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Paliani, Grace. "2. Communication and community services: Malawi Red Cross Society: Communication to promote community services." International Review of the Red Cross 30, no. 276 (June 1990): 216–19. http://dx.doi.org/10.1017/s0020860400075562.
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The topic “Communication to promote community services” sounds simple, but it is vital because it points to the contribution that any health-oriented institution should make towards the general success of its undertakings.On closer examination it will be seen that one basic communication task, which, however, involves a number of sub-tasks all geared towards achieving the same objectives, is the promotion of community services through publicity.
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Angwenyi, Vibian, Carolien Aantjes, Ketwin Kondowe, Joseph Zulu Mutchiyeni, Murphy Kajumi, Bart Criel, Jeffrey V. Lazarus, Tim Quinlan, and Joske Bunders-Aelen. "Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi." BMJ Global Health 3, Suppl 3 (November 2018): e000996. http://dx.doi.org/10.1136/bmjgh-2018-000996.
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Since the Alma Ata Declaration in 1978, community health volunteers (CHVs) have been at the forefront, providing health services, especially to underserved communities, in low-income countries. However, consolidation of CHVs position within formal health systems has proved to be complex and continues to challenge countries, as they devise strategies to strengthen primary healthcare. Malawi’s community health strategy, launched in 2017, is a novel attempt to harmonise the multiple health service structures at the community level and strengthen service delivery through a team-based approach. The core community health team (CHT) consists of health surveillance assistants (HSAs), clinicians, environmental health officers and CHVs. This paper reviews Malawi’s strategy, with particular focus on the interface between HSAs, volunteers in community-based programmes and the community health team. Our analysis identified key challenges that may impede the strategy’s implementation: (1) inadequate training, imbalance of skill sets within CHTs and unclear job descriptions for CHVs; (2) proposed community-level interventions require expansion of pre-existing roles for most CHT members; and (3) district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is needed on the appropriate forms of CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload, strengthening coordination and communication across all community actors, and financing mechanisms. Policy support through the development of an addendum to the strategy, outlining opportunities for task-shifting between CHT members, CHVs’ expected duties and interactions with paid CHT personnel is recommended.
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Cooper, Chelsea M., Jacqueline Wille, Steven Shire, Sheila Makoko, Asnakew Tsega, Anne Schuster, Hannah Hausi, Hannah Gibson, and Hannah Tappis. "Integrated Family Planning and Immunization Service Delivery at Health Facility and Community Sites in Dowa and Ntchisi Districts of Malawi: A Mixed Methods Process Evaluation." International Journal of Environmental Research and Public Health 17, no. 12 (June 24, 2020): 4530. http://dx.doi.org/10.3390/ijerph17124530.
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The Government of Malawi’s Health Sector Strategic Plan II highlights the importance of service integration; however, in practice, this has not been fully realized. We conducted a mixed methods evaluation of efforts to systematically implement integrated family planning and immunization services in all health facilities and associated community sites in Ntchisi and Dowa districts during June 2016–September 2017. Methods included secondary analysis of service statistics (pre- and postintervention), focus group discussions with mothers and fathers of children under age one, and in-depth interviews with service providers, supervisors, and managers. Results indicate statistically significant increases in family planning users and shifts in use of family planning services from health facilities to community sites. The intervention had no effect on immunization doses administered or dropout rates. According to mothers and fathers, benefits of service integration included time savings, convenience, and improved understanding of services. Provision and use of integrated services were affected by availability of human resources and commodities, community linkages, data collection procedures and availability, sociocultural barriers, organization of services, and supervision and commitment of health surveillance assistants. The integration approach was perceived to be feasible and beneficial by clients and providers.
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Batura, Rekha, and Tim Colbourn. "A stitch in time: narrative review of interventions to reduce preterm births in Malawi." International Health 12, no. 3 (December 23, 2019): 213–21. http://dx.doi.org/10.1093/inthealth/ihz101.
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Abstract Background The rising rate of preterm births (PTBs) is a global concern, and Malawi has a high rate of PTBs (10.5%). The resulting neonatal and under-5 mortality, morbidity and lifelong disability represent a significant loss of human potential affecting individuals, families and society as a whole. This study aims to review the literature to determine the risk factors for PTB in Malawi and to identify effective interventions to prevent PTBs. Methods A literature search yielded 22 studies that were categorized according to risk factors implicated for PTBs and health interventions to reduce the risks. Results The study has shown that maternal pregnancy factors, infections, nutrition, anaemia and young maternal age are the main causes and risk factors of PTBs in Malawi. The literature revealed no evidence of community-based interventions for reducing the rates of PTBs in Malawi. Conclusions Any successful effort to reduce the rate of PTBs will require a multisector, multilevel strategy targeted at the community, homes and individuals as a package to improve the education, nutrition and reproductive health of girls and women as well as focus on improving the delivery of antenatal services in the community.
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Chinguwo, Felix, and Alinane Linda Nyondo-Mipando. "Integration of Early Infant Diagnosis of HIV Services Into Village Health Clinics in Ntcheu, Malawi: An Exploratory Qualitative Study." Journal of the International Association of Providers of AIDS Care (JIAPAC) 20 (January 1, 2021): 232595822098125. http://dx.doi.org/10.1177/2325958220981256.
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Integration of Early Infant Diagnosis(EID) of HIV into Village Health Clinics (VHCs) would increase the uptake of services. This study assessed mothers and health care workers’ acceptability of integration of EID of HIV services into VHCs in Ntcheu, Malawi. We conducted an exploratory qualitative study in the phenomenological tradition among 20 mothers of either HIV exposed or non-exposed infants and 18 health care workers (HCWs) from February to July 2019. We analyzed the data using a thematic approach and guided by the theoretical framework for acceptability. There were positive perceptions of the integration of services. Acceptability is influenced by attitudes, perceived burden, intervention coherent services, and perceived effectiveness of services. The successful integration of EID of HIV into VHCs requires strengthening of the health system and community awareness. Efforts to mitigate stigma should be prioritized when integrating the services to optimize uptake of the services at a community level.
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Kachimanga, C., C. Malindi, G. Limbe, E. B. Wroe, H. Makungwa, I. Musisi, E. Dunbar, J. Ng’ambi, L. Nazimera, and J. Drake. "Using Community Health (CHWs) to increase access to maternal health services–preliminary findings from Neno, Malawi." Annals of Global Health 82, no. 3 (August 20, 2016): 392. http://dx.doi.org/10.1016/j.aogh.2016.04.641.
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Talama, George C., Mairead Shaw, Jordan Maloya, Tafwirapo Chihana, Lawrence Nazimera, Emily B. Wroe, and Chiyembekezo Kachimanga. "Improving uptake of cervical cancer screening services for women living with HIV and attending chronic care services in rural Malawi." BMJ Open Quality 9, no. 3 (September 2020): e000892. http://dx.doi.org/10.1136/bmjoq-2019-000892.
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Malawi has the second highest age-standardised incidence rate and the highest mortality rate of cervical cancer in the world. Though the prevalence of HIV is currently 11.7% for Malawian women of reproductive age, cervical cancer screening rates remain low. To address this issue, we integrated cervical cancer screening into a dual HIV and non-communicable disease clinic at a rural district hospital in Neno, Malawi. The project was implemented between January 2017 and March 2018 using the Plan-Do-Study-Act model of quality improvement (QI). At baseline (January to December 2016), only 13 women living with HIV were screened for cervical cancer. One year after implementation of the QI project, 73% (n=547) of women aged 25 to 49 years living with HIV enrolled in HIV care were screened for cervical cancer, with 85.3% of these receiving the screening test for the first time. The number of women living with HIV accessing cervical cancer services increased almost 10 times (from four per month to 39 per month, p<0.001). Key enablers in our QI process included: strong mentorship, regular provision of cervical cancer health talks throughout the hospital, nationally accredited cervical cancer prevention training for all providers, consistent community engagement, continuous monitoring and evaluation, and direct provision of resources to strengthen gaps in the public system. This practical experience integrating cervical cancer screening into routine HIV care may provide valuable lessons for scale-up in rural Malawi.
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Chimbatata, Nathan B. W., and Chikondi M. Chimbatata. "Impact Evaluation Design for Community Midwife Technicians in Malawi." European Scientific Journal, ESJ 12, no. 27 (September 30, 2016): 349. http://dx.doi.org/10.19044/esj.2016.v12n27p349.
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Maternal Mortality Ratio and neonatal mortality rate are alarmingly high in Malawi. The shortage and poor retention of midwives coupled with poor working conditions have been a major challenge affecting the provision of high-quality maternity care for women. Many women are giving birth without skilled attendants, increasing the risk of maternal and neonatal illness and death. The major driving factor in the shortage of health staff is the limited number of existing training slots and hence the minimum output from the training institutions into service delivery units. Midwifery is a key component of sexual, reproductive, maternal, and newborn healthcare. Responding to the crisis, the Malawi Government has made a commitment in strengthening human resources for health, including accelerating training and recruitment of health professionals to fill all the shortage gaps in the health sector. One mechanism implemented by Malawi Government to increase skilled attendance at birth in rural areas is the introduction of Community midwifery assistants (CMA) training. This program of training community midwives is being piloted and targets the general population of pregnant women and their new born babies in rural areas where the CMAs are deployed. However, there is a great need to have this initiative evaluated and gauge its impact in attaining the desired outcomes.
