Maternal depression affects one in five women in Malawi. Integrated interventions simultaneously addressing multiple risks are a promising strategy to improve mental health. This study evaluated the impact of a nutrition-sensitive social behaviour change (SBC) intervention (agriculture and livelihoods, male engagement and Caring for the Caregiver) with or without cash transfers on maternal perinatal depression during the lean season in rural Malawi. A midline survey for a cluster-randomised controlled trial was conducted, where 156 clusters were randomly assigned to four arms (39 clusters/arm): (1) standard of care (SoC), (2) SBC, (3) SBC+low cash (US$17 per month) and (4) SBC+high cash (US$43 per month). Pregnant women and mothers of children <2 years of age (n=2677) were enrolled at baseline (May–June 2022). A subsample of 1303 women was followed-up at midline (November–December 2023). Maternal perinatal depression was assessed using the Self-Reporting Questionnaire with a score of ≥8 indicating symptoms consistent with depression. Intervention effects were estimated using linear mixed effects models. At midline, SBC+high cash reduced depression scores relative to SoC (mean difference −1.13 (95% CI −1.96 to –0.31)) but had no impact on the proportion of women with depressive symptoms. Relative to SoC, SBC+low cash and SBC alone had no impact on depression scores or the proportion of women with depressive symptoms. Relative to SBC alone, adding cash to SBC reduced depression scores and the proportion of women with depressive symptoms regardless of the size of the cash transfer. Cash transfers integrated with SBC can benefit maternal perinatal mental health in rural Malawi during the lean season. Trial registration number ISRCTN53055824.

This study examined modifiable caregiver factors influencing child development in Malawi using baseline data from 1,021 mothers and their children <2 years of age participating in a cluster-randomized controlled trial implemented in rural Malawi (2022-2025). We fit an evidence-based theoretical model using structural equation modelling examining four caregiver factors: (1) diet diversity (sum of food groups consumed in the past 24 h), (2) empowerment (assessed using the project-level Women's Empowerment in Agriculture Index), (3) mental health (assessed using the Self-Reported Questionnaire, SRQ-20), and (4) stimulation (number of stimulation activities the mother engaged in the past 3 days). Child development was assessed using the Malawi Development Assessment Tool (norm-referenced aggregate Z-score). The model controlled for child, caregiver, and household socioeconomic characteristics. Results showed that caregiver dietary diversity was directly associated with higher child development scores (standardized coefficient 0.091 [95% CI 0.027, 0.153]) and lower SRQ-20 scores -0.058 (-0.111, -0.006). Empowerment was directly associated with higher child development scores (0.071 [0.007, 0.133]), higher stimulation score (0.074 [0.013, 0.140]), higher dietary diversity (0.085 [0.016, 0.145]), and lower SRQ-20 scores (-0.068 [-0.137, -0.002]). Further, higher empowerment was indirectly associated with improved child development through enhancement of caregiver dietary diversity, with an indirect effect of 0.008 (0.002, 0.018). These findings highlight the important role that caregiver diet and empowerment play in directly influencing child development and other aspects of caregiver well-being. Interventions aimed at enhancing child development should consider these factors as potential targets to improve outcomes for children and caregivers.

