The role of material deprivation and consumerism in the decisions to engage in transactional sex among young people in the urban slums of Blantyre, Malawi

Transactional sex has been associated with a high risk of HIV acquisition and unintended pregnancy among young women in urban slums in sub-Saharan Africa. However, few studies have explored the structural drivers of transactional sex from the perspective of both genders in these settings. This paper explores how young men and women understand the factors that lead to transactional sex among their peers, and how deprivation of material resources (housing, food and health care access) and consumerism (a desire for fashionable goods) may instigate transactional sex in the urban slums of Blantyre, Malawi. Data from 5 focus group discussions and 12 in-depth interviews undertaken with a total of 60 young men and women aged 18–23 years old, conducted between December 2012 and May 2013, were analysed using anticipated and grounded codes. Housing and food deprivation influenced decisions to engage in transactional sex for both young men and women. Poor health care access and a desire for fashionable goods (such as the latest hair or clothing styles and cellular phones) influenced the decisions of young women that led to transactional sex. Interventions that engage with deprivations and consumerism are essential to reducing sexual and reproductive health risks in urban slums.


Introduction
Transactional sexor the exchange of sex for goods or resourceshas been associated with increased risk of HIV acquisition and unintended pregnancy among young people in sub-Saharan Africa (Dunkle et al., 2004;Luke, 2005a). Recent evidence has highlighted young people in urban slums as a marginalised group at higher risk than non-slum residents (Mberu, Mumah, Kabiru, & Brinton, 2013;Mmari & Astone, 2013). These authors argue that understanding the risks in this group of young people, and how to invest in programmes that prevent increased sexual and reproductive health (SRH) risks, requires more knowledge about the structural factors that increase their vulnerability. This paper presents findings of an exploratory qualitative study on how young people living in urban slums understand the factors that promote transactional sex among their peers, and how material deprivation and consumerism may lead to decisions to engage in transactional sex in Blantyre, Malawi.

Background
Existing research in the urban slums of sub-Saharan Africa highlights that the decision to engage in transactional sex is an outcome of poverty (Greif, 2012;Izugbara, Ochako, Egesa, & Tikkanen, 2013;Luke, 2005a). However, most of this research focuses on young women in relationships with older men (Luke, 2005a), and thus we are left with little published information on transactional sex from the perspective of young men in urban slums. However, what is generally known from prior research that used data from the Demographic and Health Surveys is that 7.4%-42.8% of unmarried young men, and 3.4%-18.3% of married older men, reported giving or receiving money, gifts or favours for sexual relations in the last 12 months (Luke, 2005b). The situation where transactional sex is so common might be critical in urban slums where many young people experience an acute lack of money or resources, and where such material deprivation manifests in different ways and influences young people to make different decisions to compensate. In order to effectively reduce the known risks for HIV acquisition and unintended pregnancy associated with transactional sex, a logical question to ask is 'what are the reasons young people begin to consider this behaviour, and in what ways do they lead to decisions to engage transactional sex?' To address this question, increasing attention in sub-Saharan Africa has been devoted to explaining the decisions to engage in transactional sex by using critical aspects of deprivation (insufficient housing, food insecurity and poor access to health care) that best represent the experiences of young people in urban slums (Greif, 2012;Izugbara et al., 2013;Kamndaya, Thomas, Vearey, Sartorius, & Kazembe, 2014;Kunnuji, 2014). Mberu et al. (2013) document several reasons for this trend, while also highlighting that existing research has yielded limited information for more effective SRH programmes targeting young people in urban slums. Supporting this view, Mmari and Astone (2013) have called for a new generation of structural interventions that challenge the structural drivers of SRH risks among young people in slums, including housing, food and health care access.
Housing, food and health care access are multidimensional concepts that encompass aspects of housing quality, instability and overcrowding (Aidala, Cross, Stall, Harre, & Sumartojo, 2005); availability, accessibility and utilisation of food (Ivers & Cullen, 2011) and affordability, acceptability and availability of health care (Peters et al., 2008). However, this multidimensional perspective is infrequently used in transactional sex research.
Framing transactional sex in relation to material deprivation alone might be insufficient in urban slums in sub-Saharan Africa. Along with material deprivation, our review of the literature suggests that consumerisma desire for fashionable goodsmight be an important, albeit often overlooked, driver of young people's decisions to engage in transactional sex in an urban slum context. In our opinion, it is essential to explore the roles of both material deprivation and consumerism in decisions to engage in transactional sex as to better inform effective SRH programmes in this context.
A vast body of anthropological literature has shown that transactional sex might have more to do with consumerism than with poverty (see, for example, Hunter, 2002;Leclerc-Madlala, 2003). This literature indicates that engagement in transactional sex is often motivated by the pursuit of a particular idealised lifestyle, where young women seek older men often in pursuit of fashionable goods (Dunkle et al., 2004;Hunter, 2002;Leclerc-Madlala, 2003;Maganja, Maman, Groves, & Mbwambo, 2007;Silberschmidt & Rasch, 2001). In this regard, several authors (Hawkins, Price, & Mussá, 2009;Luke, 2005a;Poulin, 2007) have reported that young women often use transactional sex as a means to achieve their economic and social goals.
The approach used in our study to explore young people's views of the role of consumerism and material deprivation in their decisions to engage in transactional sex was to synthesise a simplified framework based on this anthropological literature. This approach is important given the profound consequences that physical, social and economic factors can have for HIV risk in urban poor settings (Galea, Freudenberg, & Vlahov, 2005). We used one strand of urban health research that focuses on the differences within urban slums (Galea et al., 2005).