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Besada, Donela, Ameena Goga, Emmanuelle Daviaud, Sarah Rohde, Jacqueline Rose Chinkonde, Susie Villeneuve, Guy Clarysse, et al. "Roles played by community cadres to support retention in PMTCT Option B+ in four African countries: a qualitative rapid appraisal." BMJ Open 8, no. 3 (March 2018): e020754. http://dx.doi.org/10.1136/bmjopen-2017-020754.
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ObjectivesTo explore the roles of community cadres in improving access to and retention in care for PMTCT (prevent mother-to-child transmission of HIV) services in the context of PMTCT Option B+ treatment scale-up in high burden low-income and lower-middle income countries.Design/MethodsQualitative rapid appraisal study design using semistructured in-depth interviews and focus group discussions (FGDs) between 8 June and 31 July 2015.Setting and participantsInterviews were conducted in the offices of Ministry of Health Staff, Implementing partners, district offices and health facility sites across four low-income and lower-middle income countries: Cote D’Ivoire, Democratic Republic of Congo (DRC), Malawi and Uganda. A range of individual interviews and FGDs with key stakeholders including Ministry of Health employees, Implementation partners, district management teams, facility-based health workers and community cadres. A total number of 18, 28, 31 and 83 individual interviews were conducted in Malawi, Cote d’Ivoire, DRC and Uganda, respectively. A total number of 15, 9, 10 and 16 mixed gender FGDs were undertaken in Malawi, Cote d’Ivoire, DRC and Uganda, respectively.ResultsCommunity cadres either operated solely in the community, worked from health centres or in combination and their mandates were PMTCT-specific or included general HIV support and other health issues. Community cadres included volunteers, those supported by implementing partners or employed directly by the Ministry of Health. Their complimentary roles along the continuum of HIV care and treatment include demand creation, household mapping of pregnant and lactating women, linkage to care, infant follow-up and adherence and retention support.ConclusionsCommunity cadres provide an integral link between communities and health facilities, supporting overstretched health workers in HIV client support and follow-up. However, their role in health systems is neither standardised nor systematic and there is an urgent need to invest in the standardisation of and support to community cadres to maximise potential health impacts.
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Wroe, Emily B., Elizabeth L. Dunbar, Noel Kalanga, Luckson Dullie, Chiyembekezo Kachimanga, Andrew Mganga, Michael Herce, et al. "Delivering comprehensive HIV services across the HIV care continuum: a comparative analysis of survival and progress towards 90-90-90 in rural Malawi." BMJ Global Health 3, no. 1 (January 2018): e000552. http://dx.doi.org/10.1136/bmjgh-2017-000552.
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IntroductionPartners In Health and the Malawi Ministry of Health collaborate on comprehensive HIV services in Neno, Malawi, featuring community health workers, interventions addressing social determinants of health and health systems strengthening. We conducted an observational study to describe the HIV care continuum in Neno and to compare facility-level HIV outcomes against health facilities nationally.MethodsWe compared facility-level outcomes in Neno (n=13) with all other districts (n=682) from 2013 to 2015 using mixed-effects linear regression modelling. We selected four outcomes that are practically useful and roughly mapped on to the 90-90-90 targets: facility-based HIV screenings relative to population, new antiretroviral therapy (ART)enrolments relative to population, 1-year survival rates and per cent retained in care at 1 year.ResultsIn 2013, the average number of HIV tests performed, as a per cent of the adult population, was 11.75%, while the average newly enrolled patients was 10.03%. Percent receiving testing increased by 4.23% over 3 years (P<0.001, 95% CI 2.98% to 5.49%), while percent enrolled did not change (P=0.28). These results did not differ between Neno and other districts (P=0.52), despite Neno having a higher proportion of expected patients enrolled. In 2013, the average ART 1-year survival was 80.41% nationally and 91.51% in Neno, which is 11.10% higher (P=0.002, 95% CI 4.13% to 18.07%). One-year survival declined by 1.75% from 2013 to 2015 (P<0.001, 95% CI −2.61% to −0.89%); this was similar in Neno (P=0.83). Facility-level 1-year retention was 85.43% nationally in 2013 (P<0.001, 95% CI 84.2% to 86.62%) and 12.07% higher at 97.50% in Neno (P=0.001, 95% CI 5.08% to19.05%). Retention declined by 2.92% (P<0.001, 95% CI −3.69% to −2.14%) between 2013 and 2015, both nationally and in Neno.ConclusionThe Neno HIV programme demonstrated significantly higher survival and retention rates compared with all other districts in Malawi. Incorporating community health workers, strengthening health systems and addressing social determinants of health within the HIV programme may help Malawi and other countries accelerate progress towards 90-90-90.
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Machira, Kennedy, Beston Maonga, and Tobias Chirwa. "Determinants of Risky Sexual Behavioral Practices among Teen-girls in Malawi." Open Public Health Journal 13, no. 1 (December 31, 2020): 839–49. http://dx.doi.org/10.2174/1874944502013010839.
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Background: In Malawi, having multiple sexual partners and engaging in sexual intercourse without using condoms remain a sexual and reproductive health challenge among women. This has consequently increased morbidity and low productivity among women, especially in young women of the country. This paper examined the determinants of risky sexual behavioral practices among teen women in Malawi. Methods: The study used 2015-16 Malawi Demographic Health Survey with a weighted sample of 5263 women under 20 years. Both Bivariate and multivariate statistical analyses were used to estimate factors influencing risky sexual behavioral practices among teen women. Results: The study found the existence of differential determinants to influence women’s conduct in having both multiple sexual partners and inability to use condom during subsequent sexual intercourses with partners other than spouses. For instance, education (complete primary, IRR=2.755, p<0.001 and complete secondary education, IRR=3.515, p< 0.001); teen motherhood status (IRR = 0.295, p< 0.001), unavailability of the health care services (IRR=1.043, p<0.05) among others positively determined having multiple sexual partners in Malawi among teen women. On the contrary, wealth status (medium, IRR=1.116, p<0.001; rich, IRR=1.194, p<0.001) reduced teen women’s behavior of not using a condom with partners other than spouses during sexual intercourse. Conclusion: The study asserts that in Malawi, there is an urgent need for advocacy programmes aimed at reducing sexual and reproductive health challenges among girls at primary school levels and upwards. Equipping the girls, at a community level, with basic knowledge and understanding about the dangers of practicing risky sexual behavior is fundamental for the enhancement of their socio-economic support.
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Kays, Megan, Godfrey Woelk, Tegan Callahan, Leila Katirayi, Michele Montandon, Felluna Chauwa, Anne Laterra, et al. "Evaluating the effect of a community score card among pregnant and breastfeeding women living with HIV in two districts in Malawi." PLOS ONE 16, no. 8 (August 11, 2021): e0255788. http://dx.doi.org/10.1371/journal.pone.0255788.
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Malawi faces challenges with retaining women in prevention of mother-to-child HIV transmission (PMTCT) services. We evaluated Cooperative for Assistance and Relief Everywhere, Inc. (CARE’s) community score card (CSC) in 11 purposively selected health facilities, assessing the effect on: (1) retention in PMTCT services, (2) uptake of early infant diagnosis (EID), (3) collective efficacy among clients, and (4) self-efficacy among health care workers (HCWs) in delivering quality services. The CSC is a participatory community approach. In this study, HCWs and PMTCT clients identified issues impacting PMTCT service quality and uptake and implemented actions for improvement. A mixed-methods, pre- and post-intervention design was used to evaluate the intervention. We abstracted routine clinical data on retention in PMTCT services for HIV-positive clients attending their first antenatal care visit and EID uptake for their infants for 8-month periods before and after implementation. To assess collective efficacy and self-efficacy, we administered questionnaires and conducted focus group discussions (FGDs) pre- and post-intervention with PMTCT clients recruited from CSC participants, and HCWs providing HIV care from facilities. Retention of HIV-positive women in PMTCT services at three and six months and EID uptake was not significantly different pre- and post-implementation. For the clients, the collective efficacy scale average improved significantly post-intervention, (p = 0.003). HCW self-efficacy scale average did not improve. Results from the FGDs highlighted a strengthened relationship between HCWs and PMTCT clients, with clients reporting increased satisfaction with services. However, the data indicated continued challenges with stigma and fear of disclosure. While CSC may foster mutual trust and respect between HCWs and PMTCT clients, we did not find it improved PMTCT retention or EID uptake within the short duration of the study period. More research is needed on ways to improve service quality and decrease stigmatized behaviors, such as HIV testing and treatment services, as well as the longer-term impacts of interventions like the CSC on clinical outcomes.
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Olaniran, Abimbola, Barbara Madaj, Sarah Bar-Zev, and Nynke van den Broek. "The roles of community health workers who provide maternal and newborn health services: case studies from Africa and Asia." BMJ Global Health 4, no. 4 (August 2019): e001388. http://dx.doi.org/10.1136/bmjgh-2019-001388.
