Browsing by Subject "Malawi"
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- ItemOpen AccessAn Analysis of the Political Dynamics that Influenced the Process of Adopting the 2016 National Land Laws in Malawi: A Gender Perspective(2019) Thindwa, Priscilla; Murithi, Timothy; Jolobe, ZwelethuThe thesis interrogates how the political dynamics that emerged in the formulation of the 2016 land legislation in Malawi influenced the gendered outcomes. It highlights the complexity of the policymaking process that was shaped by divergent interests and power dynamics of the stakeholders. It argues that although the interests and agenda complicated the process, their discourses were framed and justified their positions within the development and gender equality framework. It highlights the progressive nature of the socio-legal provisions in the legislation by significantly recognising and promoting women’s land rights. It contends that advances in legal institutions are essential; however, for inclusive transformation to be sustainable, changes in social and cultural practices and norms are imperative. This is because Malawian women continue to face exclusion in owning, controlling and accessing land albeit being the major agricultural producers. This is owed to the persistence of patriarchal attitudes in institutions that perpetuate contestation in the public and private spheres of women’s rights to access, own and control over land. Such is persistent particularly within customary laws which remain sites of struggle between traditional leaders’ claims and women’s societal positions. Hence, creating enabling environments for women will allow them to articulate their political voices and agenda and as such influence policy and legal formulation. Through a multi-faceted approach encompassing of legal pluralism, feminist perspectives on gender and development, and the theory of change, the paper discusses the complexity of policymaking that has been shaped by interests and power. For instance, most chiefs contested against their limited powers and the inclusion of women in land administration issues as stipulated in the new Land Laws, while CSOs advocated for the laws to be people-centred, gender-sensitive and responsive to women’s needs. Also, International organisations were interested in ensuring that there is improved land governance framework and its implementation is in line with VGGT. Thus, apparent realities emerge from the analysis of these political dynamics within the adoption of the 2016 Land Laws: the differing stakeholders’ agenda and how they all pressed on advancing their agenda. Nonetheless, gender equality and development discourse was an aspect that was apparent in the debates.
- ItemOpen AccessAssessing population aging and disability in sub-Saharan Africa: lessons from Malawi?(Public Library of Science, 2013) Stuck, Andreas E; Tenthani, Lyson; Egger, MatthiasThe study of Payne and colleagues is, to our knowledge, the first empirical study to report disability states, and to estimate transitions between them, for Malawi's population of 45 years of age and older. The study provides detailed estimates for healthy life expectancy (HALE, an estimate of equivalent years of good health), which differ from those recently published by the Global Burden of Disease study (GBD) [2],[3]. The GBD estimates that in Malawi 50-year old women can expect to live 76.1% of their remaining 23.4 years in good health and 50-year old men can expect to live 76.7% of their remaining 20.6 years in good health [2]. In contrast, Payne and colleagues estimated that women aged 45 years spend only 42% of 28.0 remaining years in good health, and men 59% of 25.4 years.
- ItemRestrictedContextualising journalism education and training in Southern Africa(2007) Banda, Fackson; Beukes-Amiss, Catherine M; Bosch, Tanja; Mano, Winston; McLean, Polly; Steenveld, LynetteIn this article it is argued that journalism education in Southern Africa must contend with defining a new academic identity for itself, extricating itself from dependency on Western oriented models of journalism education and training, as this has been a perennial challenge in most of Africa.
- ItemOpen AccessCould cash and good parenting affect child cognitive development? A cross-sectional study in South Africa and Malawi(2017) Sherr, Lorraine; Macedo, Ana; Tomlinson, Mark; Skeen, Sarah; Cluver, Lucie DaleBACKGROUND: Social protection interventions, including cash grants and care provision have been shown to effectively reduce some negative impacts of the HIV epidemic on adolescents and families. Less is known about the role of social protection on younger HIV affected populations. This study explored the impact of cash grants on children's cognitive development. Additionally, we examined whether combined cash and care (operationalised as good parenting) was associated with improved cognitive outcomes. METHODS: The sample included 854 children, aged 5 - 15, participating in community-based organisation (CBO) programmes for children affected by HIV in South Africa and Malawi. Data on child cognitive functioning were gathered by a combination of caregiver report and observer administered tests. Primary caregivers also reported on the economic situation of the family, cash receipt into the home, child and household HIV status. Parenting was measured on a 10 item scale with good parenting defined as a score of 8 or above. RESULTS: About half of families received cash (55%, n = 473), only 6% (n = 51) reported good parenting above the cut-off point but no cash, 18% (n = 151) received combined cash support and reported good parenting, and 21% (n = 179) had neither. Findings show that cash receipt was associated with enhanced child cognitive outcomes in a number of domains including verbal working memory, general cognitive functioning, and learning. Furthermore, cash plus good parenting provided an additive effect. Child HIV status had a moderating effect on the association between cash or/plus good parenting and cognitive outcomes. The association between cash and good parenting and child cognitive outcomes remained significant among both HIV positive and negative children, but overall the HIV negative group benefited more. CONCLUSIONS: This study shows the importance of cash transfers and good parenting on cognitive development of young children living in HIV affected environments. Our data clearly indicate that combined provision (cash plus good parenting) have added value.