Study context
Malawi is a low-income country, with 91% of its 16 million people living on less than US $2 per day (United Nations Development Programme, 2011). Approximately 5% of young women and 2% of young men aged 15-24 years were living with HIV by 2009 (National AIDS Commission, 2012). Malawi's HIV prevalence of 11% conceals ruralurban differences, where the prevalence in urban areas is nearly double that in rural areas (17.1% vs. 10.8%) (Malawi Government, 2011). Although one-fifth of the population is classified as urban, urbanisation in Malawi is linked to the increasing urbanisation of poverty, with approximately 65% of the urban population living in slums (UN-Habitat, 2011).
Much research has been undertaken on transactional sex in Malawi (Kaler, 2006;Moore, Biddlecom, & Zulu, 2007;Poulin, 2007;Swidler & Watkins, 2007;Tawfik & Watkins, 2007), with several theoretical explanations of transactional sex put forward. These explanations include a focus on financial interests (Moore et al., 2007), social and emotional ties (Poulin, 2007;Swidler & Watkins, 2007) and consumerism (Kaler, 2006;Moore et al., 2007). However, most existing research has focused on women or unmarried female adolescents in rural areas. To our knowledge, this paper is one of the first qualitative studies examining the perspectives of both young men and young women regarding the role of material deprivation and consumerism in their decisions to engage in transactional sex in urban slums in Malawi. The aim of this study was to explore how young men and young women understand the factors that promote transactional sex among their peers, and how material deprivation and consumerism may instigate transactional sex in two urban slums of Blantyre, Malawi.

Study sites
The study sites are the informal (

Ethical considerations
Study procedures were approved by the Human Research Ethics Committee (Medical) of University of the Witwatersrand and the National Health Sciences Research Committee in Malawi (Protocol Numbers M120658 and NHSRC 1078, respectively).

Study design
The study made use of an exploratory qualitative study design through focus group discussions (FGDs) and in-depth interviews (IDIs) held with young men and young women in Mtopwa and Mbayani. FGDs focused on how participants made sense of risky sex, while IDIs allowed participants to reflect on young people's motivations for having sex. Combining these two methods increased our understanding of structural and social drivers of transactional sex among young people in the study sites.

