The Malawi Diffusion and Ideational Change Project

www.malawi.pop.upenn.edu

Professor Jere Behrman, University of Pennsylvania

Dr. Agnes Chimbiri, University of Malawi

Professor Hans-Peter Kohler, University of Pennsylvania

Professor Susan Watkins, University of Pennsylvania & CCPR, UCLA

Dr. Eliya Zulu, African Population and Health Research Centre, Nairobi, Kenya

The MDICP has been supported by the Rockefeller Foundation and NIH

Misconceptions That Matter:

Ours and Theirs

Our Misconceptions About Responses to AIDS in Rural Malawi

• They don’t talk about AIDS or sex• They either deny the AIDS epidemic or are

fatalistic about prevention• They are afraid to be tested because they will be

stigmatized • Young single women are particularly vulnerable

because they are poor, passionless and powerless.

Malawi Data Surveys

– Longitudinal panel interviewed in 1998, 2001, 2004 and 2006

– Rural sample in 3 districts– Includes males and females, adults and

adolescents– Sample sizes:

• 1998 and 2001, approximately 2500• 2004 approximately 4000, (added new spouses

& 1500 adolescents to rejuvenate the sample)

Data Quality

• Reporting: Miller, Zulu & Watkins 2000: systematic discrepancies in reports of monogamously married husbands and wives

• Validity--Hewett & Mensch 2007, Pop Council, ACASI, adolescents;

• Reliability--Bignami 2003 duplicate interviews • Attrition—Alderman et al 2000, Anglewicz et al

forthcoming• Sample representativeness—Bignami et al 2003,

Anglewicz et al forthcoming• Interviewer effects—Onyango 2007

Related Quantitative Studies

• Intrafamilial transfers (Weinreb 2002) • Faith-based orgs (Trinitapoli,Lungo, Manda,

Phiri 2007; Regnerus & Trinitapoli 2007) • Expectations (Delavande & Kohler 2007)• Incentives (Kohler, Thornton in process)• Trust & Transfers (Chao, Kohler)• Sexual networks (Helleringer, Kohler)• VCT & ART (Fleming, Yeatman, Angotti, in

process)

Biomarkers – 2004 and 2006 for HIV and other

sexually transmitted infection

– Testing in homes

– Results in tents or at home

Consequences of morbidity & mortality 2008-2012

• 2 more survey rounds

• biomarker-assessed health status (HIV, CRP, TfR, EBV and glyc. hemoglobin)

• short-run nutritional status (BMI)

• anthropometric indicators of early-life conditions (height, leg-length,

• Testosterone 2D:4D digit ratios);

Qualitative Data

– Interviews• With randomly selected subsamples of the survey

respondents • Interviews with clergy• Ad hoc interviews & participant observation• Data quality—mobile men

– Ethnographic field journals

Sources: Many of the interviews and field journals (anonymized for confidentiality) are available on www.malawi.pop.upenn. See also Watkins and Swidler 2007 for the ethnographic methods.

History of Prevention Efforts

• 1980s: blood screening but little else, even in urban areas

• 1994—2001: – President leads an AIDS march in 1994 – permits government officials to work with donors on

AIDS policy, – permits donors to market condoms– Increasing newspaper coverage

• 2002: Govt finalizes an “integrated behavior change intervention strategy”

Talking about AIDS & Sex

Conventional Wisdom

– Malawi Council of Churches 2001: Workshop with the theme “Break the Silence”

– Muula, A. & Mfutso-Bengo, J. 2004, Nursing Ethics : "A culture of silence and resistance to change is prevalent in Malawi.”

– Mtika, Collins, 2005, Daily Times: “That disease of silence is what is killing us.”

• Poster at office of NAC 2001. “It’s Time to Stop being Shy”: three men, one with his eyes covered and “I don’t want to see it”, another w/his mouth covered, “I can’t speak about AIDS”, another with his ears covered, “I can’t hear it.” Then “Why don’t we talk about AIDS [AIDS in red]. We all know someone who has died of AIDS. It’s time we began talking about AIDS. Because we can save lives that way.”

• At the bottom, “It’s time to change–Let’s talk about AIDS”.

Three women talking About AIDS

Talking about AIDS

• After we greeted each other, Mrs. Bruce said to me that I did well to come and mourn for Miss Baidon because she would have killed all the people of V___ and other men from the outside areas. Miss Baidon has died of AIDS as a salary or gift for what she was doing.

• Her friend who [wore] a traditional suit, green in colour and the white sandals answered. She said that the death of Miss Baidon has concerned her very much because she was sleeping with her husband. She had been quarreling with her husband for a long time because of her and her marriage was near to an end. Her husband was challenging her that he could divorce her and marry Miss Baidon.

• About the AIDS disease, the woman said that her husband was advised at the church by the church elders and the Nkhoswes [traditional marriage counselors] that these days life is difficult because there is no time for enjoyment since there is the AIDS disease. Having one woman and depend on her is a very good thing because you can save your life and your children’s life….Though her husband changed his behaviour but the woman was still worrying….

• Now if [Miss Baidon] was infected during that time that she was moving with her husband, it is openly that her husband was also infected and if he was infected it also means that she is also infected with that AIDS therefore she will just die for nothing.

• Her husband will kill an innocent woman like her. The woman was very worried a lot because she has children and she was saying that her children will suffer a lot if their parents will die because they are very young…. She began crying and I told her that she must stop crying because [she] had no evidence that she was also infected or not.