Background Community bylaws are commonly accepted mechanisms to influence behaviour change to achieve better health and development outcomes in sub-Saharan Africa. However, the uses, benefits, and potential downsides of community bylaws are largely unclear, especially regarding sexual and reproductive health and rights (SRHR) of young people. The objective of this study was to determine the extent to which community bylaws in Machinga District in southern Malawi are responsive to young people’s realities and SRHR needs. Methods In Phase 1 of this qualitative study, 35 community members were interviewed, including 14 young people (15–24 years), five parents, five traditional leaders, and eleven key informants. Based on findings from Phase 1, eleven members from local youth groups co-created a drama performance that covered issues concerning bylaws and young people’s SRHR (Phase 2). The drama was performed in the community, after which young women (18–24 years), young men (17–24 years), female and male parents discussed on what they saw in the drama, focusing on young people’s SRHR, in four focus group discussions (Phase 3). All transcripts were coded and thematically analysed and narratives were written on main themes. Results Three community SRHR bylaws, related to teenage pregnancy, child marriage, and sexual harassment and rape were identified and commonly accepted in the community. While these bylaws intend to reduce SRHR-related issues among young people, they are often not involved in bylaw formulation. The bylaws were associated with protection of girls, and a good reputation for boys, young men and traditional leaders. Bylaw enforcement faced problems, as fines were not in line with national laws, and wealthy offenders could avoid them through bribes. Effects of bylaws on teenage pregnancy rates seemed limited, while some positive effects on school readmission, prevention of child marriage, and reporting sexual harassment were reported. Conclusions The study revealed that community bylaws were accepted but not owned by young people, and had different effects on the rich versus the poor, and girls versus young men. Bylaws were associated with punishment in terms of money, which seemed to overpower their potential to promote rights and address social norms underlying SRHR issues of the youth.

The persistence of poverty, particularly in sub-Saharan Africa, means that public policy in this region continues to debate the right mix of supply- versus demand-side interventions that can move large groups of households out of extreme or ultra-poverty. There is unlikely to be a single approach that can transition all poor or ultra-poor households out of poverty. This paper describes the use of secondary evaluation data from four government unconditional cash transfer programmes (UCTs) to identify high- and low-flyers, that is, those households that are able to use the income shock to significantly improve their living standards and those who aren’t. The authors attempt to categorize the high- and low-flyers to create typologies based on their pre-shock characteristics. They also look at post-treatment behaviours to see what participants of these programmes did with the cash to improve (or not) their living standards. Putting together these different pieces of information (pre-treatment characteristics and post-treatment behaviours) can help with understanding the different pathways out of poverty, and ultimately contribute to a middle-range theory of sustained poverty reduction.

As national social safety nets are expanding in Africa and globally, evidence on the impact of programs on youth transitions can help guide future investment and program design decisions. This paper examines the effects of Malawi's flagship cash transfer program on safe transitions to adulthood among youth living in households experiencing ultra-poverty. The evaluation was a cluster-randomized control trial implemented over three years using panel data on youth aged 13 to 19 at baseline. Household receipt of bi-monthly transfers led to improvements in four out of six outcome domains: 1) education, 2) physical health, 3) emotional wellbeing and mental health, and 4) sexual and reproductive health. There were limited or no impacts on outcomes related to HIV risk and time use. Results imply that similar programs in the region may also facilitate safe youth transitions. Nonetheless, more intentional gender- and youth-specific designs may have promise for more holistic impacts, and further evidence is needed on longer-term effects.

We explore the impacts of Malawi's national unconditional cash transfer program targeting ultra-poor households on youth mental health. Experimental findings show that the program significantly improved mental health outcomes. Among girls in particular, the program reduces indications of depression by about 15 percentage points. We investigate the contribution of different possible pathways to the overall program impact, including education, health, consumption, caregiver's stress levels and life satisfaction, perceived social support, and participation in hard and unpleasant work. The pathways explain from 46 to 65 percent of the program impact, advancing our understanding of how economic interventions can affect mental health of youth in resource-poor settings. The findings underline that unconditional cash grants, which are used on an increasingly large scale as part of national social protection systems in Sub-Saharan Africa, have the potential to improve youth mental wellbeing and thus may help break the vicious cycle of poverty and poor mental health.