- ItemOpen AccessA descriptive analysis of HIV prevalence, HIV service uptake, and HIV-related risk behaviour among patients attending a mental health clinic in Rural Malawi(Public Library of Science, 2013) Lommerse, Kinke; Stewart, Robert C; Chilimba, Queen; Akker, Thomas van den; Lund, CrickBACKGROUND: Human immunodeficiency virus (HIV) and mental illness are interlinked health problems; mental illness may pose a risk for contracting HIV and HIV-positive individuals are at higher risk of mental illness. However, in countries with high HIV prevalence, the main focus of HIV-related health programmes is usually on prevention and treatment of somatic complications of HIV, and mental illness is not given high priority. We examined HIV prevalence, uptake of HIV services, and HIV-related risk behaviour among people attending a mental health clinic in rural Malawi. METHODOLOGY: Semi-structured interviews were performed with patients capable to consent (94%), and with those accompanied by a capable caregiver who consented. HIV counselling and testing was offered to participants. FINDINGS: Among 174 participants, we collected 162 HIV test results (91%). HIV prevalence was 14.8%. Women were three times as likely to be HIV-positive compared to men. Two-thirds of participants reported having been tested for HIV prior to this study. The uptake of HIV-services among HIV-positive patients was low: 35% did not use recommended prophylactic therapy and 44% of patients not receiving antiretroviral treatment (ART) had never been assessed for ART eligibility. The reported rate of sexual activity was 61%, and 9% of sexually active participants had multiple partners. Inconsistent condom use with stable (89%) and occasional (79%) sexual partners, and absence of knowledge of the HIV status of those partners (53%, 63%) indicate high levels of sexual risk behaviour. CONCLUSIONS: HIV-prevalence among persons attending the clinic, particularly men, was lower than among the general population in a population survey. The rate of HIV testing was high, but there was low uptake of preventive measures and ART. This illustrates that HIV-positive individuals with mental illness or epilepsy constitute a vulnerable population. HIV programmes should include those with neuropsychiatric illness.
- ItemOpen AccessDetection of tuberculosis in HIV-infected and-uninfected African adults using whole blood RNA expression signatures: a case-control study(Public Library of Science, 2013) Kaforou, Myrsini; Wright, Victoria J; Oni, Tolu; French, Neil; Anderson, Suzanne T; Bangani, Nonzwakazi; Banwell, Claire M; Brent, Andrew J; Crampin, Amelia C; Dockrell, Hazel MBackground: A major impediment to tuberculosis control in Africa is the difficulty in diagnosing active tuberculosis (TB), particularly in the context of HIV infection. We hypothesized that a unique host blood RNA transcriptional signature would distinguish TB from other diseases (OD) in HIV-infected and -uninfected patients, and that this could be the basis of a simple diagnostic test. Methods and Findings: Adult case-control cohorts were established in South Africa and Malawi of HIV-infected or -uninfected individuals consisting of 584 patients with either TB (confirmed by culture of Mycobacterium tuberculosis [M.TB] from sputum or tissue sample in a patient under investigation for TB), OD (i.e., TB was considered in the differential diagnosis but then excluded), or healthy individuals with latent TB infection (LTBI). Individuals were randomized into training (80%) and test (20%) cohorts. Blood transcriptional profiles were assessed and minimal sets of significantly differentially expressed transcripts distinguishing TB from LTBI and OD were identified in the training cohort. A 27 transcript signature distinguished TB from LTBI and a 44 transcript signature distinguished TB from OD. To evaluate our signatures, we used a novel computational method to calculate a disease risk score (DRS) for each patient. The classification based on this score was first evaluated in the test cohort, and then validated in an independent publically available dataset (GSE19491). In our test cohort, the DRS classified TB from LTBI (sensitivity 95%, 95% CI [87–100]; specificity 90%, 95% CI [80–97]) and TB from OD (sensitivity 93%, 95% CI [83–100]; specificity 88%, 95% CI [74–97]). In the independent validation cohort, TB patients were distinguished both from LTBI individuals (sensitivity 95%, 95% CI [85–100]; specificity 94%, 95% CI [84–100]) and OD patients (sensitivity 100%, 95% CI [100–100]; specificity 96%, 95% CI [93–100]). Limitations of our study include the use of only culture confirmed TB patients, and the potential that TB may have been misdiagnosed in a small proportion of OD patients despite the extensive clinical investigation used to assign each patient to their diagnostic group. Conclusions: In our study, blood transcriptional signatures distinguished TB from other conditions prevalent in HIV-infected and -uninfected African adults. Our DRS, based on these signatures, could be developed as a test for TB suitable for use in HIV endemic countries. Further evaluation of the performance of the signatures and DRS in prospective populations of patients with symptoms consistent with TB will be needed to define their clinical value under operational conditions.