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IntroductionA variety of community health workers (CHWs) provide maternal and newborn health (MNH) services in low-income and middle-income settings. However, there is a need for a better understanding of the diversity in type of CHW in each setting and responsibility, role, training duration and type of remuneration.MethodsWe identified CHWs providing MNH services in Bangladesh, India, Kenya, Malawi and Nigeria by reviewing 23 policy documents and conducting 36 focus group discussions and 131 key informant interviews. We analysed the data using thematic analysis.ResultsIrrespective of training duration (8 days to 3 years), all CHWs identify pregnant women, provide health education and screen for health conditions that require a referral to a higher level of care. Therapeutic care, antenatal care and skilled birth attendance, and provision of long-acting reversible contraceptives are within the exclusive remit of CHWs with training greater than 3 months. In contrast, community mobilisation and patient tracking are often done by CHWs with training shorter than 3 months. Challenges CHWs face include pressure to provide MNH services beyond their scope of practice during emergencies, and a tendency in some settings to focus CHWs on facility-based roles at the expense of their traditional community-based roles.ConclusionCHWs are well positioned geographically and socially to deliver some aspects of MNH care. However, there is a need to review and revise their scope of practice to reflect the varied duration of training and in-country legislation.
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Rai, Rajesh Kumar, Prashant Kumar Singh, Chandan Kumar, and Lucky Singh. "Factors Associated With the Utilization of Maternal Health Care Services Among Adolescent Women in Malawi." Home Health Care Services Quarterly 32, no. 2 (April 2013): 106–25. http://dx.doi.org/10.1080/01621424.2013.779354.
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Kachale, Fannie, Imelda Mahaka, Fatima Mhuriro, Mary Mugambi, Joseph Murungu, Barbra Ncube, Getrude Ncube, et al. "Integration of HIV and sexual and reproductive health in the era of anti-retroviral-based prevention: findings from assessments in Kenya, Malawi and Zimbabwe." Gates Open Research 5 (September 15, 2021): 145. http://dx.doi.org/10.12688/gatesopenres.13330.1.
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Background: Though substantial progress has been made to curb the HIV epidemic, high rates of new HIV infections persist among adolescent girls and young women (AGYW) in sub-Saharan Africa, reflecting critical gaps in reaching them with integrated HIV prevention and sexual and reproductive health (SRH) services. With the scale-up of oral pre-exposure prophylaxis (PrEP) and multiple novel HIV prevention products on the horizon, countries have a unique opportunity to expand innovative approaches to deliver comprehensive, integrated HIV/SRH services. Methods: This article is a comparative analysis of findings from rapid landscaping analyses in Kenya, Malawi and Zimbabwe to highlight cross-country trends and context-specific realities around HIV/SRH integration. The analyses in Kenya and Zimbabwe were completed by Ministries of Health (MOH) and the HIV Prevention Market Manager project and include 20 health facility assessments, 73 key informant interviews and six community dialogues. In Malawi, the analysis was completed by the MOH and Georgetown University Center for Innovation in Global Health and includes 70 key informant interviews and a review of national policies and program implementation in Blantyre. Findings were validated through a review of literature and policies in each country. Results: The policy environment in all three countries is conducive to HIV/SRH integration, though operationalization continues to present challenges, with most policies preceding and not accounting for oral PrEP rollout. National coordination mechanisms, youth-friendly health services and prevention of mother-to-child transmission programs are promising practices, while siloed and resource-constrained health systems, limited provider capacity, lack of support for demand generation and structural factors exacerbate barriers to achieving integration. Conclusions: As new HIV prevention products are introduced, demand for integrated HIV/SRH services is likely to grow. Investing in HIV/SRH integration can help to ensure sustainable, government-led responses to the HIV epidemic, streamline service delivery and improve the health outcomes and lives of AGYW.
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Gullo, Sara, Christine Galavotti, Anne Sebert Kuhlmann, Thumbiko Msiska, Phil Hastings, and C. Nathan Marti. "Effects of the Community Score Card approach on reproductive health service-related outcomes in Malawi." PLOS ONE 15, no. 5 (May 19, 2020): e0232868. http://dx.doi.org/10.1371/journal.pone.0232868.
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Chopra, Mickey, Tanya Doherty, Saba Mehatru, and Mark Tomlinson. "Rapid assessment of infant feeding support to HIV-positive women accessing prevention of mother-to-child transmission services in Kenya, Malawi and Zambia." Public Health Nutrition 12, no. 12 (April 30, 2009): 2323–28. http://dx.doi.org/10.1017/s1368980009005606.
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AbstractObjectiveThe possibility of mother-to-child transmission (MTCT) of HIV through breast-feeding has focused attention on how best to support optimal feeding practices especially in low-resource and high-HIV settings, which characterizes most of sub-Saharan Africa. To identify strategic opportunities to minimize late postnatal HIV transmission, we undertook a review of selected country experiences on HIV and infant feeding, with the aims of documenting progress over the last few years and determining the main challenges and constraints.DesignField teams conducted national-level interviews with key informants and visited a total of thirty-six facilities in twenty-one sites across the three countries – eighteen facilities in Malawi, eleven in Kenya and seven in Zambia. During these visits interviews were undertaken with key informants such as the district and facility management teams, programme coordinators and health workers.SettingA rapid assessment of HIV and infant feeding counselling in Kenya, Malawi and Zambia, undertaken from February to May 2007.ResultsInfant feeding counselling has, until now, been given low priority within programmes aimed at prevention of MTCT (PMTCT) of HIV. This is manifest in the lack of resources – human, financial and time – for infant feeding counselling, leading to widespread misunderstanding of the HIV transmission risks from breast-feeding. It has also resulted in lack of space and time for proper counselling, poor support and supervision, and very weak monitoring and evaluation of infant feeding. Finally, there are very few examples of linkages with community-based infant feeding interventions. However, all three countries have started to revise their feeding policies and strategies and there are signs of increased resources.ConclusionsIn order to sustain this momentum it will be necessary to continue the advocacy with the HIV community and stress the importance of child survival – not just minimization of HIV transmission – and hence the need for integrating MTCT prevention.
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Phiri, Y. D. J., and K. G. Munthali. "FOSS TECHNOLOGIES IN MODELLING SPATIAL ACCESSIBILITY OF PRIMARY HEALTH CARE IN MALAWI." ISPRS - International Archives of the Photogrammetry, Remote Sensing and Spatial Information Sciences XLII-4/W14 (August 23, 2019): 189–95. http://dx.doi.org/10.5194/isprs-archives-xlii-4-w14-189-2019.
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<p><strong>Abstract.</strong> Primary health care (PHC) is the first point of contact people have with a health system. As such access to PHC services is an important factor to ensure good health of a community. While the need to provide equal and easy access to PHC is well understood, the approaches informing the decision-making process to improve the access tend to face a number of challenges in the developing world. Use of conventional Information and Communication Technologies (ICTs) comes with requisite financial costs which Free and Open Source Software (FOSS) ICT technologies have the potential to help lower among other benefits. In this study, the confluence of spatial accessibility tools provided by FOSS technologies, specifically PostgreSQL/PostGIS and QGIS, was explored to inform decision making in PHC accessibility in Zomba, Malawi. The results show that the household population (P) that is within the threshold time was 82,863, representing 59% of all households having access to health care. The mean accessibility score for the district was 0.010 and ranged from 0.00 to 0.231. While the findings provide, arguably, spatially objective PHC accessibility data to inform policy direction and also reveals accessibility to PHC in Malawi to be lower than reported, the study also reveals the usefulness of FOSS technologies, in the developing world. Use of FOSS facilitated incremental setup of the model thereby allowing to run the model with limited processing power. That notwithstanding, the study adds to the formal scientific research on the use of relational spatial analysis in the developing world.</p>
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Holm, Rochelle H., Brighton A. Chunga, Adrian Mallory, Paul Hutchings, and Alison Parker. "A Qualitative Study of NIMBYism for Waste in Smaller Urban Areas of a Low-Income Country, Mzuzu, Malawi." Environmental Health Insights 15 (January 2021): 117863022098414. http://dx.doi.org/10.1177/1178630220984147.
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When waste management infrastructure is built, there can be resistance from the local affected populations, often termed the Not in My Backyard (NIMBY) phenomenon. This study aims to understand the forms of resistance that may develop in such contexts, focusing on 2 solid waste and 1 liquid waste management site within Mzuzu City, Malawi. At the newest solid waste site, community resistance had grown to the extent that the site was reportedly destroyed by the local community. Interviews and observations of the sites are complemented by examining historic and recent satellite images. It was found that, at the new solid waste site, community engagement had not been conducted effectively prior to construction and as part of ongoing site operations. This was compounded by poor site management and the non-delivery of the promised benefits to the community. In contrast, at the liquid waste site, the community could access untreated sludge for use as fertilizer and were happier to live within its vicinity. While NIMBYism is a frustrating phenomenon for city planners, it is understandable that communities want to protect their health and well-being when there is a history of mismanagement of waste sites which is sadly common in low-income settings. It is difficult for government agencies to deliver these services and broader waste management. In this study, an unsuccessful attempt to do something better with a legitimate goal is not necessarily a failure, but part of a natural learning process for getting things right.