Talking about sex

Social Autopsies

– Symptoms– Medical history– Sexual biography

• Source: Watkins, Santow, Bracher, Biruk 2006

Responses to the epidemic

• Are “they” in denial?

Worried about getting AIDS

Source: Table 1, K.P. Smith, S.C. Watkins. Perceptions of risk and strategies for prevention: responses to HIV/AIDS in rural Malawi. Social Science & Medicine 60 (2005) 652 649–660

Women 1998 (N = 878)

Men 1998 (N = 675)

Very Worried 61% 52%

Moderately worried 22% 21%

Not at all worried 17% 27%

• Are “they” fatalistic”?

Not fatalistic

• Strategies of Prevention

– ABC’s– Unexpected strategies

• Source: Watkins 2004, PDR

Increase in justification for divorce

Women 1998 (N = 878)

Women 2001 (N = 878)

Divorce justified if think

husband has AIDS

16% 28%

Table 2 K.P. Smith, S.C. Watkins. Perceptions of risk and strategies

for prevention: responses to HIV/AIDS in rural Malawi. Social Science & Medicine 60 (2005) 652 649–660

** = p<.05, * = p<.1 (robust: adjusted for clustering on respondent) Reniers, Georges. “Marital strategies for managing exposure to HIV in rural Malawi.” Forthcoming, Demography

0.0

1.0

2.0

3.0

4

0 10 20 30marriage duration

<= 1990 >1990

by year of marriage (adj.for marriage order)Smoothed divorce hazard

• Note that although the local strategies do not provide complete protection for all individuals, they will help some to avoid infection. Thus, they have the potential to reduce HIV transmission in the aggregate and thereby to slow and perhaps reverse the epidemic.

Stigma inhibits testing

• Yoder & Matinga, 2004– Interviewed VCT counselors – Interviewed 200 individuals asking would they

like to be tested (hypothetical)

– Concluded that Malawians not ready for testing

• Afraid of stigma• Afraid because expected to be found positive and

would die from the shock

MDICP 2004

• Testing in homes by nurses trained by the UNC lab

• Tests for – HIV– Chlamydia, gonorrhea, trich

Sources: Obare-Onyango 2007; Thornton et al 2005; Thornton 2006; compare with Yoder and Matinga

• 91% agreed to be tested

Receiving results

• Receiving results: – Social event – Two-thirds received their results

• Lab delays

– Great happiness among 93%, esp. those who thought they were infected but found they were not

– Sources: Thornton 2006, Obare-Onyango 2007

Talking about AIDS revisited

• Disclosing HIV test result to a spouse:• In 2006, 86% of women and 92% of men reported disclosing

their 2004 result to their spouse

• Women: There are significant differences in disclosing HIV test result by actual HIV status for women. : 67% of HIV+ women told their test result to their spouse, compared with 86% of HIV negative women.

• There are no significant differences by HIV status for men- over 90% of both HIV positive and HIV negative men reported disclosing their test result to their spouse.

Confirmation from spouse

• Among husbands men who state that they disclosed their HIV status to their wife, only 4.4% of the wives disagree. Among women only 2.3% of husbands disagree.

• By HIV status: A larger percentage of HIV positive respondents disagree with their spouse’s claim of disclosure. – Perhaps due to small sample sizes, these differences

are not statistically significant.

Vulnerability of women

• HIV + in 2004:– Men: 5.6%– Women: 7.9%

Non-response analysis: Onyango 2007

Are young women more vulnerable?

• Adolescents 15-19 HIV+

– Males=0.4%– Females=1.0%

Young single women?

• HIV+, Women 15-24 – Unmarried Married

• 1.50 % 6.17%

• See also microsimulations of infection at lst marriage, Bracher, Santow and Watkins 2003

Probable explanations

• Unmarried women

• Unmarried men

Disease of women’s poverty-- or disease of men’s wealth?

• “Poor, passionless, powerless women”

• Men with money

Sources: Tawfik & Watkins 2007; Swidler and Watkins, 2007; Poulin 2006 (for adolescents)

Their misconceptions –a short list

• Probabilities of HIV transmission

• Duration from infection to AIDS symptoms

Overestimating subjective likelihood of infection

• Survey question: How likely do you think it is that you are currently HIV+?

– Only about 10% of respondents who say it is highly likely that they are infected are correct

Source: Anglewicz 2007; Anglewicz & Kohler 2007

Overestimating transmission probabilities

• Survey question: If you have unprotected intercourse once with an HIV+ person, how likely are you to become HIV+?

– Over 90% said “certain” or “highly likely”

Consequences of “our misconceptions”

• IEC programs: if begin by believing that people don’t talk about AIDS, won’t ask them what they say

• Misdirect efforts to what they already know • Don’t provide information on what don’t know

• Behavior change programs: if don’t know what they are actually doing

• Misdirect efforts to what they are already trying to do• Can’t learn where programs might actually help (e.g. re divorce)

• Agency: if believe that uneducated rural people can’t do anything on their own, miss opportunities to support them in their efforts

• Testing: if use hypothetical questions, can’t know what people will actually do

Discussion: “Our” misconceptions about “Their” Misconceptions”

• “Their misconceptions” was based on conventional wisdom circulating in the prevention community

• Wrong for rural Malawi

A misconception that matters

• Overestimation of HIV transmission

• Consequences: – Little incentive to adopt ABCs or other

prevention approaches? – Barrier to VCT?

Recommendations

• For us: – Skepticism about conventional wisdom– better research as a foundation for

interventions

• For rural Malawians:– Dissemination of correct & complete

epidemiological information

Thanks