................................................... 27 1.5 Significant contributions of the thesis ............................................................ 30 Chapter 2| Methodology .......................................................................................... 32 2.1 Method choice: Why interviews are the main method................................... 32 2.2 The inductive research process ...................................................................... 35 2.3 Continuous literature review .......................................................................... 37 2.4 Preliminary exploratory fieldwork ................................................................. 39 2.4.1 Introduction to rural Malawi and the context of older adults’ lives ...... 40 2.4.2 Identification of salient issues ................................................................ 43 2.4.3 Testing method choices .......................................................................... 46 2.4.4 Selecting a field site ............................................................................... 50 2.5 Substantive fieldwork..................................................................................... 54 2.5.1 Repeat dependent interviewing .............................................................. 55 2.5.2 Asking questions ..................................................................................... 58 2.5.3 In the field: Respondents, research assistants and me ........................... 61 2.5.4 Recording the answers ........................................................................... 78 2.5.5 Ensuring quality in data construction: The strengths of repeat dependent interviewing ........................................................................................................ 82 2.5.6 Impromptu focus groups ........................................................................ 87
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