- ItemOpen AccessDeveloping, implementing, and monitoring tailored strategies for integrated knowledge translation in five sub-Saharan African countries(BioMed Central, 2023-09-04) Sell, Kerstin; Jessani, Nasreen S.; Mesfin, Firaol; Rehfuess, Eva A.; Rohwer, Anke; Delobelle, Peter; Balugaba, Bonny E.; Schmidt, Bey-Marrié; Kedir, Kiya; Mpando, Talitha; Niyibizi, Jean B.; Osuret, Jimmy; Bayiga-Zziwa, Esther; Kredo, Tamara; Mbeye, Nyanyiwe M.; Pfadenhauer, Lisa M.Background Integrated knowledge translation (IKT) through strategic, continuous engagement with decision-makers represents an approach to bridge research, policy and practice. The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA +), comprising research institutions in Ethiopia, Malawi, Rwanda, South Africa, Uganda and Germany, developed and implemented tailored IKT strategies as part of its multifaceted research on prevention and care of non-communicable diseases and road traffic injuries. The objective of this article is to describe the CEBHA + IKT approach and report on the development, implementation and monitoring of site-specific IKT strategies. Methods We draw on findings derived from the mixed method IKT evaluation (conducted in 2020–2021), and undertook document analyses and a reflective survey among IKT implementers. Quantitative data were analysed descriptively and qualitative data were analysed using content analysis. The authors used the TIDieR checklist to report results in a structured manner. Results Preliminary IKT evaluation data (33 interviews with researchers and stakeholders from policy and practice, and 31 survey responses), 49 documents, and eight responses to the reflective survey informed this article. In each of the five African CEBHA + countries, a site-specific IKT strategy guided IKT implementation, tailored to the respective national context, engagement aims, research tasks, and individuals involved. IKT implementers undertook a variety of IKT activities at varying levels of engagement that targeted a broad range of decision-makers and other stakeholders, particularly during project planning, data interpretation, and output dissemination. Throughout the project, the IKT teams continued to tailor IKT strategies informally and modified the IKT approach by responding to ad hoc engagements and involving non-governmental organisations, universities, and communities. Challenges to using systematic, formalised IKT strategies arose in particular with respect to the demand on time and resources, leading to the modification of monitoring processes. Conclusion Tailoring of the CEBHA + IKT approach led to the inclusion of some atypical IKT partners and to greater responsiveness to unexpected opportunities for decision-maker engagement. Benefits of using systematic IKT strategies included clarity on engagement aims, balancing of existing and new strategic partnerships, and an enhanced understanding of research context, including site-specific structures for evidence-informed decision-making.
- ItemOpen AccessEvaluation of mhGAP training for primary healthcare workers in Mulanje, Malawi: a quasi-experimental and time series study(2020-01-20) Kokota, Demoubly; Lund, Crick; Ahrens, Jennifer; Breuer, Erica; Gilfillan, SheilaAbstract Background There has been a growing global movement championed by the World Health Organization (WHO) to integrate mental health into primary health care as the most effective way of reducing the mental health treatment gap. This study aimed to investigate the impact of WHO Mental Health Gap Action Programme (mhGAP) training and supervision on primary health workers’ knowledge, confidence, attitudes and detection rate of major mental disorders in Mulanje, Malawi. Method The study used a quasi-experimental method (single cohort pre- and post-measures) with an interrupted time-series design. A 2 day mhGAP training was delivered to 43 primary healthcare workers (PHWs) working in 18 primary care clinics serving the entire population of Mulanje, Malawi (population 684,107). Modules covered were psychosis, moderate-severe depression, and alcohol & substance use disorders. The PHWs completed pre and post-tests to assess knowledge, confidence and attitudes. Number of diagnosed cases was obtained from clinic registers for 5 months prior to and 7 months following training. Data was analyzed using mean scores, t-test, one-way analysis of variance and linear regression. Results The mean knowledge score increased significantly from 11.8 (SD: 0.33) before training to 15.1 (SD: 0.38) immediately after training; t (42) = 7.79, p < 0.01. Similarly, mean knowledge score was significantly higher 6 months post training at 13.9 (SD: 2.52) compared to before; t (42) = 4.57, p < 0.01. The mean confidence score also increased significantly from 39.9 (SD: 7.68) before training to 49.6 (SD: 06.14) immediately after training; t (84) = 8.43, p < 0.01. It was also significantly higher 6 months post training 46.8, (SD: 6.03) compared to before; t (84) = 6.60, p < 0.01. One-way analysis of variance showed no significant difference in mean scores on all four components of the scale used to measure attitudes. A significant positive change in the trend in mental health service utilization after the intervention was demonstrated using a segmented linear regression (β = 2.43 (95% CI 1.02; 3.83) as compared to before (β = − 0.22 (95% CI − 2.67; 2.23) and immediately after (β = 1.63 (95% CI − 7.31; 10.57). Conclusion The findings of this study add to the growing evidence for policy makers of the effectiveness of mhGAP training and supervision in a resource-constrained country.