Data generation
Sixty young people (24 young men and 36 young women, 18-23 years of age) participated in five FGDs (2 for young men and 3 for young women), conducted between December 2012 and May 2013. Each FGD had 12 participants. Inclusion criteria for FGDs were age, schooling status, sex and self-reported multiple sexual partnering or monogamous sexual relationships. Each FGD had more individuals who self-reported multiple sexual partners than monogamous sexual relationships. Both purposive and snowball sampling were used for the selection of participants. Two local, trained research assistants (male and female) from each study site identified their friends who were willing to take part in the study as initial participants for snowball sampling. We first identified the local research assistants with the help of community leaders from the study sites. Then 3 days were spent recruiting young people from the pre-existing friendship groups of these initial participants, so that they knew each other well and were hopefully free to discuss sensitive issues in each other's presence. The two FGDs for young men were organised according to marital status (married and unmarried), while the three FGDs for young women were organised as follows: (1) married and out-of-school, (2) unmarried and out-of-school and (3) unmarried and in-school. This organisation of FGDs was based on the feedback during piloting phase of this study.
The IDIs were held with a subset of FGD participants so as to build on the rapport established during the group discussion, and to explore some of the issues that had emerged during FGDs. Approximately 2-3 interviewees were purposively sampled per FGD to represent schooling status and marital status, and to include both dominant and reserved FGD participants. A total of 12 IDIs were conducted with 6 young men and 6 young women.
The research was conducted in Chichewa, the national language of Malawi. Two trained male (aged 26 years) and female (aged 25 years) fieldworkers, experienced in qualitative data collection, facilitated the discussions. The FGD guide questions were concerned with sexual practices and norms, and the circumstances that lead young people to engage in transactional sex. For example, participants were asked the following question: 'Some young people know that if they have sex without a condom or with many different people they risk getting HIV, but still they do not protect themselves. Why is this the case?' When relevant, participants were asked to describe in detail the mechanisms by which material deprivations and consumerism could contribute to the decision to engage in transactional sex with the following question: 'Please tell us in what way(s) do (the factors that they have mentioned) influence your decisions as young men (/young women) to have sex?' These issues were discussed in more detail with the 12 young people who participated in the IDIs. Questions from the IDI guide sought views of what respondents considered the critical issues that promote risky sex in their community, and how material deprivation and consumerism influenced their decisions to engage in transactional sex. We sought this information by asking respondents: 'What expectation do you have as a young man (/young woman) when it comes to sexual intercourse?'; 'What do you think are the reasons why some of you are having sex?'; 'What do you think are some of the reasons why some of you have multiple sexual partners?' and 'What do you do when there is (less or no food to eat) in your household?' The interview guides were flexible to accommodate emerging issues.

Data analysis
The data was transcribed and translated into English. Each transcript was summarised to identify key themes, entered into QSR International's Nvivo 9 software and coded. A pragmatic approach that combined the use of anticipated codes and grounded codes (Mason, 2006) was adopted to code the data. Grounded codes were developed from multiple reviews of the transcripts, while anticipated codes were developed from prior knowledge as well as multiple reviews of transcripts. Thereafter, codes were developed into conceptual categories, sub-themes and, finally, major themes (Table 1).

Description of the sample
The sample included 36 young women and 24 young men, equally split between the 2 study sites. The participants were aged 18-23 years, with a median age of 19 and 21 years for females and males, respectively (Table 2). A large proportion of out-of-school participants had primary education, while in-school participants were in secondary school. The mean years of completed formal schooling was approximately 7 years. The occupations of those currently out-of-school ranged from casual labouring, gardening and farming, to hawking, schooling and self-employment in informal artisan jobs. A larger proportion of women (45%) than young men (13%) were not currently earning an income. The majority of the participants had children. Monthly incomes were low (averaging approximately US$70), and the majority of participants reported being Christian.
Transactional sexoperating as exchange of sex for goods or resources in casual or committed relationshipswas reported to be common among young people in the study sites. Our findings are presented according to the two key emergent themes from the data analysis: (1) the relationship between transactional sex and material deprivation and (2) the relationship between transactional sex and consumerism. Pseudonyms are used in all quotations illustrating the main findings.

