The complex, integrated, overlapping and composite social structure and economic systems that lead to the arousal of various health inequities is termed as social determinants of health. In addition to person’s individual characteristics and behaviors, the social and economic environment as well as the physical environment accounts for the determinants of health. Health improvement for the most vulnerable population who are likely to encounter the health related challenges is of particular importance to the policy makers and health and social care workers who are directly associated with the provision of adequate facilities to the service recipients. Inequalities in health that seem to be bogged down under the impact of these social determinants are of particular relevance and importance to the common people. Global efforts are in progress to tackle the throbbing situation that appears to threaten the lives of many (Marmot 2005). Narrowing of the gap that is present in the social realm in relation to the social determinants of health is conducted in recent times for creating equality and minimizing the chances of disparities. Fostering of an environment devoid of any health inequity will further lead to the improvement of the life expectancy in the general population. Moreover, it will account for enhancing their health and wellbeing through proper execution to establish fairness in treatment of patients and curtail the incidences due to lack of service exposure, educational insufficiency and dearth of knowledge and awareness (Camargo Jr 2011). In this backdrop, the prospective study is of relevance and importance to steer positive changes in terms of health and wellbeing for the Malawian girls to assess their relative threat to be affected by public health concerns such as that of HIV/AIDS in later lives due to improper health and wellbeing belonging to the specified age group.
Among the issues specific to the low income countries, the prevalence of diseases that mostly emanate due to poor public health and hygiene are of grave concern owing to their potential debilitating effects. Malawi has been recognized as a low income country where the prevalence rates of disease like HIV/AIDS is quite high. In order to mitigate the issue of HIV/AIDS and other similar condition, knowledge pertaining to the factors that lead to the emanation of such diseases in the vulnerable population need to be gained. Research has focused on the introduction of definite indices for measuring the socio-economic position in low economic countries (Howe, Hargreaves and Huttly 2008). Situation specific to Malawi has been explored in study that showed inverse association exist between HIV-1 and socio-economic status alongside the sexually transmitted disease (STD) and socio-economic status. The findings are of significance in combating the condition and reduce the risk of HIV/AIDS in the concerned population through implementation of appropriate interventions (Dallabetta et al 1993). Hence corroborating with these study findings the tentative study will strive to explore various factors that might lead to the prevalence of HIV/AIDS in the concerned population of Malawian girls by focusing on certain vital aspects. The factors encompassing the lack of education, persistent inequalities between boys and girls in education will be explored in the study. Furthermore, cultural beliefs and the possible association between poverty and HIV/AIDS prevalence will be investigated in course of the study. A detailed and extensively systematic review of literature will be highlighted in the study following definite approaches.
Fig: Conceptual framework for study
The goal of the study that has been undertaken is to provide an elaborate and in-depth insight and analysis of the impact of education on the health and wellbeing among the girls in Malawi who belong to the age group of 15-30 years. The study will be of particular significance as it will cover the various aspects related to the health and well being of the concerned individuals. Emphasis will be laid in carrying out the discussion related to the prevalence of HIV among the Malawi resident girls under the impact of several pertinent socio-cultural factors. Elaborative explanations will be provided in the context of the influence of lack of education that might affect girls and the possible association with HIV. Further, inequalities existing between boys and girls due to dearth of education will also be highlighted. The cultural beliefs that might impact upon the health of the community residents will be analyzed in addition to providing an overview on the socio-economic and political factors that might culminate in the onset of poverty. The link between poverty and measures that might be effective in mitigating the HIV menace in the concerned population will be highlighted as well. The possible impacts of a country’s economy in shaping the mitigating strategies to curb the disease prevalence in a population will be addressed in the study to indicate the possible remedies for resolving the issues. A broad overview on the association of HIV and the outcomes related to health and wellbeing of the Malawi people will be provided through the study.