- ItemOpen AccessFinancial System Development and Economic Development in Malawi(2022) Chikafa, Scora; Ndlovu, GodfreyThe financial system development and economic development nexus has been a debate for over a decade. Both theory and empirical evidence provides conflicting evidence on the direction and nature of the relationship between financial system development and economic development. Results vary widely depending on whether one uses bank-based or market-based indicators of financial development. This paper seeks to address by using the composite indicator of financial development, developed by the International Monetary Fund( IMF), which captures depth, access, and efficiency of the financial system. Using yearly data of the period range 1980 to 2019, and employing an Autoregressive Distributed Lag (ARDL) cointegration technique or bound cointegration technique, the paper finds a significant long run negative relationship between financial system development and economic development, which runs from financial system development to economic development of Malawi. Therefore, in order to improve economic development, Malawi has been advised to improve its financial system through easy credit access and boosting its forex market, improve infrastructure and implement financial literacy programs that would teach citizens how best they can utilize resources given to them.
- ItemOpen AccessIncreasing utilisation of perinatal services: estimating the impact of community health worker program in Neno, Malawi(2020-01-06) Kachimanga, Chiyembekezo; Dunbar, Elizabeth L; Watson, Samuel; Cundale, Katie; Makungwa, Henry; Wroe, Emily B; Malindi, Charles; Nazimera, Lawrence; Palazuelos, Daniel; Drake, Jeanel; Gates, Thomas; van den Akker, Thomas; Shea, JawayaAbstract Background By 2015, Malawi had not achieved Millennium Development Goal 4, reducing maternal mortality by about 35% from 675 to 439 deaths per 100,000 livebirths. Hypothesised reasons included low uptake of antenatal care (ANC), intrapartum care, and postnatal care. Involving community health workers (CHWs) in identification of pregnant women and linking them to perinatal services is a key strategy to reinforce uptake of perinatal care in Neno, Malawi. We evaluated changes in uptake after deployment of CHWs between March 2014 and June 2016. Methods A CHW intervention was implemented in Neno District, Malawi in a designated catchment area of about 3100 women of childbearing age. The pre-intervention period was March 2014 to February 2015, and the post-intervention period was March 2015 to June 2016. A 5-day maternal health training package was delivered to 211 paid and supervised CHWs. CHWs were deployed to identify pregnant women and escort them to perinatal care visits. A synthetic control method, in which a “counterfactual site” was created from six available control facilities in Neno District, was used to evaluate the intervention. Outcomes of interest included uptake of first-time ANC, ANC within the first trimester, four or more ANC visits, intrapartum care, and postnatal care follow-up. Results Women enrolled in ANC increased by 18% (95% Credible Interval (CrI): 8, 29%) from an average of 83 to 98 per month, the proportion of pregnant women starting ANC in the first trimester increased by 200% (95% CrI: 162, 234%) from 10 to 29% per month, the proportion of women completing four or more ANC visits increased by 37% (95% CrI: 31, 43%) from 28 to 39%, and monthly utilisation of intrapartum care increased by 20% (95% CrI: 13, 28%) from 85 to 102 women per month. There was little evidence that the CHW intervention changed utilisation of postnatal care (− 37, 95% CrI: − 224, 170%). Conclusions In a rural district in Malawi, uptake of ANC and intrapartum care increased considerably following an intervention using CHWs to identify pregnant women and link them to care.
- ItemOpen AccessIs it ethical to prevent secondary use of stored biological samples and data derived from consenting research participants? The case of Malawi(2015) Mungwira, Randy G; Nyangulu, Wongani; Misiri, James; Iphani, Steven; Ng’ong’ola, Ruby; Chirambo, Chawanangwa M; Masiye, Francis; Mfutso-Bengo, JosephBackgroundThis paper discusses the contentious issue of reuse of stored biological samples and data obtained from research participants in past clinical research to answer future ethical and scientifically valid research questions. Many countries have regulations and guidelines that guide the use and exportation of stored biological samples and data. However, there are variations in regulations and guidelines governing the reuse of stored biological samples and data in Sub-Saharan Africa including Malawi.DiscussionThe current research ethics regulations and guidelines in Malawi do not allow indefinite storage and reuse of biological samples and data for future unspecified research. This comes even though the country has managed to answer pertinent research questions using stored biological samples and data. We acknowledge the limited technical expertise and equipment unavailable in Malawi that necessitates exportation of biological samples and data and the genuine concern raised by the regulatory authorities about the possible exploitation of biological samples and data by researchers. We also acknowledge that Malawi does not have bio-banks for storing biological samples and data for future research purposes. This creates room for possible exploitation of biological samples and data collected from research participants in primary research projects in Malawi. However, research ethics committees require completion and approval of material transfer agreements and data transfer agreements for biological samples and data collected for research purposes respectively and this requirement may partly address the concern raised by the regulatory authorities. Our concern though is that there is no such requirement for biological samples and data collected from patients for clinical or diagnostic purposes.SummaryIn conclusion, we propose developing a medical data and material transfer agreement for biological samples and data collected from patients for clinical or diagnostic purposes in both public and private health facilities that may end up in research centers outside Malawi. We also propose revision of the current research ethics regulations and guidelines in Malawi in order to allow secondary use of biological samples and data collected from primary research projects as a way of maximizing the use of collected samples and data. Finally, we call for consultation of all stakeholders within the Malawi research community when regulatory authorities are developing policies that govern research in Malawi.