BACKGROUND:Equitable access to health services is a key ingredient in reaching health for persons with disabilities and other vulnerable groups. So far, research on access to health services in low- and middle-income countries has largely relied on self-reported survey data. Realizing that there may be substantial discrepancies between perceived and actual access, other methods are needed for more precise knowledge to guide health policy and planning. The objective of this article is to describe and discuss an innovative methodological triangulation where statistical and spatial analysis of perceived distance and objective measures of access is combined with qualitative evidence.METHODS:The data for the study was drawn from a large household and individual questionnaire based survey carried out in Namibia and Malawi. The survey data was combined with spatial data of respondents and health facilities, key informant interviews and focus group discussions. To analyse access and barriers to access, a model is developed that takes into account both measured and perceived access. The geo-referenced survey data is used to establish four outcome categories of perceived and measured access as either good or poor. Combined with analyses of the terrain and the actual distance from where the respondents live to the health facility they go to, the data allows for categorising areas and respondents according to the four outcome categories. The four groups are subsequently analysed with respect to variation in individual characteristics and vulnerability factors. The qualitative component includes participatory map drawing and is used to gain further insight into the mechanisms behind the different combinations of perceived and actual access.RESULTS:Preliminary results show that there are substantial discrepancies between perceived and actual access to health services and the qualitative study provides insight into mechanisms behind such divergences.CONCLUSION:The novel combination of survey data, geographical data and qualitative data will generate a model on access to health services in poor contexts that will feed into efforts to improve access for the most vulnerable people in underserved areas.

Improved female control over land is often put forth as a means of raising the productivity of smallholder agriculture, enhancing female bargaining power and raising women’s incomes. The article uses some quantitative but primarily qualitative data on access to income and decision making, to analyse gender patterns related to welfare, incomes and control over resources in a context where women’s rights to land are particularly strong, that is in a matrilineal and uxorilocal setting. Women’s land rights are contextualized in relation to labour intensive, low productive smallholder systems and the paper assesses to what extent female control over land affects welfare outcomes, decision making and intra-household control over incomes and labour. While we find that female control over land does affect intra household relations it is clear that land reform is not enough to ensure gender equality. For any land use policy reform to have a profound affect it would have to also take into account control over other productive resources, e.g. labour, as well as the wider institutional and political context.

Who does what and when during an impact evaluation has an important influence on the credibility and usefulness of the evidence generated. We explore such choreography from technical, political and ethical perspectives by reflecting on a case study that entailed collaborative design of a qualitative impact evaluation protocol (‘the QuIP’) and its pilot use in Ethiopia and Malawi. Double blind interviewing was employed to reduce project-specific confirmation bias, followed by staged ‘unblindfolding’ as a form of triangulation. We argue that these steps can enhance credibility of evidence, and that ethical concerns associated with them can be addressed by being open with stakeholders about the process. The case study illustrates scope for better use of qualitative impact evaluation methods in complex international development contexts.

Abstract In this chapter a variety of methods were used to collect data to study smallholders in Malawi. The surveys were complemented by a set of qualitative interviews to establish gender dynamics in agriculture and for livelihoods. Key informant interviews were conducted with agricultural personnel in the sampled districts and focus group discussions were held with some farmers. For a bigger picture of the agricultural policies and practices, the study relied on a review of key documents and publications by government and other agencies implementing agricultural programmes in the country. Descriptive statistics demonstrate that a shift from maize and tobacco to Irish potatoes, groundnuts, and soya beans in the areas under study has provided an opportunity for smallholder farmers to diversify and increase production and thus improve their livelihoods. Another noticeable change has been the increased participation of women in the production and marketing of crops.

Les méthodes traditionnelles d’évaluation du soutien aux entreprises considèrent l’entreprise comme une «boîte noire» et leur but principal est de voir dans quelle mesure une politique a produit les effets escomptés. Les mécanismes causaux qui expliquent comment certains effets sont générés ne sont pas mis au jour. Dans cet article nous montrons l’applicabilité de l’analyse du réseau bayésien en combinaison avec l’évaluation basée sur la théorie comme nouvelle approche mixte pour découvrir les mécanismes, attendus et inconnus, qui expliquent les changements dans le comportement et la performance économique d’une entreprise sous l’effet du soutien public . En combinant l’analyse de la carte graphique avec l’analyse statistique, l’analyse du réseau bayésien révèle les interdépendances entre les différents moteurs de changement dans les entreprises afin de confirmer, de nier ou de mieux qualifier la théorie du changement de la politique.

