Study settings

The study was primarily conducted in Blantyre, Malawi. Some additional data from health care workers for objective 2 were collected in Mangochi and from health care workers and policy makers in Lilongwe. These were added subsequent to the initial study design based on recommendations from UNICEF Malawi, who provided supplementary funds in late 2011 to further investigate the health sector response.

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Both rural and urban sites were included in the study, although these were difficult to differentiate clearly in the peri-urban setting as illustrated in the following photograph of Ndirande (figure 4.3)

Figure 4.4 Ndirande location, Blantyre, Malawi

4.4.1 Blantyre District

Blantyre as a district has a population of 732,518 and is divided into Blantyre rural and Blantyre urban (Blantyre city), making it suitable for a study targeting both urban and rural populations with limited funding. Fighting Gender based violence( GBV ) is also one of the priority areas for the district according to the gender needs assessment report released in 2010 369 . Residents are more likely to have access to some domestic violence services compared to typical rural areas. The accessibility of these referral points was a key ethical consideration in district selection since the research has potential to raise issues that may require onward referral.

Blantyre district and city are divided into eight traditional authorities (see Figure 4.4). They cover a wide area and up to three health centres may be located within each traditional authority.

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Figure 4.5 Traditional authorities in Blantyre District

The district of Blantyre is home to the oldest city in Malawi and in Southern Africa. It was established in 1876 when Scottish missionaries, led by Dr. David Livingstone, passed through the area. Later more missionaries and traders followed to set up a church (the Blantyre Mission, which is still standing today) and businesses. Today, the City of Blantyre is the main industrial and commercial centre for Malawi. People of diverse socio-economic and ethnic backgrounds reside in this city. About 60% of this population lives in unplanned or squatter areas that are characterized by congestion of houses and poor infrastructure and social services. The city has a young population hence a high dependency rate with about 60% of the total population being below 25years. The population of Blantyre City is growing by 3.4% due to both natural growth and rural urban migration. The migrants are attracted to the city by economic activities, services and opportunities that are available in the city. Unemployment rate at the moment is 57%; illiteracy rate is at 27% while 82% are lacking formal skills. About 46% of all households in the city earn less than $50 a month. Poverty is pervasive in the city with 65% of the total households in the city living below the poverty line.

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The health care delivery system in the district has both curative and preventive health care services, and this is provided through a network of hospitals and health centres/clinics which are distributed in different parts of the city. The government runs Queen Elizabeth Central Hospital (QECH), the biggest referral hospital in the country, which has a total of 1,000 hospital beds, and the three private hospitals, have a total of 122 hospital beds. The Queen Elizabeth Central Hospital (QECH) is the largest referral hospital in Malawi, a country with over 13,000,000 citizens. QECH has been selected because it is the largest referral hospital in Malawi and is a teaching hospital for the College of Medicine and Kamuzu College of Nursing, both constituency colleges of the University of Malawi. This is an added advantage as perceptions elicited at QECH may be reflective of some of the attitudes in the other hospitals since most of the health care providers in the country get their early professional socialisation through this hospital. The catchment area for QECH is large as it also serves as the district hospital for Blantyre district. As such it also acts as referral centre for all health centres in the district.

In addition to QECH five community locations within Blantyre’s traditional authorities were selected based on willingness of the communities to take part and with consideration of geographical spread, presence of health centres, availability or absence of GBV services and previous recognised association with IPV. Dziwe, Limbe, Mdeka, Madziabango and Ndirande were selected for inclusion. Dziwe and Limbe have been previously identified as having a high prevalence of suicide cases, which has a recognised association with intimate partner violence 370.

4.4.2 Mangochi District

Due to a lack of a ‘proper’ district hospital in Blantyre, the researcher decided to explore perceptions of health care providers in a ‘proper district hospital’ (designated as such by MOH). Mangochi district, south of Lake Malawi and 150 kilometers north of Blantyre, was selected for this particular purpose. For this study health facilities under Mangochi DHO were purposefully selected taking into consideration the levels of service provision available: District hospital, rural hospital and health centres including village health committees. The following were included:Mangochi district hospital; Namwera rural hospital or health centre; Malukula Health Centre; Chipalamawamba village health committee

102 4.4.3 Lilongwe District

Lilongwe was selected because it is in the central region. Lilongwe is the capital city of Malawi. Lilongwe has a central and district hospital, unlike Blantyre where the referral hospital (Queens) doubles as a central and district hospital. For the interest of this research, Lilongwe is the only Central Hospital among the four that had not yet incorporated the One Stop Centre model in its provision of services to survivors of violence. This was of particular interest to the study. The following were included: Bwaila hospital; Kawale health centre; Mitundu health centre; Mitundu village health committee.