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Dharmayat, Kanika I. "Sustainability of ‘mHealth’ interventions in sub-Saharan Africa: a stakeholder analysis of an electronic community case management project in Malawi." Malawi Medical Journal 31, no. 3 (September 3, 2019): 177–83. http://dx.doi.org/10.4314/mmj.v31i3.3.
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BackgroundThe global health community and funding agencies are currently engaged in ensuring that worthwhile research-based programmes are sustainable. Despite its importance, few studies have analysed the sustainability of global health interventions. In this paper, we aim to explore barriers and facilitators for the wider implementation and sustainability of a mobile health (mHealth) intervention (Supporting LIFE Community Case Management programme) in Malawi, Africa.MethodsBetween January and March 2017, a qualitative approach was used to carry out and analyse 13 in-depth semi-structured interviews with key stakeholders across all levels of healthcare provision in Malawi to explore their perceptions with regards to the implementation and sustainability of the mHealth programme. Data were analysed thematically by two reviewers. ResultsOverall, our analysis found that the programme was successful in achieving its goals. However, there are many challenges to the wider implementation and sustainability of this programme, including the absence of monetary resources, limited visibility outside the healthcare sector, the lack of integration with community-based and nationwide programmes, services and information and communication technologies, and the limited local capacity in relation to the maintenance, further development, and management.ConclusionsFuture developments should be aligned with the strategic goals and interests of the Ministry of Health and engage with national and international stakeholders to develop shared goals and strategies for nationwide scale-up. These developments should also focus on building local capacity by educating trainers and ensuring that training methods and guidelines are appropriately accredited based on national policies. Our findings provide a framework for a variety of stakeholders who are engaged in sustaining mHealth programmes in resource-poor settings and can be used to develop an evidence-based policy for the utilization of technology for healthcare delivery across developing countries.
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Gausman, Jewel, Megan E. Schmitt, and Jane Wickstrom. "Advancing contraceptive security, availability, and choice in Malawi using a quality improvement methodology." Gates Open Research 3 (April 3, 2019): 1111. http://dx.doi.org/10.12688/gatesopenres.12896.1.
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Many initiatives to improve contraceptive security (CS) rightly focus on strengthening national and regional systems. However, local health facilities are often under-resourced and lack technical capacity that feed into the larger supply chain. This study’s objective was to assess whether changes in facility CS indicators were associated with participation in 2014-2016 implementation and scale-up of a quality improvement methodology—Client-Oriented, Provider efficient services (COPE®) for Contraceptive Security—in 60 facilities across 10 districts of Malawi. The intervention included facility self-assessment guides and action plans to address local challenges. Results showed significant improvements in facilities having both a trained provider and contraceptive supplies. The percentage of health centers with all requirements for implant services increased significantly, including implant removal (from 26.5%; 95% CI: 14.9-41.1 to 77.6%; 95% CI: 63.4-88.2, p<.001). Health centers (from 0.0%; 95% CI: 0.0-7.3 to 10.2%; 95% CI: 3.4-22.2, p<0.05) and hospitals (from 45.5%; 95% CI: 16.7-76.7 to 90.9%; 95% CI: 58.7-99.8, p<0.05) significantly improved in the percentage of facilities able to insert intrauterine devices. Hospitals improved their ability to offer female sterilizations (27.2%; 95% CI: 6.0-61.0 to 63.6%; 95% CI: 30.7-89.1, p<0.05) and male sterilizations. Low performing health centers showed significant improvement in staff capacity, logistics management information systems, equipment, and total CS performance. The percentage of facilities placing emergency orders for contraceptives during the three months prior to an assessment showed a decreasing, non-significant trend among hospitals but was significant among health centers (from 69.2%; 95% CI: 54.6-81.7 to 36.7%; 95% CI: 23.4-51.7; p<0.001). Facility staff commitment was associated with action item completion. Improvements tended to be sustained over time. Community engagement is thought to be important to intervention success. COPE for CS may be an effective intervention and future research/programs can build off of this preliminary programmatic experience when seeking to address last mile challenges.
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Callaghan-Koru, Jennifer A., Adnan A. Hyder, Asha George, Kate E. Gilroy, Humphreys Nsona, Angella Mtimuni, and Jennifer Bryce. "Health Workers' and Managers' Perceptions of the Integrated Community Case Management Program for Childhood Illness in Malawi: The Importance of Expanding Access to Child Health Services." American Journal of Tropical Medicine and Hygiene 87, no. 5_Suppl (November 7, 2012): 61–68. http://dx.doi.org/10.4269/ajtmh.2012.11-0665.
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Luke, Melissa, J. Scott Hinkle, Wendi Schweiger, and Donna Henderson. "Mental Health Facilitator (MHF) Service Implementation in Schools in Malawi, Africa: A Strategy for Increasing Community Human Resources." Professional Counselor 6, no. 1 (March 2016): 1–21. http://dx.doi.org/10.15241/ml.6.1.1.
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Masiano, Steven P., Tiffany L. Green, Bassam Dahman, and April D. Kimmel. "The effects of community-based distribution of family planning services on contraceptive use: The case of a national scale-up in Malawi." Social Science & Medicine 238 (October 2019): 112490. http://dx.doi.org/10.1016/j.socscimed.2019.112490.
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Kumar, Meghan Bruce, Jason J. Madan, Maryline Mireku Achieng, Ralalicia Limato, Sozinho Ndima, Aschenaki Z. Kea, Kingsley Rex Chikaphupha, Edwine Barasa, and Miriam Taegtmeyer. "Is quality affordable for community health systems? Costs of integrating quality improvement into close-to-community health programmes in five low-income and middle-income countries." BMJ Global Health 4, no. 4 (July 2019): e001390. http://dx.doi.org/10.1136/bmjgh-2019-001390.
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IntroductionCountries aspiring to universal health coverage view close-to-community (CTC) providers as a low-cost means of increasing coverage. However, due to lack of coordination and unreliable funding, the quality of large-scale CTC healthcare provision is highly variable and routine data about service quality are not trustworthy. Quality improvement (QI) approaches are a means of addressing these issues, yet neither the costs nor the budget impact of integrating QI approaches into CTC programme costs have been assessed.MethodsThis paper examines the costs and budget impact of integrating QI into existing CTC health programmes in five countries (Ethiopia, Indonesia, Kenya, Malawi, Mozambique) between 2015 and 2017. The intervention involved: (1) QI team formation; (2) Phased training interspersed with supportive supervision; which resulted in (3) QI teams independently collecting and analysing data to conduct QI interventions. Project costs were collected using an ingredients approach from a health systems perspective. Based on project costs, costs of local adoption of the intervention were modelled under three implementation scenarios.ResultsAnnualised economic unit costs ranged from $62 in Mozambique to $254 in Ethiopia per CTC provider supervised, driven by the context, type of community health model and the intensity of the intervention. The budget impact of Ministry-led QI for community health is estimated at 0.53% or less of the general government expenditure on health in all countries (and below 0.03% in three of the five countries).ConclusionCTC provision is a key component of healthcare delivery in many settings, so QI has huge potential impact. The impact is difficult to establish conclusively, but as a first step we have provided evidence to assess affordability of QI for community health. Further research is needed to assess whether QI can achieve the level of benefits that would justify the required investment.
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Museka-Saidi, Tendai Mary, Trust Takudzwa Mlambo, Nancy Aburto, and Regina Susan Keith. "Strengthen iron folate supplementation of pregnant women in Ntchisi District, Malawi." World Nutrition 9, no. 3 (December 29, 2018): 254–60. http://dx.doi.org/10.26596/wn.201893254-260.
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While an estimated 45% of pregnant women in Malawi are anaemic, only 33% take iron tablets for a minimum of 90 days during pregnancy. The study explored the capacity of health facilities and communities to strengthen antenatal iron folate supplementation in Ntchisi, to support the achievement of Malawi’s nutrition target on halving anaemia in women of reproductive age by 2025.
This qualitative study employed systematic random and purposeful sampling. Eight Focus Group Discussions with mothers of children 0-23 months, eight with Care Group volunteers and eight in-depth interviews with Village Health Workers (Health Surveillance Assistants) were conducted in each village falling within the catchment area of each of 8 health facilities. Health facilities had been sampled each from the 7 Traditional Authorities with the district hospital and direct observations had been conducted at each for antenatal care service delivery. 10 key informants from the health facilities and the District Health Office were interviewed. Thus a total of 16 FGDs, 8 HSA interviews, and 10 key informant interviews provided the data analysed in this paper. Data were analysed manually using thematic framework analysis.
Poor access to and follow up of antenatal care at the health facility has limited access to iron folate supplements, as the health facility is the main source of Iron folates. Recurrent depletion of stock of iron folate were reported by mothers at most health facilities. Consumer demand for the tablets was low due to side effects, poor acceptability, associated myths, forgetfulness and frustration from having to take a daily medication. There was limited training and education materials at the health facility and community with inadequate support given to women. The absence of clear policies and guidelines on iron folate supplementation resulted in inconsistencies in messaging. Uptake and adherence were not routinely monitored.