In today’s fast-paced life, the advancement of science and technology has brought remarkable changes in the lives of the people who inhabit diverse regions and belong to different nationalities in a worldwide scenario. However, there are places where the light of modern era has not reached adequately thereby culminating in a rage of adverse outcomes among which disease prevalence is a common observation. Therefore in these down trodden countries that are still lagging behind, understanding of the expanse and reach of factors like education is crucial in order to make way for bringing positive changes where disease prevention measures may be satisfactorily conducted. The situation relevant to the South-East African country like Malawi where underdevelopment, corruption and the prevalence of HIV/AIDS have thwarted the lives of a large proportion of its citizens, the impact of education need to be investigated in a proper manner to make way for case appropriate strategies and effective measures (bbc.com 2017). The wellbeing of a country is dependent upon factors that exert direct or indirect influence on its social and cultural contexts. Research carried out by the political scientists and public health scholars have paid attention towards the relative distribution and utilization of the economic resources available to a country in maintaining the public health. Quite expectedly, variation among countries in terms of public health expenditures and the health related outcomes have been observed. The potential confounding factors that seem to suppress the public resources allocation to health care have been recognized that include severe income disparity, dictatorship, ethnic heterogeneity in addition to persistent international hostilities. Furthermore, civil conflicts, unequal provision of services and facilities apart from rapid urbanization has also been found to exert considerable influence in terms of public health allocation (Ghobarah, Huth and Russett 2004). Another pertinent study explored the contributions of the four basic types of capital including the human, social, natural and built, in depicting the life satisfaction among people belonging to various demographics. The findings of the study depicted that in case of the evaluation of the life satisfaction, people tend to incorporate the natural environment surroundings considering its potential positive influences in stress recovery and maintenance of good health. Proposition has been made to devise a National Wellbeing Index (NWI) that will address the social capital as well for the sake of assessing the significance and impacts of friend and family (Vemuri and Costanza 2006). In this connection, study carried out to demonstrate the possible link between incomes; health and wellbeing of the residents in rural Malawi bring forth important findings. Owing to the status of low-income country, Malawi has been found to be afflicted by high morbidity and mortality coupled with high prevalence of HIV/AIDS alongside poor reproductive health and high fertility. The study interpreted that a 10% increase in the income is sufficient to improve the health status of the rural Malawians by 1%, while mean subjective wellbeing enhanced by 1.2% (Chin 2010). Vital social determinants of health accounting for the health and wellbeing of the people suggested that political violence, ethnic conflicts as well as contemporary wars act as potential contributors. Impoverishment has set in because of environmental and economic decline, depression of subsistence base and asset depletion (Pedersen 2002). Thus, all these aspects need to be extensively reviewed and analyzed for the sake of gaining an insight on the impact of education on health and wellbeing of the concerned Malawi population of girls in course of the projected study.
Education is considered as a fundamental human right and a gratifying knowledge that aid the girls and boys to reach onto their optimal potential in the society. However, a bulk proportion of children in Africa are deprived of this basic human right without having the privilege to receive formal education in schools with majority being girls. Acquisition of academic or professional skills is derived through education thereby equipping the boys and girls for later life through practice of suitable endeavors (Okafor 2010). The factors that contribute to the development of prevalence of HIV/AIDS among the vulnerable population have been investigated through various researches. The importance of education in enlightening people with the most appropriate knowledge and adequate awareness on matter that require greater attention has been identified as a crucial step in fostering a healthy environment conducive for holistic growth and development. However, the potential implications in case of the lack of education are often overlooked despite it being a major factor harboring negative consequences. The condition pertinent to the prevalence of HIV/AIDS may be analyzed in this context for better understanding about the possible outcomes. Evidence from randomized evaluation from Western Kenya reported and compared three school based HIV/AIDS interventions. Training of the teachers as part of the Kenyan Government’s education curriculum, encouraging pupils to argue on the use of condoms and writing essays on protecting against HIV/AIDS in conjunction with mitigating the cost of education were adopted as the intervention measures. Findings revealed that enhancement of practical knowledge along with self reported us of condoms resulted from the condom debates and essays without elevating self reported sexual activity. Reduction in the dropout rates, childbearing and teen marriage was evident following mitigation of the cost of education through payment of school uniforms. However little impacts in terms of effects in student’s knowledge, behavior and attitudes alongside incidence of teen childbearing was noted as an outcome of the program. Following teacher’s training in schools, the girl students studying in those schools were reported of more likely to get married on the event of pregnancy (Duflo et al. 2006). Further study has indicated on the impact of the HIV/AIDS epidemic on the education sector in the context of Sub-Saharan Africa. The impacts of HIV/AIDS on the primary and secondary schooling in countries like that of Botswana, Malawi and Uganda has been assessed in course of the study. In the Malawi context, the adult HIV prevalence rates were estimated to be 21% for the year 1999. Issues related to prevention of HIV/AIDS among the students, in addition to impact on students and teachers have been explored in such study. The study also depicted that HIV/AIDS is likely to affect the educational sector in Sub-Saharan Africa. In this connection, the supply and demand of the educational services that might effectively act to control the HIV epidemic has been indicated to fulfill the purposes of education (Bennell, Hyde and Swainson 2002).