- ItemOpen AccessKeeping health staff healthy: evaluation of a workplace initiative to reduce morbidity and mortality from HIV/AIDS in Malawi(BioMed Central Ltd, 2011) Bemelmans, Marielle; van den Akker, Thomas; Pasulani, Olesi; Tayub, Nabila; Hermann, Katharina; Mwagomba, Beatrice; Jalasi, Winnie; Chiomba, Harriet; Ford, Nathan; Philips, MitBACKGROUND: In Malawi, the dramatic shortage of human resources for health is negatively impacted by HIV-related morbidity and mortality among health workers and their relatives. Many staff find it difficult to access HIV care through regular channels due to fear of stigma and discrimination. In 2006, two workplace initiatives were implemented in Thyolo District: a clinic at the district hospital dedicated to all district health staff and their first-degree relatives, providing medical services, including HIV care; and a support group for HIV-positive staff. METHODS: Using routine programme data, we evaluated the following outcomes up to the end of 2009: uptake and outcome of HIV testing and counselling among health staff and their dependents; uptake and outcomes of antiretroviral therapy (ART) among health staff; and membership and activities of the support group. In addition, we included information from staff interviews and a job satisfaction survey to describe health workers' opinions of the initiatives. RESULTS: Almost two-thirds (91 of 144, 63%) of health workers and their dependents undergoing HIV testing and counselling at the staff clinic tested HIV positive. Sixty-four health workers had accessed ART through the staff clinic, approximately the number of health workers estimated to be in need of ART. Of these, 60 had joined the support group. Cumulative ART outcomes were satisfactory, with more than 90% alive on treatment as of June 2009 (the end of the study observation period). The availability, confidentiality and quality of care in the staff clinic were considered adequate by beneficiaries. CONCLUSIONS: Staff clinic and support group services successfully provided care and support to HIV-positive health workers. Similar initiatives should be considered in other settings with a high HIV prevalence.
- ItemOpen AccessMalawi Farm Input Subsidy Programme - impact on income of smallholder farmers(2015) Musonzo, Charity Priscilla; Biekpe, Nicholas; Standish, BarryAgriculture is the single most important sector in Malawi due to its contribution to the economy ranging from employment creation, contribution to GDP growth to source of foreign exchange earnings. These significant contributions have necessitated the Government of Malawi to develop strategies and policies such as the Farm Input Subsidy Programme (FISP), whose main aim is to increase household incomes and reduce food insecurity and ultimately reduce poverty. It is nine years since the introduction of FISP but its results remain mixed. Using the 2009/10 Integrated Household Survey Phase 3 (IHS3) dataset, a logistic regression in a multivariate data analysis approach was used to investigate the impact of FISP on income levels and food security of rural smallholder farmers in Malawi. The analysis showed that about 82 percent of smallholder farmers live in rural areas, about 75 percent of them were males, 71 percent were married, 70 percent did not go to school and 69 percent benefited from FISP. In farming, 68 percent of these smallholder farmers had less than 1 hectare of farms, 70 percent of them had labour force of less than 5 people, 51 percent of them harvest less than 5 bags of 50kgs of maize of which 92 percent sell most of their harvested maize and 89 percent of them receive less than MK5, 000 from sales. In addition, about 99 percent of these smallholder farmers were food insecure as they save less than 1 bag of 50kgs after harvest. Only 1 percent of these smallholder farmers receive remittances and 21 percent had other income generating activities (IGAs). Demographic and socio-economic factors have no impact on these farmers capability to increase income levels and enhance their food security. There is also no statistically significant difference between FISP beneficiaries and non-beneficiaries in terms of capabilities of increasing incomes and enhancing food security. It is, therefore, concluded that FISP had no significant impact on the abilities of these smallholder farmers to increase their incomes and enhancing their food security. Hence, FISP did not prove to be the best food security and poverty alleviation tool in Malawi.