There is a need to improve the main building blocks of the iron folate programme, including the: delivery system, tablet supply, patient education, consumer demand, monitoring and evaluation and policy.
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Lelijveld, Natasha, Nora Groce, Seema Patel, Theresa Nnensa, Emmanuel Chimwezi, Melissa Gladstone, Macpherson Mallewa, Jonathan Wells, Andrew Seal, and Marko Kerac. "Long-term outcomes for children with disability and severe acute malnutrition in Malawi." BMJ Global Health 5, no. 10 (October 2020): e002613. http://dx.doi.org/10.1136/bmjgh-2020-002613.
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IntroductionSevere acute malnutrition (SAM) and disability are major global health issues. Although they can cause and influence each other, data on their co-existence are sparse. We aimed to describe the prevalence and patterns of disability among a cohort of children with SAM.MethodsA longitudinal cohort study in Malawi followed SAM survivors up to 7 years postdischarge. Clinical and anthropometric profiles were compared with sibling and community controls. Disability at original admission was identified clinically; at 7-year follow-up a standardised screening tool called ‘the Washington Group Questionnaire’ was used.Results60/938 (6.4%) of admissions to SAM treatment had clinically obvious disability at admission. Post-treatment mortality was high, with only 11/60 (18%) surviving till 7-year follow-up. SAM children with a disability at admission had 6.99 (95% CI 3.49 to 14.02; p<0.001) greater risk of dying compared with children without disability. They were also older, less likely to be HIV positive or have oedema and more severely malnourished. Long-term survivors were more stunted, had less catch-up growth, smaller head circumference, weaker hand grip strength and poorer school achievement than non-disabled survivors.The Washington Group Questionnaire confirmed disability in all who had been identified clinically, and identified many who had not been previously flagged.ConclusionDisability is common among children affected by SAM. Those with disability-associated SAM have greatly increased risk of dying even if they survive the initial episode of malnutrition. Survivors have poorer growth, physical strength and school achievement. To enable all children to survive and thrive post-SAM, it is vital to focus more on those with disabilities. SAM treatment programmes should consider using not just clinical assessment but structured assessments to better identify at-risk individuals as well as understand the population of children for which they are developing services.
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Walsh, Aisling, Pieternella Pieterse, Zoe McCormack, Ellen Chirwa, and Anne Matthews. "Improving breastfeeding support through the implementation of the baby friendly hospital and community initiatives: a scoping review protocol." HRB Open Research 4 (January 4, 2021): 1. http://dx.doi.org/10.12688/hrbopenres.13180.1.
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Background: Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. Exclusively breastfeeding infants for the first six months would lead to the largest infant mortality reduction. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund (UNICEF), which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) is an extension of the BHFI’s 10th step of the Ten Steps to Successful Breastfeeding and of the BFHI overall. Its focus is on community-based breastfeeding supports for women. There have been no known attempts to synthesise the overall body of evidence on the BFHI in recent years, and no synthesis of empirical research on the BFCI. This scoping review asks the question: what is known about the implementation of the BFHI and the BFCI globally? Methods and analysis: This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria will follow the Population, Concepts, Contexts approach. A data charting form will be developed and applied to all the included studies. Qualitative and quantitative descriptive analysis will be undertaken. In order to address equity of access to the BFHI/BFCI, the Levesque et al. (2013) access to health care framework will be used as a lens to analyse the charted data in relation to this aspect of the review. An already established group of stakeholders with experience of infant feeding policy and implementation in Malawi will be consulted, to obtain expert views on the findings of the scoping review. Conclusion: This review will establish gaps in current evidence which will inform areas for future research in relation to this global initiative.
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Katenga-Kaunda, Lillian, Penjani Rhoda Kamudoni, Gerd Holmboe-Ottesen, Heidi Fjeld, Ibrahimu Mdala, Per Ole Iversen, and Zumin Shi. "Nutrition Knowledge and Dietary Intake in Pregnancy in Rural Malawi: Comparing Supplementary Nutrition Education and -Counseling With Routine Antenatal Care." Current Developments in Nutrition 5, Supplement_2 (June 2021): 145. http://dx.doi.org/10.1093/cdn/nzab035_053.
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Abstract Objectives To describe and compare changes in nutrition knowledge, perception and dietary habits between the intervention and control group and to evaluate the effects of nutrition knowledge on dietary diversification among the two study groups. Methods This study was a two armed randomised control trial. We recruited 257 women (gestational week 9–12) of which 195 (76%) were available for analyses: intervention 92; Control 103) the women were assessed at inclusion (baseine) and two weeks before the expected date of delivery (study end-point) for differences in nutrition knowledge, perception (using a structured questionnaire) and dietary habits (assessing dietary diversity score). We performed descriptive analyses to assess these differences between the two study groups. Three-level linear multilevel regression models with random intercept and random effect of time on participant at level 1 and village level 2 were used to expore the association between nutrition knowledge and dietary habits Results Our results show that both nutrition knowledge and dietary diversity improved in both study groups, but the improvement were significantly higher in the intervention group at study-end point. Increase in nutrition knowledge was associated with improved dietary diversity only among women in the intervention group. Moreover, women in the intervention group improved their nutrition perception and behaviour. Conclusions Our results provide evidence that poor nutrition knowledge is a barrier to consumption of healthy diet during pregnancy, thus supporting the relevance for augmenting nutrition education offered at ANC with supplementary and community-based nutrition interventions. We thus suggest that efforts should be made to strengthen the education component of ANC services as these are decentralized and locally accessible in Malawi and other low-income countries Funding Sources This project was funded by the University of Oslo, The Global Health and Vaccination Program (GLOBVAC) of the research council of Norway and by the Throne Holst foundation.
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Njuguna, Rebecca G., James A. Berkley, and Julie Jemutai. "Cost and cost-effectiveness analysis of treatment for child undernutrition in low- and middle-income countries: A systematic review." Wellcome Open Research 5 (October 5, 2020): 62. http://dx.doi.org/10.12688/wellcomeopenres.15781.2.
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Background: Undernutrition remains highly prevalent in low- and middle-income countries, with sub-Saharan Africa and Southern Asia accounting for majority of the cases. Apart from the health and human capacity impacts on children affected by malnutrition, there are significant economic impacts to households and service providers. The aim of this study was to determine the current state of knowledge on costs and cost-effectiveness of child undernutrition treatment to households, health providers, organizations and governments in low and middle-income countries (LMICs). Methods: We conducted a systematic review of peer-reviewed studies in LMICs up to September 2019. We searched online databases including PubMed-Medline, Embase, Popline, Econlit and Web of Science. We identified additional articles through bibliographic citation searches. Only articles including costs of child undernutrition treatment were included. Results: We identified a total of 6436 articles, and only 50 met the eligibility criteria. Most included studies adopted institutional/program (45%) and health provider (38%) perspectives. The studies varied in the interventions studied and costing methods used with treatment costs reported ranging between US$0.44 and US$1344 per child. The main cost drivers were personnel, therapeutic food and productivity loss. We also assessed the cost effectiveness of community-based management of malnutrition programs (CMAM). Cost per disability adjusted life year (DALY) averted for a CMAM program integrated into existing health services in Malawi was $42. Overall, cost per DALY averted for CMAM ranged between US$26 and US$53, which was much lower than facility-based management (US$1344). Conclusion: There is a need to assess the burden of direct and indirect costs of child undernutrition to households and communities in order to plan, identify cost-effective solutions and address issues of cost that may limit delivery, uptake and effectiveness. Standardized methods and reporting in economic evaluations would facilitate interpretation and provide a means for comparing costs and cost-effectiveness of interventions.
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Eshun-Wilson, Ingrid, Ajibola A. Awotiwon, Ashley Germann, Sophia A. Amankwaa, Nathan Ford, Sheree Schwartz, Stefan Baral, and Elvin H. Geng. "Effects of community-based antiretroviral therapy initiation models on HIV treatment outcomes: A systematic review and meta-analysis." PLOS Medicine 18, no. 5 (May 28, 2021): e1003646. http://dx.doi.org/10.1371/journal.pmed.1003646.