A study conducted with respect to examination of knowledge and risk perception through assessment of their associations with demographic features, first source of HIV/AIDS information in addition to behavioral and cognitive risk exposures among men and women residing in a rural district in Malawi generated vital information. Results from descriptive statistics and multivariate regression analysis suggested that it do not necessarily imply that the knowledge about the HIV/AIDS will translate into perceived risk. Moreover, gender differences in the impact of cognitive and behavioral factors in perceived risk have been recognized in the study finding (Barden-O’Fallon et al. 2004). The association between HIV/AIDS and education in Malawi has been explored in another study. Combating of the HIV/AIDS has been found to be directly dependent upon the reach of education that may be utilized as an effective tool for rendering sufficient knowledge to the target group. The participation of the children in school has been recognized as a definite measure of curbing the pandemic of HIV/AIDS. Overcoming of the barriers due to HIV/AIDS has been proposed to be done through the implementation of open, distance and flexible learning (ODFL) as a complement to traditional schooling in Malawi. In order to meet onto the full potential of the students through access to education has been ODFL initiatives and structures have been suggested. Recommendations have been provided for the sake of designing inclusive programs for reaching onto the vulnerable children and specifically those who belong to the lowest socio-economic backgrounds. Certain good practices have been put forward in this respect for alleviating the menace due to prevalence of HIV/AIDS (Streuli and Moleni 2008).
However, the positive effects of education and whether they are actually beneficial for the chosen mass comprising of the Malawian girls has been introspected through various studies. One such study investigated the causal relationship between primary schooling and the status of HIV among the adults in two of the East African countries of Malawi and Uganda that represented a fairly high incidence rates for HIV/AIDS. Data procured from the current Demographic Health Surveys in Malawi for the year 2010, it was shown that in the defined region, a one year increase in schooling for a girl culminates in 6-7% mitigation in the rates of probability of being tested positive for HIV in case of the adults. Adolescent sexual behavior to some extent in addition to effects exerted upon overall schooling attainment is a resultant effect of increased exposure to primary schools and without much influencing the adult sexual behavior (Behrman 2015). In another study, the relationship between educational attainment in adolescence on young women’s lifetime experience on sexual violence in case of Malawi and Uganda was examined. The findings depicted through careful analysis that increased grade attainment accounts for heightening the literacy and premarital sex in Malawi, simultaneously curbing the probability of ever being married (Behrman, Peterman and Palermo 2017).
A report from the UNICEF has brought to the forefront an important aspect whereby the girls have been indicated to be relatively more prone to encounter challenges in the pursuit of academics through educational interventions. Girls belonging to primary school age and secondary school age are more vulnerable to face social exclusion and adverse demerits in education system. Statistics revealed that the Sub-Saharan region girls are more likely to get afflicted by HIV/AIDS than their male counterparts (unicef.org 2017). Education imparted to women and their overall emancipation have been found to be particularly beneficial and an effective tool mean for increasing the economic productivity, diminishing the rates of infant and maternal mortality, improvement of the nutritional status and enhancing the overall health status of the concerned individuals. Other vital advantages borne out of educating girls include conferring protection against teenage pregnancy and other sexual or reproductive harms such as that of HIV/AIDS (Malusu and Philomena 2014; Sommer 2010). In this connection, facilitation of quality education along with skill-oriented training and education related to HIV/AIDS for all individuals irrespective of their age and gender must be provided to combat the adverse outcomes and effects due to HIV/AIDS (Bennell, Hyde and Swainson 2002).