Material deprivation and transactional sex
Three dimensions of material deprivationbasic unmet needs relating to housing, food and health care deprivationswere cited as reasons for young people's decisions to engage in transactional sex.

Housing deprivation
For young people in-and out-of-school, housing deprivation (overcrowding, poor quality of housing and housing instability) exacerbated their difficulties in maintaining safe sexual practices. Young people were explicit about their lived experiences of housing deprivation, using phrases such as 'find a place', 'the houses are squeezed', 'renting a house', 'overcrowding', which they linked to their decisions to engage in transactional sex to meet their unmet housing needs. They also described feeling frustrated that they lived in houses with walls, floors and roofs made from temporary materials, and cited this as a reason for their motivations for transactional sex: When a girl lacks housing and she wants to find a place to sleep, or she does not have rent, she is mostly found in a bar as she does not have a place to live. She will have sex with a guy A mixed-methods study on transactional sex with unmarried female adolescents in Malawi (Moore et al., 2007) found that insufficient housing influenced their decisions to engage in transactional sexual relationships with older men. To a large extent, this research is supported by our study of young people living in urban slums. Housing deprivation was mentioned frequently by the young women as a reason for becoming in involved in transactional sex. Young women also claimed that housing was a driver for young men to engage in transactional sex by seeking support from older women: Naje: Young men here sometimes sleep with older women, just because they want to stay [and sleep] at a decent place. Several young men get STIs in the process.
Namila: It is because of poverty that some young men end up having sex with older women... If a young man lacks a safer sleeping place even two days, of course you would go to a woman who shows you love. (FGD 3, married, out-of-school female 18-23) Previous research in Malawian cities has also highlighted how housing insecurity, particularly homelessness, is associated with young men's involvement in different forms of risky sexual behaviours including transactional sex (Mandalazi, Banda, & Umar, 2013). In addition to housing insecurity, food insecurity also emerged in our study as an important determinant for both young men's and young women's motivations for transactional sex.

Food insecurity
Food insecurity has been found to be acute in urban slum contexts in sub-Saharan Africa (see, for example, Greif, 2012;Vearey, Palmary, Thomas, Nunez, & Drimie, 2010). Common concerns about food insecurity were raised by the young people in our study as they talked about high food prices and a scarcity of maize, a key staple food in Malawi: When you go to the market there is no maize and when we go to the vendors it's at K8500 [about US$22 per 50 kg bag of maize], which we don't have. We just use sex with men so that we source food but there is still no maize at the market … You just have sex to source enough money to buy enough food for you and your children. (Nankho,unmarried,female,21) Young women described food insecurity as a 'visa' for their decisions to engage in transactional sex: You cannot sleep on an empty stomach when you have a 'business' (meaning vagina) that does not need capital. We think that, 'when you have sex with a particular man then we will at least have a "visa" for eating that particular day'. (Nachi, married, out-of-school female, 20) Nankho's and Nachi's quotes are illustrative of the Ivers and Cullen (2011) definition of food insecurity that encompasses aspects of availability, accessibility and utilisation faced by young women in slums and how these aspects determine young women's decisions to become involved in transactional sex. Unlike transactional sexual encounters where young women receive gifts or resources after sex, young men talked about how the unmet needs of young women for food made it easier for them to approach young women for transactional sex. One young man said: With a plate of food here, you can easily get a girl. It happens here regularly. (FGD 5,unmarried,(18)(19)(20)(21)(22)(23).
The problem in our area is that girls accept to have sex with a man with just a plate of Nsima 1 . They accept having sex for eating Nsima at someone's home. So the main issue is poverty. It cannot happen if one has food at home. (Yotamu,male,unmarried,22) Young men also told us about young men's food related involvement in transactional sex by seeking support from older women (Mandalazi et al., 2013): I have even witnessed it; the (young) man is my friend and he tells me how an older woman uses him for sex after giving food. (FGD 4, married and unmarried out-of-school young men aged 18-23 years)