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Background Antiretroviral therapy (ART) initiation in the community and outside of a traditional health facility has the potential to improve linkage to ART, decongest health facilities, and minimize structural barriers to attending HIV services among people living with HIV (PLWH). We conducted a systematic review and meta-analysis to determine the effect of offering ART initiation in the community on HIV treatment outcomes. Methods and findings We searched databases between 1 January 2013 and 22 February 2021 to identify randomized controlled trials (RCTs) and observational studies that compared offering ART initiation in a community setting to offering ART initiation in a traditional health facility or alternative community setting. We assessed risk of bias, reporting of implementation outcomes, and real-world relevance and used Mantel–Haenszel methods to generate pooled risk ratios (RRs) and risk differences (RDs) with 95% confidence intervals. We evaluated heterogeneity qualitatively and quantitatively and used GRADE to evaluate overall evidence certainty. Searches yielded 4,035 records, resulting in 8 included studies—4 RCTs and 4 observational studies—conducted in Lesotho, South Africa, Nigeria, Uganda, Malawi, Tanzania, and Haiti—a total of 11,196 PLWH. Five studies were conducted in general HIV populations, 2 in key populations, and 1 in adolescents. Community ART initiation strategies included community-based HIV testing coupled with ART initiation at home or at community venues; 5 studies maintained ART refills in the community, and 4 provided refills at the health facility. All studies were pragmatic, but in most cases provided additional resources. Few studies reported on implementation outcomes. All studies showed higher ART uptake in community initiation arms compared to facility initiation and refill arms (standard of care) (RR 1.73, 95% CI 1.22 to 2.45; RD 30%, 95% CI 10% to 50%; 5 studies). Retention (RR 1.43, 95% CI 1.32 to 1.54; RD 19%, 95% CI 11% to 28%; 4 studies) and viral suppression (RR 1.31, 95% CI 1.15 to 1.49; RD 15%, 95% CI 10% to 21%; 3 studies) at 12 months were also higher in the community-based ART initiation arms. Improved uptake, retention, and viral suppression with community ART initiation were seen across population subgroups—including men, adolescents, and key populations. One study reported no difference in retention and viral suppression at 2 years. There were limited data on adherence and mortality. Social harms and adverse events appeared to be minimal and similar between community ART initiation and standard of care. One study compared ART refill strategies following community ART initiation (community versus facility refills) and found no difference in viral suppression (RD −7%, 95% CI −19% to 6%) or retention at 12 months (RD −12%, 95% CI −23% to 0.3%). This systematic review was limited by few studies for inclusion, poor-quality observational data, and short-term outcomes. Conclusions Based on data from a limited set of studies, community ART initiation appears to result in higher ART uptake, retention, and viral suppression at 1 year compared to facility-based ART initiation. Implementation on a wider scale necessitates broader exploration of costs, logistics, and acceptability by providers and PLWH to ensure that these effects are reproducible when delivered at scale, in different contexts, and over time.
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McGann, Patrick T., Anne M. Williams, Kathryn E. McElhinney, Laurel Romano, Julia Woodall, Thad A. Howard, Graham Ellis, et al. "Genetic Causes of Anemia in Malawian Children Less Than 5 Years of Age: Results from the Malawi Demographic and Health Survey." Blood 128, no. 22 (December 2, 2016): 313. http://dx.doi.org/10.1182/blood.v128.22.313.313.
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Abstract CCHMC IRB Protocol Background: Anemia is an important contributor to morbidity and mortality among young children in sub-Saharan Africa. Although nutritional and environmental etiologies of anemia are common, the causes are multi-factorial and include inherited blood disorders that are thought to be prevalent across sub-Saharan Africa.There are few data across Africa, including Malawi, regarding the prevalence of inherited blood disorders and contributions to anemia burden. Methods: The Malawi Demographic and Health Survey (MHDS) was conducted between October 2015 and February 2016 by the Malawi National Statistical Office in collaboration with the Community Health Services Unit of the Ministry of Health. The MHDS included a sub-study to investigate the nutritional and genetic causes of anemia. For the substudy, 105 clusters were randomly selected from the MHDS sample. In each cluster, 21 households were randomly selected and all eligible children 6-59 months were enrolled. Following visits to each household for informed consent, children were brought to the field lab for assessment of anthropometry and venous blood collection. Hemoglobin concentration was measured by the Hemocue device, and 200µL was spotted onto dried bloodspots (DBS). The DBS were frozen, and samples were transported to the US for DNA extraction and genetic analyses. DNA was extracted from DBS using two 3mm punches and frozen at -85C. Genetic causes of anemia were determined using a combination of PCR-based techniques: HbS allele (rs334) using TaqMan RT-PCR analysis; G6PD deficiency (A- variant) using 3 TaqMan RT-PCR analyses for G202A (rs1050829) to distinguish A and B isoforms followed by A376G (rs1050828) to identify the A- variant, and gender (SRY_VIC, ABCD1_CCHS0H-FAM); and deletional -α3.7-thalassemia using a copy-number variant RT-PCR assay with probes inside and outside the α-globin region (Hs03947236_cn, HbA_Tri_CCPAD0C). Results:Of 1263 children for whom informed consent was obtained, 1137 ultimately had adequate bloodspots collected for molecular analyses. The mean (±SD) hemoglobin concentration for the entire cohort was 11.5±1.7 g/dL. Twenty nine percent of all children (355/1205) were anemic (Hb<11 g/dL). A majority of anemic children (212/355, 59.7%) had mild anemia (Hb 10-11 g/dL), while 134 (37.7%) had moderate anemia (Hb 7.0-9.9 g/dL) and 2.5% (9 children) had severe anemia (Hb<7 g/dL). The allele frequency for the G6PD A- variant was 0.19 for the entire cohort, while G6PD deficiency was present in 20.8% of males and 2.5% of females with a female carrier rate of 32.2%. Alpha-thalassemia trait was found in 33.5% of children, including 25.6% with a single α-globin gene deletion (α-/αα) and 8.0% of children with a two gene deletion (α-/α-). The HbS allele frequency was 0.05 with a carrier rate (sickle cell trait, HbAS) of 10.1%. The table summarizes the hemoglobin concentrations according to each inherited hematological condition (for the samples that had both genetic analyses and hemoglobin concentrations measured). Alpha-thalassemia status was associated with a significantly lower hemoglobin concentration compared to non-carriers. Further data on the frequency of other common nutritional deficiencies (iron, vitamin A) and infectious (malaria, hookworm) causes of anemia are currently being analyzed. Conclusions: Anemia is a common and multi-factorial problem in Malawian children. In addition to nutritional and other environmental factors, this study demonstrates that genetic causes of anemia are common in this cohort of children. As expected, alpha-thalassemia trait is associated with decreased hemoglobin concentration, while steady state G6PD deficiency and sickle cell trait are not associated with anemia. The importance and frequency of these inherited hematological disorders is underappreciated in Malawi and across sub-Saharan Africa and should be considered when evaluating the prevalence and management of anemia in African children. Larger scale surveillance of these disorders with careful geospatial mapping will be important to further describe the incidence, co-inheritance, and clinical significance of these common inherited hematological disorders. Table. Table. Disclosures Ware: Addmedica: Research Funding; Biomedomics: Research Funding; Global Blood Therapeutics: Consultancy; Nova Laboratories: Consultancy; Bristol Myers Squibb: Research Funding; Bayer Pharmaceuticals: Consultancy.
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Hausmann Muela, Susanna, Joan Muela Ribera, Elizabeth Toomer, and Koen Peeters Grietens. "The PASS-model: a model for guiding health-seeking behavior and access to care research." Malaria Reports 2, no. 1 (December 13, 2012): 3. http://dx.doi.org/10.4081/malaria.2012.e3.
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The mobilization of affordable measures and treatments has brought health services and health care tools closer to the poor. This is particularly the case in the context of malaria control and elimination efforts. Still, the other side of delivery is use: the targeted populations have to access and accept these resources. Although the need to better align the delivery and user sides is increasingly recognised, there still is a gap between this awareness and researchers’ response to adequately address the community side in a way that actionable results can be achieved. In order to avoid actions based on preconceptions, practical applications should draw from theoretical knowledge. Furthermore, in order to get a total view, such applications should consider the full array of potential factors relevant for access to care or health-seeking behavior (HSB). We believe that one of the reasons why theoretically-based, holistic approaches to HSB and access to care still are scarce is the lack of a hands-on and easy-to-use model that allows the researcher to ask the right questions and to interpret the results. In this article, we present such a model, the PASSmodel for HSB and access to care. Founded on theory, the model facilitates the formulation of questions to cover the broad array of elements that guide HSB and access to care. It is adaptable to different contexts and research questions. The goal is that any researcher interested in situating health behavior in a given social, political, and economic landscape can use this tool for any health condition, in low income as well as high income countries.
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Baum, Mulwafu, Phiri, Polack, and Bright. "An Intervention to Improve Uptake of Referrals for Children with Ear Disease or Hearing Loss in Thyolo District, Malawi: Acceptability and Feasibility." International Journal of Environmental Research and Public Health 16, no. 17 (August 28, 2019): 3144. http://dx.doi.org/10.3390/ijerph16173144.
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(1) Introduction: Poor uptake of referral for ear and hearing services in Malawi has been demonstrated in previous research. A multi-component educational intervention was developed to address poor uptake. The aim of this study was to explore the feasibility and acceptability of the intervention. In addition, we aimed to provide a case study of an intervention development and feasibility testing process in preparation for a potential randomised trial. (2) Methods: The intervention included three components: (i) an information booklet; (ii) personalised counselling by a community health worker and an expert mother; (iii) a text message reminder. To assess feasibility, the counselling and information booklet were provided for caregivers of eligible children (<18 years) at ear and hearing outreach camps in Thyolo. Text message reminders were sent to caregivers after the camps. After 4 weeks, all caregivers were revisited and completed a structured questionnaire and a subset were interviewed in-depth. (3) Results: 30 children were recruited, and 53% took up the referral. Interviews found counselling with a booklet was acceptable. It provided motivation, enabled a two-way conversation, and helped dispel fear. It allowed information to be shared with social networks, initiating conversations about raising funds. The text message reminder was reported to be a valued prompt. Challenges to feasibility included low network coverage, and time needed for counselling. Residual barriers included the costs of transportation. The cost was £3.70/camp. (4) Conclusions: The study found that counselling with an information booklet was feasible and acceptable. The process of testing the feasibility of the intervention identified some adaptations to the intervention components and delivery which could be implemented before it is tested in a trial. This study highlighted the value of the feasibility testing process.