One of the world’s most AIDS afflicted country is Malawi and a study has aimed to investigate the perceptions of the individuals and the risks associated with the development of AIDS in the vulnerable population. The conversations carried out by the Malawi men in their naturalistic settings through everyday life experiences in addition to their assessments about perceptions and understanding about AIDS risk have been conducted in the study. The results reported a lack of consensus regarding the necessity of the change of behavior to avoid the chances of risk associated with HIV/AIDS. Contrary to the display of this belief, a counter perception was noted among men who adopted to scrutinizing of their prospective partners rather than abstaining from sex or using condoms to reduce the chance of acquiring AIDS and other STDs (Kaler 2004). Another study explored the subjective expectations in the context of HIV/AIDS in Malawi, a country that has been recognized having low levels of literacy and numeracy. Findings revealed that the respondents are well aware about the differential risks associated with the chance of acquiring HIV/AIDS infection. However, in contrast to the life table estimates, the mortality expectations are found to be severely overestimated that might greatly mask the benefits of adopting HIV risk remediation strategies (Delavande and Kohler 2009). The differential responses to HIV has been reported in the Malawians. Urban adult response has been found to be 23% in comparison to rural prevalence that was found to be 12.4%. As per the reports of the study, it was indicated that coping mechanisms in relation to HIV/AIDS was not adequate and it did not evolve much over time owing to certain factors. The prevalence of AIDS was accentuated under the effect of food crisis and depeasantization, debilitating local economies in conjunction with traumatizing communities. Further, the morbidity and mortality experienced was accompanied by denial and despair following the suddenness of events in the initial years of coping (Bryceson and Fonseca 2006). In another potential research, it has been reported that HIV/AIDS prevalence occurs as a major offshoot of ignorance. The light of knowledge given to the vulnerable population through proper educational facilities is likely to reduce the incidence rates of morbidity and mortality due to AIDS following proper educational and awareness campaigns to inform them regarding the potential effects of the disease. In this context it has been observed that illiterate women are more likely to represent a notion that healthy looking men cannot be sero-positive therefore representing the chances of spreading HIV/AIDS infection. Thus, lack of basic and bare minimum knowledge about disease prevalence in case of conditions like that of HIV/AIDS is particularly risky to predispose individuals towards the acquiring of such infections from infected partners or due to poor hygiene (Vandemoortele and Delamonica 2000). Hence, adequate educational interventions are the only ways out for tackling these public health issues and ensure healthy and wellbeing of the vulnerable individuals.
Gender Inequality can be defined as the lack of equality between men and women that arise due to negative perceptions by the society. Gender inequalities is one of the contributing factors that has led to a lack of education among women in sub Saharan Africa (Sia et al 2016). According to the United Nations Gender Inequality Index (GII) Malawi is ranked 173 out of 188 countries. Education plays an important role in empowering the individuals. It has been reported that the education of girls leads to an improvement in their health conditions and also their families (School education of girls leads to an increase in the family income by 10%, increase in life expectancy and reduced fertility. According to a survey of Malawi Demographic and Health around 51 percent of men and 38% of women belonging to an age group of 20-24, had completed schooling at a primary level that shows the gender biasness between men and women. It has also been observed that only 3 girls will obtain education at a secondary level out of every 100 girls who undergo their education from 1st Standard Dworkin et. al 2013).
HIV/AIDs as another generalized epidemic in this region .It has been reported that that there is an increase in the possibility to get diagnosed with HIV or get infected with sexually transmitted disease for the sub Saharan population. Moreover, girls are at a greater risk of unintended pregnancies that lead issues in the future ( Grant 2015). This is because of the lack of provision of education to girls in the Malawi region. There has been an another research found that there were higher number of youngsters who got engaged in sex before the age of 15, got married and they even had children at a very early age (McCleary-Sills et al. 2015). This was particularly seen in rural areas having individuals belonging suffering from poverty and a lack of education. A research was conducted in the year 2015 that utilized a similar concept and managed to draft that provision of proper education, guidance , training and counseling can result in a betters society (Ansell 2017).
Social determinants of health , primary health care, and health well being of populations and communities at risk of exposure to HIV are directly interlinked to one another. Social determinants of HIV include social discrimination of the infected individuals,gender biasness ,low socioeconomic status and experiences in childhood such as sexual abuse or children who have faced emotional issues are seen to have infected with HIV during adulthood (Adimora and Schoenbach 2013). Primary health care for HIV includes lack of information regarding safe sex due to low socioeconomic status and financial crisis, lack of proper counseling and treatment especially to women due to gender biasness. It is important to provide to medical facilities to individuals infected with HIV without any discrimination to lower down the rate of HIV patients on a global level.