Poor access to health care
Young women told us about various circumstances, prompted by inadequate access to public health services, which forced young women to spend their resources in private clinics: You go to a government hospital with a child and wait for hours on a queue. When it is your turn, they tell you there are no drugs or just give you Panadol. How can Panadol cure Malaria? Sometimes they tell you to go and buy medication. That's why you end up meeting a man to save [the] life of your child. (Nabiyeni, unmarried female, out-of-school, 23) Namalata: I suffer from Asthma and when I go to the hospital for an injection they tell me to go to a (private) clinic since they do not have it in stock. Since I don't have money, I just find other means to get it and pay for the injection.
Interviewer: What other means do you use? Namalata: 'Uhule' (exchanging sex for money) so that I get K1000 and pay for the injection.
(Married female out-of-school, 23) Young people also told us about their seeking 'effective' medical care in the private sector. The perception that effective medical care is found in private clinics forces these young people to develop coping mechanisms to meet the greater financial costs of private medical care. A 19-year-old mother of two children told us how the need to alleviate her family's health needs routinely resulted in her engaging in transactional sex: Well it [consideration of having sex in exchange for care for her sick child] has happened to me a number of times, it usually happens when my child is very sick and I have no means to go to clinic [Referring to private clinic] and there is no money. Something tells me, 'Why am I rejecting the men, after all, my child will be better …' When my mother or my child is sick you ask him to help. Just know that you will have sex. Otherwise, next time he will refuse to help you. And it goes on. (Nagama,unmarried,female,19) The following dialogue with a 23-year-old married mother of three children suggests that the absence of attention from health care staff and drugs in public hospitals also drives young women into transactional sex to access private health care for their children: Interviewer: So what happens if you don't have money to take your child to a hospital? Nasimati: Most of the nurses in the public hospital are careless and don't even want to touch your sick child. I go to a public hospital only to be told that there are no drugs. They tell you to go and buy medication. (Married,22) Although material deprivation (unmet basic needshousing, food and health care) were cited by young women as reasons for their decision to engage in transactional sex, consumerism was also identified as an important driver of young people's decisions to become involved in transactional sex. In these instances, young women in particular described purposefully engaging in transactional sex to satisfy their desires for fashionable goods and lifestyles. Their narratives are presented in detail in the following section.

Consumerism and transactional sex
Young people spoke about the popularity of transactional sex in their communities as a way of meeting their aspirations and desires for fashionable goods. When discussing their involvement in transactional sex in relation to consumerism, the young people mentioned a variety of items that are exchanged or purchased with proceeds from transactional sex. These items included fashionable clothing, money (often for fashionable goods or hair styles), better quality food and use of cellular phones: Who is going to ask you out? Nowadays men want to ask out a girl who wears clothes with a label. So, a modern girl here wants to have leggings, fishnets, cellular phone… (Ndazi, outof-school unmarried female, 21) As seen in existing literature (Leclerc-Madlala, 2003), from the above quote we see an indication of young women in urban slums in Malawi wanting to achieve 'modernity' through their outward appearancenot necessarily for their own identity purposes, but in order to increase their desirability for men.
Everything is fashion nowadays. When I get a skin jean, others want to have theirs as well and will accept any man for sex, be it older, to get money for a skin jean. (Selina, out-ofschool unmarried female, 20) The above quote suggests that young women in this community will do whatever is required of them, including having sex with older men, to obtain money to purchase fashionable items of clothing. Further, in some discussions with young men, they reported taking advantage of young women's desires for fashionable goods by engaging transactional sex. These men highlighted their perceived economic advantage, which allowed them to control the terms of their sexual encounters: With a cellular phone here, you can easily get a girl. Girls here are easy to convince. It happens here regularly. (FGD 5,(18)(19)(20)(21)(22)(23) Our study also showed that young women who understood how to negotiate transactional sex felt they could use it to their advantage. For example, young women spoke about 'provoking men' and understanding 'how the mind of the man works'. This issue is also highlighted in recent anthropological research (Hawkins et al., 2009;Maganja et al., 2007) stating that some young women use their sexuality as a resource for financial gains from men.
You tell yourself that you have feelings for this (married) man and invite him to buy fishnets for you. I think that it is the older men who take care of us a lot because if they leave K500 at their home, they make sure to leave me with K500 as well. It's not just the same with young men. Older men are able to pay school fees and buy clothes for you. (Ireen, unmarried inschool female, 18) Ireen's story above is indicative of how young women intentionally participate in transactional sex with older men in an attempt to secure fashionable goods. Additionally, young women talked about transactional sex with older men being the quickest and easiest way of accessing money to buy fashionable goods and achieve their aspirations: One emerging issue from the quotes provided in this paper is that views around transactional sex were predominant amongst married young women. These quotes may suggest that young unmarried women in the study community are involved in transactional sex and, therefore, in multiple, concurrent sexual partnerships. A study among Luo men in the urban slums of Nairobi, Kenya (Izugbara et al., 2013) reported similar findings of married young women having affairs with other men. Another emerging issue from the quotes in this paper is that while young women provided examples of their own practice of transactional sex, young men only described friends or acquaintances who may have engaged in this practice. This issue could indicate something about the acceptability of the practice between young women and young men in the study sites.