This study analyzes the short-term impact of an exogenous, positive income shock on caregivers' subjective well-being (SWB) in Malawi using panel data from 3,365 households targeted to receive Malawi's Social Cash Transfer Program that provides unconditional cash to ultra-poor, labor-constrained households. The study consists of a cluster-randomized, longitudinal design. After the baseline survey, half of these village clusters were randomly selected to receive the transfer and a follow-up was conducted 17 months later. We find that the short-term impact of household income increases from the cash transfer leads to substantial SWB gains among caregivers. After a year's worth of transfers, caregivers in beneficiary households have higher life satisfaction and are more likely to believe in a better future. We examine whether program impacts on consumption, food security, resilience, and hopefulness could explain the increase in SWB but do not find that any of these mechanisms individually mediate our results.

Government agricultural policies which favour large-scale agriculture and rapid population growth on a limited land area have combined to create a situation of land poverty in many parts of Malawi, especially in the southern region of the country. The government's response to land poverty has so far been focused on the creation of resettlement schemes. As such initiatives are expensive, they have tended to be piecemeal and benefit only a small fraction of land poor families. Frustrated land poor families have now resorted to land encroachment on privately held land. The emergence of movements dedicated to the restoration of estates to families with ancestral claims to the land marks a new stage in land relations which could have unwelcome consequences.

This study analyzes the impact of a positive income shock on child schooling outcomes using experimental data from an unconditional cash transfer program in Malawi. Since households receive the cash and parents are responsible for making spending decisions, we also examine the intervening pathways between cash transfers and child schooling. Data comes from a cluster-randomized study of Malawi's Social Cash Transfer Program (SCTP). After a baseline survey, households in village clusters were randomly assigned to treatment and control arms with treatment villages receiving transfers immediately and control villages assigned a later entry. We test for treatment impacts on a panel of school-aged children (6-17) using a differences-in-differences model. After a years' worth of transfers, we find the Malawi SCTP both improves enrollment rates and decreases dropouts. The main intervening pathway between the program and schooling is education expenditures, suggesting that the cash improves the demand for education by reducing financial constraints. (C) 2017 Elsevier Ltd. All rights reserved.

Unconditional cash transfer programs are a form of structural intervention to address poverty, a "fundamental cause" of disease. Such programs increasingly aim to build resilience to sustain improved outcomes and provide a solid foundation for longer term transformations. As such, there is a need to understand what resilience means in specific contexts. The goal of this formative study was to explore local experiences of resilience and vulnerability among 11 youth-caregiver dyads (n = 22) who were beneficiaries of the Malawi Social Cash Transfer Program in Balaka district. We used a photo-elicitation approach informed by the participatory, visual methodology photovoice to guide the study and conducted an iterative content analysis using thematic coding of transcripts and photos. Participants took pictures of their daily struggles and shocks and participated in audio-recorded discussions to reflect on the photos using an adapted version of the SHOWeD method. We found that participants characterized resilience as a tireless process of using all available individual, family, and community resources at all times in pursuit of survival and well-being. In the context of daily struggles, resilience was an essential part of survival. Shocks, mostly health-related, were depicted through staged images candidly highlighting individual and environmental vulnerabilities. Community support was an essential component of resilience for both daily struggles and shocks. Using photo-elicitation methods facilitated an intergenerational, community-driven reflection on the meaning of resilience and the multilevel determinants of health in a context of extreme poverty. Findings can inform the design of resilience-focused cash transfer programs to improve health equity.

This study uses panel data for 3290 households to analyze the effect of an unconditional cash transfer on food and nutrition security among ultra-poor and vulnerable households. Study data are from an impact evaluation of the Government of Malawi's Social Cash Transfer Program, a cluster-randomized control trial that employs both random selection and random assignment. We use the difference-in-differences specification to estimate average treatment effects of the program on three components of food and nutrition security- current economic vulnerability, diet quantity, and diet quality. Results show protective program impacts during the lean season on diet quantity as beneficiary households are 11 percentage points more likely to consume multiple meals per day than control households (p<.001), have a higher level of apparent caloric availability (267.49 kcal, p<.05), are 10 percentage points less likely to be food-energy deficient (p<.05), and have a reduced hunger depth (111.11 kcal, p<.05). However, study findings indicate that after one year of program exposure beneficiary households have experienced little improvement in diet quality or current economic vulnerability to food insecurity. Clear policy and program implications emerge related to the purchasing power of the cash transfer, particularly during the lean season, and the importance of integrated social protection initiatives.