The issue of inequality in education has been there since the formation of the Millennium development goals came to existence. Gender biasness starts at a young age between 15 to 24 year old women in the Sub-Sahara Africa (SSA) that is double as compared to men and get infected with HIV. This was also explained by Sia et al, (2016) study on the determinants of gender inequality in HIV/AIDS in SSA which included uneducated and unemployed women, impoverished than men and poverty which attracts them to transactional sexual exchanges which are often made with casual sex partners and without protection. Equity in primary health care refers to the various reasons that result in different qualities of healthcare in different populations residing in regions. This differentiation is done on the basis of caste, creed, sex, and financial status of the populations (Sen and Mukherjee 2014).It involves a lack of proper medical facilities such as lack of medicines to the people and is completely injustice to them. Health inequity leads to decrease in life expectancy of women and increase in mortality rate. A large proportion of women lag behind as compared to men to avail primary health care. The main reason behind this is that women lack economic and social power. Lack of proper healthcare facilities also results in depression, anger, sadness and low self-esteem in women
Education is a human right and a gratifying knowledge that helps girls and boys reach their full potential in society, although millions of children in Malawi are still out of school, with most of them being girls .The main purpose of education either being academic or through life skills based education, helps to equips both boys and girls later in their lifetime. According to the reports of The World Bank the level of disparities in gender is large in spite of positive actions been taken by the University of Malawi. The percentage of women in the fields of Science, engineering and ICT is very less as compared to men (Shahidul, and Karim 2015).Women Scientists are not given due respect and recognition in the society. Young girls are not provided training in technical fields like science and mathematics which can play a significant role to improve their chances employment and hence improve their livelihood. According to the traditional customs of Malawi women are not considered important as compared to men. It has a culture in which the role of men and women are divided. The women help in maintaining the stability in social aspects and have a role in raising their children and managing family relationships in an effective manner.
There has been a prevalence of violence and abuse based on gender that includes aggression against girls in the adolescent stage. In the schools, teachers also followed the belief for boys that it was embarrassing to secure less marks as compared to girls and the same beliefs were followed by the parents at home. This is the main root cause of gender biasness in Malawi as home is the first school for young boys and girls. The teachers also believe that girls are weak in science and mathematics at the primary as well as the secondary level. Malawi was ranked 38 I the survey of a total of 86 countries according to a report of Social Institutions and Gender Index for the year 2012.Women have to face negative consequences and suffer a lot as compared to men as they are provided equal opportunities in the society. According to the reports of UNICEF, 2013 girls in primary school age and early years of their secondary school were out of school in 2013 with an estimate of 31and 32 million respectively (Conroy 2014).
KOffi Annan explained in his speech that teaching a girl is a powerful and effective tool and plays a significant role in raising the economic productivity, lower mortality rate of infants and mothers , improves nutrition and promotes health. Other key benefits associated with girls’ education include protection against early pregnancy and other sexual/reproductive harms including HIV/AIDS (Malusi et al, 2014, Sommer et al 2010). Proper education as well as skills-based HIV/AIDS education must be provided to both boys and girls in an equal manner (Bennel et al 2002). The issue of gender inequalities has been studied by many researchers all over the world. They should be given proper counseling and medical testing facilities for HIV. They should also be provided antiretroviral therapy to prevent themselves from HIV. Adolescents should be given HIV Vaccination to prevent the HIV disease from infecting them. Pre- Exposure Prophylaxis should be made available to these key populations as they have a high risk of getting HIV infection. There should be a proper methodology and various strategies should be followed to reduce this gap between men and women.
Various healthcare programs should be organized to deal with their health issues to achieve health equity for patients suffering from HIV. It is the human right of every AIDS patient to receive proper counseling about the preventive measures and the treatment tests. Equity and Rights should be balanced for all the patients affected by HIV (Maluwa-Banda 2004). Proper policies and laws are required to protect the individual rights of such patients. There has been various measures to improve the education of girls in Malawi such as an Early Grade Reading Activity (EGRA) by USAID’s plays an important role in develops various skills such as reading for girls and boys at a school level.. Various scientific and technological methods should be developed to improve the rate of education among women living in rural areas at a reasonable cost. Equity and Rights should be balanced for both men and women affected by HIV (Ameli et. al.2017). Proper policies and laws are required to protect the individual rights of such patients. The government should follow various principles to promote equal rights of education for both men and women. Women should be given equal respect as compared to men in the family specially living in the rural areas as they receive worse treatment in employment, political issues, and primary and secondary education.
The cultural beliefs and traditional practice models have undermined the education of girls and boys in Malawi groups. Firstly, their educational attainment is affected by delay in starting school at appropriate time and this creates inequitable schooling environment for them. Secondly, girls are vulnerable to disadvantages in completing primary education because Malawi’s have the practice of giving girls in marriage following the initiation of menstruation. Women have been regarded as a source for domestic labor thus discouraging girls from educational attainment. In addition, poverty also contributes to gender disparities in education of Malawi girls (Changwada 2017).
The research by Thornton et al. (2014) gives insight into the influence of cultural beliefs of Malawi’s in community development. Efforts have been made to disseminate bad culture and gender disparity in Malawi and replace them with western family ideals. Recognizing cultural barrier to education in females, international organizations like UNICEF invested in monthly banners for stopping early marriages. These banners also focused on eliminating other violation of human rights in Malawian. As cultural change and transformation is dependent on how people receive these messages, the article examined the association between demographic characteristics of Malawi’s and developmental thinking. However, contrary to the developmental idealism, the research findings showed that majority of Malawi did not preferred increasing age of women at marriage. This might undermine efforts of completing educational attainment in girls too.