- ItemOpen AccessOn Marriage Dynamics and Fertility in Malawi: How Does Remarriage Affect Fertility Preferences and Childbearing Behaviour?(2018) John, Benson; Adjiwanou, VisséhoThe interplay between remarriage and fertility is among the most poorly documented subjects in sub-Saharan Africa, yet remarriage is one of the fundamental aspects of marriage dynamics in the region. Referring to classical demographic and statistical techniques, this research uses data collected since 1992 from Malawi Demographic and Health Surveys to establish the pattern and level of union dissolution and remarriage, and to assess the influence of remarriage on fertility preference and childbearing. The results reveal increasing stability of unions over time and a declining proportion of remarried women. The probability of experiencing first union dissolution within 15 years dropped from 45.9 to 40.0 per cent between 1992 and 2015, while the comparable likelihood of remarriage decreased from 36.1 to 27.7 per cent over the same interval duration. The effect of remarriage on the desire for more children is positive at advanced interval durations relative to the onset of first marriage. At shorter interval periods, where remarriage is relatively most recent, remarriage inhibits the desire for additional children. For example, in 2015, among women who first married 15-19 years before the survey, the odds of desiring another child were 4 per cent significantly higher among remarried women relative to their counterparts in intact unions. In contrast, for women who were married for 0-5 years, remarried women had 3 per cent lower olds of desiring another child. Furthermore, the childbearing pattern of remarried women is found to be distinct from that of women in intact unions. Remarried women give birth to more children sooner than their counterparts in intact unions, but eventually end up with fewer children. Indeed, the results show that in 2015, women in intact unions had 0.4 more children on average than their remarried counterparts. However, the difference in complete family size is steadily diminishing (difference of 1.5 in 2000), largely due to more marked fertility decline among women in intact unions. This trend, together with the long-term pattern of cumulated fertility differentials at younger reproductive ages, and current fertility disparities over the past two decades, strongly reveals that a new regime, where remarried women will end up with higher complete family size than those in intact unions, is emerging.
- ItemOpen AccessProteinuric kidney disease in children at Queen Elizabeth Central Hospital, Malawi(BioMed Central, 2018-01-31) Mwanza, Zondiwe V; McCulloch, Mignon; Drayson, Mark; Plant, Timothy; Milford, David V; Dreyer, GavinBackground: There is a paucity of data on paediatric kidney disease in developing countries such as Malawi. Descriptive research on kidney disease is essential to improving patient outcomes. Methods: We conducted a cross-sectional study at a tertiary hospital in Malawi from 2012 to 2013. Children under 14 years with proteinuric kidney disease were enrolled from paediatric wards and outpatient clinics at Queen Elizabeth Central Hospital (QECH). Demographic, clinical and laboratory data were collected from patients at enrolment and at 3 months review at which point clinical status and disease outcome were ascertained. Results: Thirty-four (22 male) patients were studied, mean age 8.54 (SD = 3.62 years). Glomerular disease (n = 25, 68%) was the most common presumed renal lesion at presentation. Nephritic syndrome (10) was characterised by a lower baseline complement C3 than nephrotic syndrome (p = 0.0027). Seven (47%) cases of nephrotic syndrome achieved complete remission. Eight (80%) cases of nephritic syndrome improved with supportive therapy. Nineteen (56%) patients presented with clinically significant renal damage with eGFR< 60 ml/min/1.73m2 . Six patients presented in chronic kidney disease (CKD) stage 5 of unclear aetiology, five (83%) died. Three (9%) patients had impaired kidney function and obstructive uropathy demonstrated on ultrasound, two recovered after surgery and one died. Eight (24%) patients had acute kidney injury (AKI) due to primary kidney disease, three of these patients progressed to CKD stage G3a. Seven (21%) patients were lost to follow up. Conclusion: Kidney disease is a significant cause of mortality and morbidity in children at QECH. Less than half of Nephrotic syndrome cases achieved complete remission. Mortality is highest in children with CKD of unclear cause. Some patients with AKI secondary to primary renal disease progressed to CKD. Understanding the aetiology of paediatric kidney disease and improving patient outcomes by developing enhanced diagnostic and clinical services are priorities at QECH and within Malawi.
- ItemOpen AccessRapid urine-based screening for tuberculosis to reduce AIDS-related mortality in hospitalized patients in Africa (the STAMP trial): study protocol for a randomised controlled trial(2016) Gupta-Wright, Ankur; Fielding, Katherine L; van Oosterhout, Joep J; Wilson, Douglas K; Corbett, Elizabeth L; Flach, Clare; Reddy, Krishna P; Walensky, Rochelle P; Peters, Jurgens A; Alufandika-Moyo, Melanie; Lawn, Stephen DAbstract Background HIV-associated tuberculosis (TB) co-infection remains an enormous burden to international public health. Post-mortem studies have highlighted the high proportion of HIV-positive adults admitted to hospital with TB. Determine TB-LAM and Xpert MTB/RIF assays can substantially increase diagnostic yield of TB within one day of hospital admission. However, it remains unclear if this approach can impact clinical outcomes. The STAMP trial aims to test the hypothesis that the implementation a urine-based screening strategy for TB can reduce all cause-mortality among HIV-positive patients admitted to hospital when compared to current, sputum-based screening. Methods The trial is a pragmatic, individually randomised, multi-country (Malawi and South Africa) clinical trial with two study arms (1:1 recruitment). Unselected HIV-positive patients admitted to medical wards, irrespective of presentation, meeting the inclusion criteria and giving consent will be randomized to screening for TB using either: (i) ‘standard of care’- testing of sputum using the Xpert MTB/RIF assay (Xpert) or (ii) ‘intervention’- testing of sputum using Xpert and testing of urine using (a) Determine TB-LAM lateral-flow assay and (b) Xpert following concentration of urine by centrifugation. Patients will be excluded if they have received TB treatment in the previous 12 months, if they have received isoniazid preventive therapy in the last 6 months, if they are aged <18 years or they live outside the pre-specified geographical area. Results will be provided to the responsible medical team as soon as available to inform decisions regarding TB treatment. Both the study and routine medical team will be masked to study arm allocation. 1300 patients will be enrolled per arm (equal numbers at the two trial sites). The primary endpoint is all-cause mortality at 56 days. An economic analysis will be conducted to project long-term outcomes for shorter-term trial data, including cost-effectiveness. Discussion This pragmatic trial assesses an intervention to reduce the high mortality caused by HIV-associated TB, which could feasibly be scaled up in high-burden settings if shown to be efficacious and cost-effective. We discuss the challenges of designing a trial to assess the impact on mortality of laboratory-based TB screening interventions given frequent initiation of empirical treatment and a failure of several previous clinical trials to demonstrate an impact on clinical outcomes. We also elaborate on the practical and ethical issues of ‘testing a test’ in general. Trial registration ISRCTN Registry (ISRCTN71603869) prospectively registered 08 May 2015; the South African National Controlled Trials Registry (DOH-27-1015-5185) prospectively registered October 2015.