Extensive research documents that social network characteristics affect health, but knowledge of peer networks of youth in Malawi and sub-Saharan Africa is limited. We examine the networks and social participation of youth living in extreme poverty in rural Malawi, using in-depth interviews with 32 youth and caregivers. We describe youth's peer networks and assess how gender and the context of extreme poverty influence their networks and participation, and how their networks influence health. In-school youth had larger, more interactive, and more supportive networks than out-of-school youth, and girls described less social participation and more isolation than boys. Youth exchanged social support and influence within their networks that helped cope with poverty-induced stress and sadness, and encouraged protective sexual health practices. However, poverty hampered their involvement in school, religious schools, and community organizations, directly by denying them required material means, and indirectly by reducing time and emotional resources and creating shame and stigma. Poverty alleviation policy holds promise for improving youth's social wellbeing and mental and physical health by increasing their opportunities to form networks, receive social support, and experience positive influence.

The problems of accessibility to formal credit markets by the poor in developing countries have been well documented and remain a central issue in the pervasive ness of poverty. Often the poor have resorted to informal credit markets that are more accessible and flexible compared with formal financial institutions, but with limited re sources to reach as many poor as possible (Wai, 1980). Other advantages of the informal financial sector over formal financial institutions include low transaction costs and flexibility with respect to loan use, loan size and loan repayment. However, Schaefer-Kehnert and Von Pischke (1986) note that in informal credit markets, the conditions of credit are often not specified or are so imprecise such that the line between loans and gift is sometimes blurred. Besides, informal financial markets are unable to intermediate between surplus and deficit units that are widely separated and they usually offer credit at very high interest rates (Burkett, 1989). This problem of credit markets for the poor have made interventions in microfi nance in developing countries a worldwide development issue. Most governments, non-governmental organisations (NGOs) and the private sector in developing coun tries with the support of local and international donors, have deliberately intervened in rural finance markets by improving accessibility to credit and providing low cost credit to the poor. In Malawi, under the Social Dimension of Adjustment (SDA) project, the government provided seed capital to six institutions to implement credit schemes for the poor on a pilot basis. The institutions supported under this project are Ekwendeni Mission Hospital (EMH), Foundation for International Community Assistance (FIN CA), Mulanje Community Development Office (MCDO), National Association of Busi ness Women (NABW), Thyolo Youth Enterprise Development Office (TYEDO) and Women's World Banking (WWB) Malawi Affiliate1. Mulanje Community Development Office and Thyolo Youth Development Office are governmental departments, while the rest are non-governmental organisations. This paper examines the capacity constraints and effectiveness of poverty-orien ted institutions that received grants from the Social Dimensions of Adjustment project. 1 These credit institutions are among the ten institutions offering poverty-oriented credit schemes that are

This study analyzes the impact of an exogenous, positive income shock on caregivers’ subjective well-being in Malawi using panel data from 3,365 households targeted to receive Malawi’s Social Cash Transfer Programme that provides unconditional cash to ultra-poor, labour-constrained households. The study consists of a cluster-randomized, longitudinal design. After the baseline survey, half of these village clusters were randomly selected to receive the transfer and a follow-up survey was conducted 17 months later. Utilizing econometric analysis and panel data methods, we find that household income increases from the cash transfer can have substantial subjective well-being gains among caregivers. Households use the cash to improve their families’ livelihoods, ensuring provision of their basic needs including food, shelter, and clothing. Reduction of these daily stresses makes caregivers happier about their current situations and gives them hope that the future will continue to get better.