International and non-governmental organizations have focused on improving education in girls particularly, because of the rise in HIV prevalence among the Malawi population. About 10.6% of the Malawi adult’s populations are living with HIV thus becoming the highest HIV prevalence region in the world. It has disproportionately affected women in comparison to men in Malawi because of issues of sexual violence among women in the age of 15-17 years. The main perpetrators of sexual violence include spouses and romantic partners of females (avert.org 2017). Educational development in young Malawi girls can make them acquire useful sexual health information. Considering the resistance showed by Malawi’s in increasing marriage age of girls, one research article investigated the role of grandmothers in giving sexual education to girls in Malawi. The research identified that sociocultural milieu of the group exposes young girls to high risk of HIV exposure. Their traditional practice of allowing single male to have sex with all girls who reach puberty (fisi) and widow inheritance also increases the risk to HIV exposure in girls. In addition, lack of education and employment in women further contributed disempowerment of women and resorting them to unintended pregnancy. However, as very few girls complete primary school education, they are deprived of essential sex education (Limaye et al. 2015). Therefore, the article gave solution to the issue by exploiting the potential of community leaders like grandmothers (agogos) to engage them in sex education.
HIV risk has been found to be aggravated by gender inequality in specific regions. Malawi population is an example of gender inequality in women compounded by their cultural preference. The research articles by (Fedor et al. 2016) gives insight regarding their belief of greater preference to family life and low or no education in young girls has contributed women’s constrained economic position and dependence on male members for financial support. Gender norms in society also expect women to act as passive receivers in sexual relationship and maintain their chastity by not carrying condoms. The cultural practices and behaviors of Malawi encourage men to fulfill sexual needs with more than one women and expect women to fulfill the desire of their partner. Due to this belief, majority of men engage in sex outside marriage regularly and women remain powerless. The strengths of this article is that it gives strong evidenced regarding the influence of cultural norms on low educational attainment and rise in prevalence of HIV particularly in Malawi females. Considering the risk to HIV in Malawi women due to their cultural beliefs and practices, the literature gives direction for future action. This includes improving the level of female self-efficacy and female empowerment by giving educational opportunities to women and arranging for sex education program to prevent HIV. Voluntary HIV counseling and testing is also critical to change women’s beliefs and make them realize their own rights. This will enable them to take preventive steps against risk of HIV and improve health and well-being of the Malawi population (Kamen et al. 2015).
The review of literature also revealed the pathways that increase HIV exposure in Malawi population. Contrary to links of poor education and HIV risk in Malawi people, the article by Small and Nikolova (2015) emphasized that educational attainment had a weaker association with HIV risk compared to use of condom and HIV testing. This further proves that cultural attitudes and perception of women towards violence influence exposure to HIV. Social researchers recognize HIV as social and behavioral and social problem arising due to power imbalance between men and women and the cultural analysis of the Malawi population effectively highlights the link between HIV and social issues. Cultural belief systems in community mainly elevate men over women in decision making and the Malawi culture also reflects gender-power difference and subjugation of women. The article gives evidence to the fact that Malawi women are vulnerable to physical and sexual violence. The traditional Malawian culture also regards battering wives as a normal act further increasing the incidence of HIV in Malawi. Therefore, the article was successful in bringing to attentions the impact of cultural attitude of Malawians in increasing the prevalence of HIV.
To curb the irrational cultural practice in Malawi, gender based educational model is needed to changes the cultural perceptions of Malawi population and enhance educational opportunity for them. Long term-behavioral changes can be brought by addressing mysogynistic cultural attitudes. This will increasingly slow down the pace of transmission of HIV infection (Amin 2015). Although the above article does not links education with HIV risk, however educational programmes for Malawi population is important because educated men will discard irrational traditional norms of wife inheritance and facilitate change in cultural practices and preferences in the region.
Poverty and link between socio-political and economic factors
Several researchers in the past have established the connection between poverty an HIV/AIDS. Poverty has been recognized to be the critical factor in transmission of HIV/AIDS. Hence, this disease is called a “disease of poverty” (Lopman et al. 2007). The link between poverty and measures that might be effective in mitigating the HIV menace in the concerned population will be highlighted in this section.