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Topp, Stephanie M., Nicole B. Carbone, Jennifer Tseka, Linda Kamtsendero, Godfrey Banda, and Michael E. Herce. "“Most of what they do, we cannot do!” How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi." BMJ Global Health 5, no. 6 (June 2020): e002220. http://dx.doi.org/10.1136/bmjgh-2019-002220.
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BackgroundIn the era of Option B+ and ‘treat all’ policies for HIV, challenges to retention in care are well documented. In Malawi, several large community-facility linkage (CFL) models have emerged to address these challenges, training lay health workers (LHW) to support the national prevention of mother-to-child transmission (PMTCT) programme. This qualitative study sought to examine how PMTCT LHW deployed by Malawi’s three most prevalent CFL models respond to known barriers to access and retention to antiretroviral therapy (ART) and PMTCT.MethodsWe conducted a qualitative study, including 43 semi-structured interviews with PMTCT clients; 30 focus group discussions with Ministry of Health (MOH)-employed lay and professional providers and PMTCT LHWs; a facility CFL survey and 2–4 hours of onsite observation at each of 8 sites and in-depth interviews with 13 programme coordinators and MOH officials. Thematic analysis was used, combining inductive and deductive approaches.ResultsAcross all three models, PMTCT LHWs carried out a number of ‘targeted’ activities that respond directly to a range of known barriers to ART uptake and retention. These include: (i) fulfilling counselling and educational functions that responded to women’s fears and uncertainties; (ii) enhancing women’s social connectedness and participation in their own care and (iii) strengthening service function by helping clinic-based providers carry out duties more efficiently and effectively. Beyond absorbing workload or improving efficiency, however, PMTCT LHWs supported uptake and retention through foundational but often intangible work to strengthen CFL, including via efforts to strengthen facility-side responsiveness, and build community members’ recognition of and trust in services.ConclusionPMTCT LHWs in each of the CFL models examined, addressed social, cultural and health system factors influencing client access to, and engagement with, HIV care and treatment. Findings underscore the importance of person-centred design in the ‘treat-all’ era and the contribution LHWs can make to this, but foreground the challenges of achieving person-centredness in the context of an under-resourced health system. Further work to understand the governance and sustainability of these project-funded CFL models and LHW cadres is now urgently required.
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Furlotte, Charles, and Karen Schwartz. "Mental Health Experiences of Older Adults Living with HIV: Uncertainty, Stigma, and Approaches to Resilience." Canadian Journal on Aging / La Revue canadienne du vieillissement 36, no. 2 (March 28, 2017): 125–40. http://dx.doi.org/10.1017/s0714980817000022.
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RÉSUMÉCette étude décrit les expériences des personnes âgées vivant avec le VIH à Ottawa en santé mentale. Onze participants âgés de 52-67 complété des entrevues personnelles approfondies. Problèmes de santé mentale sont omniprésentes dans la vie de ces personnes âgées. Nous avons identifié trois thèmes centraux communs aux histoires des participants: l’incertitude, la stigmatisation et la résilience. Pour certains de ces participants, l’incertitude impact sur la santé mentale centrée sur la survie inattendue; interprétation de l’un des symptômes; et l’incertitude médicale. Les expériences de stigmatisation des participants comprenaient la discrimination dans les interactions de soins de santé; désinformation; sentir stigmatisés en raison de certains aspects de leur apparence physique; stigmatisation aggravée; et la stigmatisation prévu. Les participants ont signalé l’utilisation de plusieurs stratégies d’adaptation, qui nous encadrent les approches à titre individuel à la résilience. Ces stratégies comprennent la réduction de l’espace VIH prend dans sa vie; faire des changements de style de vie pour accueillir sa maladie; et coopérant avec le soutien social. Ces résultats informent la compréhension des services pour les personnes vieillissantes avec le VIH qui peuvent éprouver des problèmes de santé mentale.
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Markle-Reid, Maureen, Gina Browne, Amiram Gafni, Jacqueline Roberts, Robin Weir, Lehana Thabane, Melody Miles, et al. "A Cross-Sectional Study of the Prevalence, Correlates, and Costs of Falls in Older Home Care Clients ‘At Risk’ for Falling." Canadian Journal on Aging / La Revue canadienne du vieillissement 29, no. 1 (March 2010): 119–37. http://dx.doi.org/10.1017/s0714980809990365.
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RÉSUMÉCette étude a examiné la prévalence pendant 6 mois, à l’aide des services de soutien à domicile, des facteurs de risque et des coûts de chutes de personnes âgées qui sont à risque de chute. Des 109 participants, 70,6 pour cent ont indiqué une chute dans les six mois précédents et 27,5 pour cent ont éprouvé plusieurs chutes. Bien qu’il n’y avait aucune différence statistiquement significative dans n’importe quel facteur de risque lié à la chute parmi ceux qui sont tombés (1+ chutes) et ceux qui ne sont pas tombés (0 chutes), ceux qui sont tombés ont montrés des tendances de plus en plus évidentes de fonctionnement réduit sur le plan physique, social et psychologique. Dans le coût total par personne d’utilisation des services de santé au cours des 6 derniers mois, il n’y avait aucune différence statistiquement significative entre ceux qui sont tombés et ceux qui ne sont pas tombés; toutefois, il y avait des différences significatives entre les groupes dans certains types de services de santé. L’analyse multivariable a révélé la présence de cinq facteurs de risques de chutes: troubles neurologiques (p. ex., diminution cognitive, maladie de Parkinson), l’âge ≥85 ans, risques environnementaux, glissade ou trébuchant précédente et déficience visuelle.
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Kainga, Hamilton Wales, Steven Ssendagire, Jacquellyn Nambi Ssanyu, Sarah Nabukeera, Noel Namuhani, and Fred Wabwire Mangen. "Proportion of children aged 9–59 months reached by the 2017 measles supplementary immunization activity among the children with or without history of measles vaccination in Lilongwe district, Malawi." PLOS ONE 16, no. 1 (January 11, 2021): e0243137. http://dx.doi.org/10.1371/journal.pone.0243137.
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Background The measles Supplementary Immunization Activity (SIA) was implemented in June, 2017 to close immunity gaps by providing an additional opportunity to vaccinate children aged between 9 months and up to 14 years in Lilongwe District, Malawi. This study was conducted to determine the proportion of eligible children that were reached by the 2017 measles SIA among those children with or without history of measles vaccination, and possible reasons for non-vaccination. Methods A cross-sectional survey using mixed methods was conducted. Caretakers of children who were eligible for the 2017 measles SIA were sampled from 19 households from each of the 25 clusters (villages) that were randomly selected in Lilongwe District. A child was taken to have been vaccinated if the caretaker was able to explain when and where the child was vaccinated. Eight Key Informant Interviews (KIIs) were conducted with planners and health care workers who were involved in the implementation of the 2017 measles SIA. Modified Poisson regression was used to examine the association between non-vaccination and child, caretaker and household related factors. A thematic analysis of transcripts from KIIs was also conducted to explore health system factors associated with non-vaccination of eligible children in this study. Results A total of 476 children and their caretakers were surveyed. The median age of the children was 52.0 months. Overall, 41.2% [95% CI 36.8–45.7] of the children included in the study were not vaccinated during the SIA. Only 59.6% of children with previous measles doses received SIA dose; while 77% of those without previous measles vaccination were reached by the SIA. Low birth order, vaccination history under routine services, low level of education among caretakers, unemployment of the household head, younger household head, provision of insufficient information by health authorities about the SIA were significantly associated with non-vaccination among eligible children during the 2017 measles SIA. Qualitative findings revealed strong beliefs against vaccinations, wrong perceptions about the SIA (from caretakers’ perspectives), poor delivery of health education, logistical and human resource challenges as possible reasons for non-vaccination. Conclusion Many children (41%) were left unvaccinated during the SIA and several factors were found to be associated with this finding. The Lilongwe District Health Team should endeavor to optimize routine immunization program; and community mobilization should be intensified as part of SIA activities.
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Demers, Marie. "Age Differences in the Rates and Costs of Medical Procedures and Hospitalization during the Last Year of Life." Canadian Journal on Aging / La Revue canadienne du vieillissement 17, no. 2 (1998): 186–96. http://dx.doi.org/10.1017/s0714980800009259.