- ItemOpen AccessSkills of general health workers in primary eye care in Kenya, Malawi and Tanzania(BioMed Central Ltd, 2014) Kalua, Khumbo; Gichangi, Michael; Barassa, Ernest; Eliah, Edson; Lewallen, Susan; Courtright, PaulBACKGROUND:Primary eye care (PEC) in sub-Saharan Africa usually means the diagnosis, treatment, and referral of eye conditions at the most basic level of the health system by primary health care workers (PHCWs), who receive minimal training in eye care as part of their curricula. We undertook this study with the aim to evaluate basic PEC knowledge and ophthalmologic skills of PHCWs, as well as the factors associated with these in selected districts in Kenya, Malawi, and Tanzania. METHODS: A standardized (26 items) questionnaire was administered to PHCWs in all primary health care (PHC) facilities of 2 districts in each country. Demographic information was collected and an examination aimed to measure competency in 5 key areas (recognition and management of advanced cataract, conjunctivitis, presbyopia, and severe trauma plus demonstrated ability to measure visual acuity) was administered. RESULTS: Three-hundred-forty-three PHCWs were enrolled (100, 107, and 136 in Tanzania, Kenya, and Malawi, respectively). The competency scores of PHCW varied by area, with 55.7%, 61.2%, 31.2%, and 66.1% scoring at the competency level in advanced cataract, conjunctivitis, presbyopia, and trauma, respectively. Only 8.2% could measure visual acuity. Combining all scores, only 9 (2.6%) demonstrated competence in all areas. CONCLUSION: The current skills of health workers in PEC are low, with a large per cent below the basic competency level. There is an urgent need to reconsider the expectations of PEC and the content of training.
- ItemOpen AccessSupervised and unsupervised self-testing for HIV in high-and low-risk populations: a systematic review(Public Library of Science, 2013) Pai, Nitika Pant; Sharma, Jigyasa; Shivkumar, Sushmita; Pillay, Sabrina; Vadnais, Caroline; Joseph, Lawrence; Dheda, Keertan; Peeling, Rosanna WBackground: Stigma, discrimination, lack of privacy, and long waiting times partly explain why six out of ten individuals living with HIV do not access facility-based testing. By circumventing these barriers, self-testing offers potential for more people to know their sero-status. Recent approval of an in-home HIV self-test in the US has sparked self-testing initiatives, yet data on acceptability, feasibility, and linkages to care are limited. We systematically reviewed evidence on supervised (self-testing and counselling aided by a health care professional) and unsupervised (performed by self-tester with access to phone/internet counselling) self-testing strategies. Methods and Findings: Seven databases (Medline [via PubMed], Biosis, PsycINFO, Cinahl, African Medicus, LILACS, and EMBASE) and conference abstracts of six major HIV/sexually transmitted infections conferences were searched from 1st January 2000–30th October 2012. 1,221 citations were identified and 21 studies included for review. Seven studies evaluated an unsupervised strategy and 14 evaluated a supervised strategy. For both strategies, data on acceptability (range: 74%–96%), preference (range: 61%–91%), and partner self-testing (range: 80%–97%) were high. A high specificity (range: 99.8%–100%) was observed for both strategies, while a lower sensitivity was reported in the unsupervised (range: 92.9%–100%; one study) versus supervised (range: 97.4%–97.9%; three studies) strategy. Regarding feasibility of linkage to counselling and care, 96% (n = 102/106) of individuals testing positive for HIV stated they would seek post-test counselling (unsupervised strategy, one study). No extreme adverse events were noted. The majority of data (n = 11,019/12,402 individuals, 89%) were from high-income settings and 71% (n = 15/21) of studies were cross-sectional in design, thus limiting our analysis. Conclusions: Both supervised and unsupervised testing strategies were highly acceptable, preferred, and more likely to result in partner self-testing. However, no studies evaluated post-test linkage with counselling and treatment outcomes and reporting quality was poor. Thus, controlled trials of high quality from diverse settings are warranted to confirm and extend these findings.