In the health industry, the impact of the economic inequality on health is well recognized. The study executed by Bello et al. (2011) on the Malawi’s 27 districts assessed the economic inequality and the HIV infections. The study was limited to the sample of young women (age 15-30) who are highly -likely to contribute to the intergenerational transmission of HIV. The results showed a positive association between the Economic inequality and HIV. However, the study failed to deduce the relationship between the poverty indicators such as neighborhood median wealth; household wealth; and district median consumption with the HIV status. This study did not indicate that poorer women are highly likely to be HIV positive than others. There are more number of studies focusing on poverty and its link to HIV then those conducted on inequality and HIV. The results are not clear and appear that poverty is not responsible for spread of HIV in samples restricted to developing countries. Instead, rich countries were found to have high infection rate. Similar studies conducted in the Malawi showed that in comparison to the men in the poorest two quintiles the one in the three richest wealth quintiles are about 2.5 times more likely to be infected (Wilkinson and Pickett 2006).
In communities below poverty line, unprotected sex is highly prevalent. As per the Malawian National Aids Commission, the rate of unprotected heterosexual sex between the married partners comprise of 67% of the all the newly diagnosed HIV cases in 2013. These group of people are increasingly vulnerable to the infections. The reason being lack of resources to access the health care benefits, counseling or treatment services. Consequently, they lack health education and hygiene practices (Macro 2005.). According to Lopman et al. (2007) implementing the education, training and counseling programs can result in betterment of community. Lack of access to counseling services promote poor people to engage in risky sexual behavior. It is common phenomenon in unequal society. According to the “economic theory”, people in poverty may become shortsighted. These support the previous argument that these people are least aware of consequences after ten years and thus highly engage in risk. Further this theory explains that poor women of young age group of 15-30 years are sexually active and they may be induced to exchange sex for money (Banerjee and Somanathan, 2007). Similarly, the men in this age group also exhibit high sexual activity. They may stay away from home for extended period to earn money and are highly vulnerable to extra marital affairs and transactional sex. Such risk behavior may be stimulated by external shocks such as drought in addition to poverty. It is also supported by the case study of Malawi published in the study of Bello et al. (2011). The study showed that women in Malawi particularly in rural area engage in transactional sex for both monetary benefits and attractive goods.
Mishra et al. (2008) argued that not only poor but also the rich accessing the health care services may be highly likely to be infected. In addition, they have the greater probability to be exposed to the contaminated needles and syringes. Accessing the services may give them more confident to engage in riskier sexual behavior. These results also highlighted that no systemic pattern have been established between the individual income and the infection. Gupta et al. (2008) argued that the in Malawi, women visiting the antenatal clinic are not represented as general population. Therefore, the prevalence in the young women may be overestimated. These group women are sexually active and are not associated with widowhood, fertility, HIV, divorce, and sexually transmitted diseases. Similarly, in low socioeconomic status women, the visit to the antenatal clinic is less and including other clinics, which may underestimate the prevalence of HIV among them. The study executed by Leigh et al. (2009) claims that in Malawi the people who are wealthy may live longer after being diagnosed with HIV. It may occur even if the incident rate is equal or higher for people. Among the wealthy people, the HIV positive men have higher survival rate when compared to the poor counterparts. Wealthy men in any unequal society engage in transactional sex. Inequality in economic language means gaining additional partner at low price (Bryceson and Fonseca 2006).
The above data does not support the hypothesis that the HIV is highly prevalent among the poor suggested by many researchers. It could be because of the underfunded health care in remote areas and sexual networking between rich and poor, where both sections of society are vulnerable to infections. This parameter is ignored by the individual level income (Holmqvist 2009). The other hypothesis suggested are society-wide effects hypothesis, the relative income hypothesis, and the absolute income hypothesis. These hypotheses were developed to deduce the association between the income inequality and HIV prevalence and the mechanism involved. The relationship between the both as per Bärnighausen et al. (2007) is poverty and not the income inequality. It can be argued that if the money is transferred from the rich to the poor it will decrease the income inequality. It will lead to health improvement for the poor person and decline for the rich person. On the contrary, Geubbels and Bowie (2006) found the link between poverty and the diminishing health returns and highlighted its association with the income hypothesis which may be applicable in any country. However, it can be argued that in uncommon societies such as Malawi the inequality seems to matter.
Highlighted society wide effects as the cause of increase in spread of HIV by economic inequality. It is mainly due to lack of social cohesion in Malawi. It hinders the process of mobilizing collective action to implement strategies in the places of epidemic. Consequently, there is more gender violence in unequal societies and greater incidents of rapes. It consequently increases the spread of HIV (Wilkinson and Pickett 2006).