Conclusions
The key findings in our study are that acute economic pressure in combination with a lack of quality health care and a desire for fashion influenced the decisions of young women to engage in transactional sex. Housing and food deprivation influenced the decisions of both young men and young women to engage in transactional sex. These findings suggest that the role of deprivation of material resources and desire for fashion in transactional sex practices might be different for young women and young men based on prevailing gender norms in a community. Further research is needed to explore this issue.
While not all young people spoke about their own involvement in transactional sex, it was recognised by both genders as a common practice and expectation in the study sites. While transactional sex in non-slum settings in Malawi has been studied before (Kaler, 2006;Moore et al., 2007;Poulin, 2007;Swidler & Watkins, 2007;Tawfik & Watkins, 2007), this paper is one of the first to concurrently explore material deprivation and consumerism in relation to young people's motivations for engaging in transactional sex in urban slums. This paper makes a contribution to the literature with respect to unpacking the components of material deprivation, and offers a perspective on one critical componentacute economic shocks associated with lack of quality health carein relation to transactional sex among young women in urban slums.
Quantitative studies undertaken in urban slums in Nigeria (Kunnuji, 2014), Kenya (Greif, 2012) and South Africa (Kamndaya et al., 2014) found significant associations between various indicators of material deprivation and sexual risk behaviours (age at first sex, multiple sexual partners, non-use of condoms and transactional sex). The qualitative approach in this study allowed us to explore the roles of multiple aspects of deprivation in greater depth than have previous quantitative studies.
However, as with all qualitative inquiry, our analysis is influenced by subjective interpretation, although every effort was made to remain true to the data. Thus, our study findings must be interpreted in light of two major limitations. First, given the sensitivity of transactional sex, it is possible that respondents would have given socially desirable answers. Second, we approached this study from a concept of vulnerability, which is a negative condition. However, existing research (Kabiru, Beguy, Ndugwa, Zulu, & Jessor, 2012) has indicated that focusing on vulnerability gives a limited set of clues for positive action. Therefore, further research should consider positive conditions (resilience) in order to know what to strengthen and how to strengthen it in urban slums.
Notwithstanding these limitations, the findings from this research have potential implications for strategies required to reduce SRH risks among young people residing in urban slums in Malawi. For example, our research indicates that some young married women are having extramarital relationships that involve transactional sex. Furthermore, material deprivation and consumerism are pull factors in decisions among these young people to engage in transactional sex. Therefore, interventions that engage with material deprivation and consumerism are essential to reduce SRH risks among young people residing in urban slums.