- ItemOpen AccessTask shifting for cataract surgery in eastern Africa: productivity and attrition of non-physician cataract surgeons in Kenya, Malawi and Tanzania(BioMed Central Ltd, 2014) Eliah, Edson; Lewallen, Susan; Kalua, Khumbo; Courtright, Paul; Gichangi, Michael; Bassett, KenBACKGROUND:This project examined the surgical productivity and attrition of non-physician cataract surgeons (NPCSs) in Tanzania, Malawi, and Kenya. METHODS: Baseline (2008-9) data on training, support, and productivity (annual cataract surgery rate) were collected from officially trained NPCSs using mailed questionnaires followed by telephone interviews. Telephone interviews were used to collect follow-up data annually on productivity and semi-annually on attrition. A detailed telephone interview was conducted if a surgeon left his/her post. Data were entered into and analysed using STATA. RESULTS: Among the 135 NPCSs, 129 were enrolled in the study (Kenya 88, Tanzania 38, and Malawi 3) mean age 42 years; average time since completing training 6.6 years. Employment was in District 44%, Regional 24% or mission/ private 32% hospitals. Small incision cataract surgery was practiced by 38% of the NPCSs. The mean cataract surgery rate was 188/year, median 76 (range 0-1700). For 39 (31%) NPCSs their surgical rate was more than 200/year. Approximately 22% in Kenya and 25% in Tanzania had years where the cataract surgical rate was zero. About 11% of the surgeons had no support staff.Factors significantly associated with increased productivity were: 1) located at a regional or private/mission hospital compared to a district hospital (OR = 8.26; 95 % CI 2.89 - 23.81); 2) 3 or more nurses in the eye unit (OR = 8.69; 95% CI 3.27-23.15); 3) 3 or more cataract surgical sets (OR = 3.26; 95% CI 1.48-7.16); 4) a separate eye theatre (OR = 5.41; 95% CI 2.15-13.65); 5) a surgical outreach program (OR = 4.44; 95% CI 1.88-10.52); and 6) providing transport for patients to hospital (OR = 6.39; 95% CI 2.62-15.59). The associations were similar for baseline and follow-up assessments. Attrition during the 3 years occurred in 13 surgeons (10.3%) and was due to retirement or promotion to administration. CONCLUSIONS: High quality training is necessary but not sufficient to result in cataract surgical activity that meets population needs and maintains surgical skill. Needed are supporting institutions and staff, functioning equipment and programs to recruit and transport patients.
- ItemOpen AccessTreatment-seeking for tuberculosis-suggestive symptoms: a reflection on the role of human agency in the context of universal health coverage in Malawi(Public Library of Science, 2016) Kumwenda, Moses; Desmond, Nicola; Hart, Graham; Choko, Augustine; Chipungu, Geoffrey A; Nyirenda, Deborah; Shand, Tim; Corbett, Elizabeth L; Chikovore, JeremiahTuberculosis (TB) is highly infectious and one of the leading killers globally. Several studies from sub-Saharan Africa highlight health systems challenges that affect ability to cope with existing disease burden, including TB, although most of these employ survey-type approaches. Consequently, few address community or patient perspectives and experiences. At the same time, understanding of the mechanisms by which the health systems challenges translate into seeking or avoidance of formal health care remains limited. This paper applies the notion of human agency to examine the ways people who have symptoms suggestive of TB respond to and deal with the symptoms vis-à-vis major challenges inherent within health delivery systems. Empirical data were drawn from a qualitative study exploring the ways in which notions of masculinity affect engagement with care, including men's well-documented tendency to delay in seeking care for TB symptoms. The study was carried out in three high-density locales of urban Blantyre, Malawi. Data were collected in March 2011 -March 2012 using focus group discussions, of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers; and in-depth interviews with 20 TB patients (female = 14) and 20 un-investigated chronic coughers (female = eight). The research process employed a modified version of grounded theory. Data were coded using a coding scheme that was initially generated from the study aims and subsequently progressively amended to incorporate concepts emerging during the analysis. Coded data were retrieved, re-read, and broken down and reconnected iteratively to generate themes. A myriad of problems were described for health systems at the primary health care level, centring largely on shortages of resources (human, equipment, and drugs) and unprofessional conduct by health care providers. Participants consistently pointed out how the problems could drive patients from promptly reporting symptoms at primary healthcare centres. The accounts suggest that in responding to illness symptoms including those suggestive of TB, patients navigate their options taking into cognisance past and current experiences with formal health systems. Understanding and factoring in the mediating role of such 'agency' is critical when implementing efforts to promote timely response to TB-suggestive symptoms.