Based on the above discussion it can be summarized that HIV/AIDS may be linked with poverty and inequality. Increase in discrimination along with increase in rates of migration leads to higher prevalence of HIV. Geographical migration of the laborers in areas such as mines and other places having inequality in Malawi poses threats for predisposing individuals to be infected by HIV. The migrant workers in these places are highly infected because prostitution and transactional sex is highly prevalent in this location. These migrant workers are more vulnerable than the general population. In short there is a mixed result about positive correlation between poverty and HIV. There is need of further research in this field to pro[perly understand the “HIV/AIDS NEXUS and poverty” (Mwakalobo 2007). Thus, in order to prevent HIV it is to necessary to address the structural features and economic inequality.
According to McCulloch (2013) the prime focus should be on the public education rather on structural features. In order to reach the full potential in the society, every girl and boy must be given their basic right to education. Mainly girls than boys in Malawi are out of school. They thus lack the skills to contemplate the positive and negative social or health behavior. The main purpose of education is to ensure that children earn lifetime sills and endow worldly knowledge. As per the records of UNICEF, girls are at disadvantage stage when compared to boys inspite of the advancement in the recent years. Girls at the age of attending primary and secondary schools were found with high absenteeism and most were out of school. Similar condition was found in Malawi. Most girls and boys from poor family were pushed into prostitution after they have attained their puberty for money and goods. Statistics shows that most girls of 15-20 years were twice at risk of HIV as boys in Malawi. As per UNICEF, education to girls is an effective tool to minimize infant and maternal mortality, increase the economic productivity, and to promote health and well-being. Education will help girls to avoid risky sexual behavior, prevent early pregnancy and HIV (UNICEF 2015).
Without education, gender gap would persist and the developing countries will be affected by the epidemics. Health education to combat HIV/AIDS must be provided to both girls and boys equally and to eliminate disparity and poverty (Fenton 2004). HIV education will help people indulge in safe sex practices, use of condom, avoid having multiple partners Gender proportion is existing since ages back. In places like Malawi, most girls of 15-20 years were twice as likely as adult men to contract HIV and tend to have sex with multiple partners (Fonner et al. 2014). In the similar study conducted by Hargreaves et al. (2007) in Sub-Sahara Africa concluded that the involvement in transactional sexual exchanges by women is triggered by lack of education among women, gender disproportion, unemployment, and poverty. Thus, it leads to increase in spread of HIV. The more educated people are the more likely they are to respond to the education program or early intervention.
According to Nikolopoulos et al. (2015) a country with strong economic growth will overcome the loss incurred by the decrease in labor supply and productivity due to AIDS. It will maintain the balance between the imports and the exports and the average national economic growth. Therefore, it will be easy for the country to invest highly on the HIV prevention and treatment programs as well as targeted training and skills of the health care workers. Country without fluctuation in economy growth despite HIV can work on HIV reduction by estimating the combined effect of HIV on economy such as reduced labor productivity. Malawi can introduce HIV reduction program once the country quantifies the effect of the HIV/AIDS on GDP per capita, which may include controlling other factor such as nutrition. This will positively affect the HIV reduction programs in country.
On the other hand, if the countries have high literacy rate and equal opportunities for girl and boys then the country will be rich with skilled labor. Therefore, HIV rates would decrease there will be little change in the skill composition of the labor force. It will prevent decrease of skilled labor, growth rate and productivity. It will prevent the decrease in investment, the important, and the export of the products (Wirtz et al. 2017). Bärnighausen et al. (2007) argued that a country must have an international economic assistance. It is an effective tool to reduce the impact of the pandemic on the economic. It includes development of policies that bests suits the country. It will also include policies to prevention and treatment of HIV with controlled economic measures. Various clinical studies have published the effectiveness of the national programs in addition to the cost. Knowing these cost effective and successful interventions of preventing HIV, the best one that will suit Malawi can be chosen that will give best value for money.
Dixon et al. (2005) suggested that a country should take macroeconomic effect of interventions into consideration that will give birth to political dilemmas. For instance, Malawi can target for antiretroviral drugs although expensive to maintain economic stability. It can be targeted to highly productive socioeconomic groups based on the generation of the economic output in addition to the heath care needs. It will help the county generate more funds and earn greater economic prosperity. Moreover, this strategy will allow time for training of the labor that were replaced due to lack of sufficient skills. Training will reduce the overall impact of the pandemic and thus reduce HIV rates simultaneously. Thus, every country must have an economic model that will maintain environment for the implementation of sustainable medical programs.
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