Measuring women’s wellbeing and quality of life in rural Malawi: A mix-methods approach

1. Measuring women’s wellbeing and quality of life in rural Malawi: A mix-methods approach Giulia Greco1, Jolene Skordis-Worrall1,2, Anne Mills1 1Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine 2UCL Centre for International Health and Development, University College London, UK

2. Rationale Public health programs and community-based initiatives are complex interventions that; aim at improving the well-beingof healthy individuals Generate health and non-health outcomes Vast body of literature on inadequacy of using standard methods for economic evaluation How do we assess the impact on overall well-being?

3. Why the Capability Framework? Conceptual advance in welfare economics Multidimensional framework for policy evaluation In line with societal values Applications in a wide range of disciplines Many issues unresolved at conceptual and empirical levels ...so a fruitful area for further research

4. Sen’s Capability Approach A theoretical and broad normative framework for; the evaluation and assessment of individual well-being the design, evaluation and assessment of social policies

5. Background: MaiMwana Project Community-based participatory intervention Aim is to reduce maternal and neonatal mortality in rural Malawi Women are organized in groups to discuss, develop and implement strategies to overcome maternal and neonatal health issues Evaluated with a cRCT. The trial has been designed to detect a reduction in maternal and neonatal mortality. However, programme effects might impact other aspects of quality of life

7. Women’s Group Cycle

8. Research objectives To develop an outcome measure for assessing women’s quality of life in rural Malawi Identify a set of capability dimensions relevant to the study and context Measure robustly these dimensions in a quantitative manner Translate the measurement into a single metric (index) Validate and test the instrument Recommend a framework for using this approach as an evaluation tool or as an extension of conventional evaluation techniques

9. Methods: Data collection 16 focus group discussions Sample stratified by; rural/peri-urban and presence/absence of WG age below/above 25 years Discussion organized in two sections: Responsive questioning to explore concepts of quality of life (what is good life, what is bad life, what do you value in life, why do you do what you do) Discussion on the values, partial-ordering and ranking of the dimensions, using beans (from 0 to 10)

10. Focus group discussion

11. Framework analysis • “Paper-based” framework analysis in three steps: • Identification of macro and micro areas of quality of life (matrixes), factors influencing QoL and enablers, using local terminology • adaptation of language and concepts to English • Construction of the final framework and compacting of the dimensions • 1st principle: data management (matrixes) and interpretation are separate stages in analytical process • 2nd principle: material is not verbatim text but a summarised version

12. Results Physical strength Inner wellbeing Household wellbeing Community relations Economic security

13. Physical strength free from diseases (being hygienic, clean, able to protect oneself from HIV) having enough energy to work hard in the fields (having a good diet) able to bear children when choosing (being fertile but also being able to practice family planning)

14. Inner wellbeing peace of mind (free from worries, not being scared of witchcraft) being independent (having control of your life) able to express freely (take out what you have inside) respected and admired content and fulfilled knowledgeable (being able to read and write, agricultural skills, numeracy for business) able to relax and enjoy good things in life

15. Household wellbeing free from domestic violence able to be loved and respected by the husband able to move freely (visiting relatives, attending a funeral) having decent housing, pit latrines, clean water able to feed and educate the children able to work together, united and cooperative

16. Community relations able to associate with others (community groups, church groups) respected and appreciated in the community able to help the needy confident that you’ll be helped if in need (safety social networks) able to access social services (distances, money) able to walk alone without being assaulted

17. Economic security financially independent, being able to buy things on your own able to cope with risks (owing assets, social networks) able to start small business (being able to access micro loans)

18. Ranking and weighting The dimensions generated from the discussions were written on A4 paper and shown to participants Participants discussed the value of each, and reached an agreement (deliberative democracy) using beans (from 0 up to 10) In some cases the exercise was considered difficult and cognitively too demanding A ranking question has been added to the large scale survey

19. Discussion (1/2) “Basic needs” and more complex capabilities No clear distinction between factors influencing QoL, “enablers” and dimensions of QoL Multi-stage analysis for extrapolating the core attributes No significant difference between areas (rural/peri-urban), some differences between age groups (e.g. being admired)

20. Discussion (2/2) Compares well with attributes of quality of life developed by other populations (ICECAP) Compares well with predefined lists of dimensions of wellbeing (e.g. Nussbaum) Group dynamics are appropriate for generating information on social values in a low-literacy rural context

21. Acknowledgements The project participants who gave so generously of their time The Maiwana Research Team who made the fieldwork possible Advisors Dr Jo Borghi and Dr Arnab Acharya  Professor Anthony Costello for access to the research site Giulia Greco was funded by an MRC/ESRC Scholarship Additional financial assistance was provided by the Wellcome Trust  Thank you