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RÉSUMÉCette étude examine les variations associées à l'âge dans la fréquence et le coût moyen des services diagnostiques, thérapeutiques et chirurgicaux dispensés durant la derniàre année de vie parmi la population adulte du Québec. Elle documente aussi l'hospitalisation durant la derniàre année de vie. Elle est basée sur 90 pour cent des décàs survenus au Québec en 1991 dans la population âgée de 15 ans ou plus. L'information provient des fichiers administratifs de la Régie de l'assurance-maladie, soit plus spécifiquement des demandes de paiement des médecins rémunérés à l'acte. Les coûts considérés sont les montants payés aux médecins pour les interventions réalisées. En ce qui a trait au taux d'utilisation de ces catégories de service, les résultats indiquent d'abord une augmentation avec l'âge atteignant un maximum parmi les adultes d'âge moyen et diminuant ensuite chez les personnes âgées. Une tendance similaire est observée pour le coût moyen de chirurgie et d'actes diagnostiques par usager. Pour sa part, le coût moyen des interventions thérapeutiques par usager est plus élevé chez les jeunes et subit une diminution constante avec l'âge. Ces données suggàrent que les personnes tràs âgées ne semblent pas plus soumises à des traitements intensifs au cours de la derniàre année de vie que les groupes d'âge plus jeunes.
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Lussier, Ginette, and Andrew V. Wister. "A Study of Workforce Aging of the British Columbia Public Service, 1983–1991." Canadian Journal on Aging / La Revue canadienne du vieillissement 14, no. 3 (1995): 480–97. http://dx.doi.org/10.1017/s0714980800009065.
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RÉSUMÉ:Cet article étudie le vieillissement de la main-d'oeuvre au sein des services publics de la Colombie-Britannique entre 1983 et 1991. Les inscrits aux fichiers annuels de rémunération du personnel du gouvernement ont été répartis selon l'âge, le sexe et la classification d'emploi des employés et par leur utilisation des programmes de maladie à court terme et d'invalidité prolongée. Des données sur la retraite sont également tirées des rapports annuels de la caisse de retraite des services publics. Ces données sont analysées en fonction des tendances en matière de retraite, du taux de rotation de la main-d'oeuvre et des tendances au plan de l'absentéisme. Les résultats révèlent une forte hausse au sein de la catégorie des travailleurs d'âge moyen et une faible augmentation du vieillissement de la main-d'oeuvre. L'embauche d'un plus grand nombre de travailleurs ayant atteint leur mi-carrière et d'un nombre inférieur de jeunes travailleurs conjuguée à des programmes de retraite anticipée ont causé une bulle dans la structure d'âge de la main-d'oeuvre, plutôt que son allongement, comme on peut observer au sein de l'ensemble de la population. Les auteurs discutent ensuite des conséquences à long terme et à court terme en regard de l'utilisation des ressources humaines.
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Chappell, Neena L., Alexander Segall, and Doris G. Lewis. "Gender and Helping Networks among Day Hospital and Senior Centre Participants." Canadian Journal on Aging / La Revue canadienne du vieillissement 9, no. 3 (1990): 220–33. http://dx.doi.org/10.1017/s0714980800010679.
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RÉESUMÉCet article examine les différences de sexe qui existent au sein des réseaux d'entraide pour ce qui est de trois différents genres de maladies (malaises usuels, les cas d'urgence hypothétiques affectant la santé à court terme, et incapacité fonctionnelle) chez les personnes qui séjournent dans des hôpitaux de jour et dans des foyers d'accueil à Winnipeg au Manitoba. Selon les résultats, les femmes ont plus de chances de recevoir l'aide de la famille, excluant un époux, et elles bénéficient plus des services offerts par leurs amies. Le sexe est done devenu lié étroitement à qui assistait, même lorsqu'on tenait compte de la disponibilité de cette personne, de la durée de la maladie, et d'autres facteurs de santé ainsi que des particularités du réseau social.
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Bond, John B. "Norah Keating. Aging in Rural Canada. Toronto: Butterworths, 1991, pp. xxii, 139." Canadian Journal on Aging / La Revue canadienne du vieillissement 12, no. 1 (1993): 104–7. http://dx.doi.org/10.1017/s071498080000831x.
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RÉSUMÉCe livre présente une série d'articles, principalement publiés au Canada et aux États-Unis, ayant pour thème la situation des personnes âgées vivant en milieu rural. Le premier chapitre analyse des définitions, des approches et des concepts relatifs à la « ruralité ». Dans le dernier chapitre, les auteurs font des suggestions concernant la recherche, les politiques et la mise sur pied de programmes pour les aânés qui habitent en milieu rural. Les quatre autres chapitres examinent le travail, la retraite et les loisirs; l'autonomie, le réseau familial et social ainsi que la santé. Tout en résumant de nombreuses études, Keating souligne aussi les problèmes qui existent dans plusieurs secteurs. Très peu d'études ont été menées sur la vie des personnes âgées qui vivent en milieu rural et qui n'exploitent pas de ferme, ainsi que sur la retraite dans les villages où sévissent le chômage saisonnier ou le chômage chronique. Les facteurs subjectifs et objectifs doivent être pris en conséderation lorsque l'on examine les services de soutien pour les personnes auto-nomes; les problèmes des autochtones et des services en région éloignée doivent également étre étudiées. Des facteurs subjectifs doivent être explorées en relation avec l'efficacité du soutien familial, et les questions entourant la santé doivent être dégagées de l'optique de la « maladie » et refléter davantage une approche plus subjective et holistique qui est aussi celle des mesures des politiques actuelles.
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Elbourne, Heather Fillmore, Kathryn Hominick, Laurie Mallery, and Kenneth Rockwood. "Characteristics of Patients Described as Sub-acute in an Acute Care Hospital." Canadian Journal on Aging / La Revue canadienne du vieillissement 32, no. 2 (May 31, 2013): 203–8. http://dx.doi.org/10.1017/s0714980813000214.
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RÉSUMÉLes patients frêles et âgés souffrent de multiples besoins complexes qui souvent passent non-traitées dans un établissement de soins actifs. Ne pas reconnaître les géants gériatriques au sein de ces aînés frêles provoque des erreurs de classement de cette population. Cette étude a examiné des aînés malades “sub-aiguë” hospitalisés dans un hôpital de soins tertiaires. Bien qu’ils aient été identifiés comme n’étant plus gravement malades, tous les participants avaient besoin des soins medicaux actifs et/ou de soins infirmiers. Lorsque l’acuité de leur maladie est passée inaperçue, les patients âgés et fragiles ont été classés par erreur comme sub-aiguë. La majorité des participants ont souhaité être soignés chez eux ou à proximité. L’absence, dans notre système de soins de santé, des soins post-aigus, ainsi que l’aversion au risque de la part du personnel de l’hôpital, a abouti aux hospitalisations prolongées ou/et les patients étaient rélégués* dans les services existants (maisons de soins infirmiers) contre leur désir de rentrer chez eux.
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Lund, C., A. Alem, M. Schneider, C. Hanlon, J. Ahrens, C. Bandawe, J. Bass, et al. "Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM." Epidemiology and Psychiatric Sciences 24, no. 3 (April 2, 2015): 233–40. http://dx.doi.org/10.1017/s2045796015000281.
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There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurse-led service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.
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Kauye, Felix. "Management of mental health services in Malawi." International Psychiatry 5, no. 2 (April 2008): 29–30. http://dx.doi.org/10.1192/s1749367600005531.
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Malawi is a country in sub-Saharan Africa bordering Mozambique, Tanzania and Zambia. It has an area of approximately 118000 km2 and is divided into northern, central and southern regions. It has an estimated population of 13 million, 47% of whom are under 15 years of age and just 5% over 60 years. Its economy is largely based on agriculture, with tobacco being the main export. The projected growth in gross domestic product (GDP) for 2007 was 8.8%; GDP per capita was $284 per annum.
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Lilford, Philippa. "Mental health in Malawi." BJPsych International 17, no. 2 (November 20, 2019): 32–33. http://dx.doi.org/10.1192/bji.2019.28.
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This is a reflective essay about the time I spent volunteering in mental healthcare in Malawi, prior to commencing my psychiatry training. The burden of illness I saw was enormous and the resources very limited; however, I describe some particular experiences where we were able to deliver excellent care, and which made me reflect about mental health services in low-income countries in general. Details of the patients discussed in this essay have been fully anonymised.
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Goodarzi, Zahra, Heather M. Hanson, Nathalie Jette, Scott Patten, Tamara Pringsheim, and Jayna Holroyd-Leduc. "Barriers and Facilitators for Guidelines with Depression and Anxiety in Parkinson’s Disease or Dementia." Canadian Journal on Aging / La Revue canadienne du vieillissement 37, no. 2 (April 5, 2018): 185–99. http://dx.doi.org/10.1017/s0714980818000053.
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RÉSUMÉNotre principal objectif était de comprendre les barrières et les facilitateurs associés à l’application de guides de pratique clinique (GPC) de haute qualité pour la dépression et l’anxiété chez les patients atteint de démence ou de la maladie de Parkinson (MP). Des groupes de discussion et des entrevues ont été réalisés avec des participants atteints de démence ou de la MP, leurs soignants et les médecins impliqués dans les soins de ces patients à Calgary (Alberta). Le cadre conceptuel des domaines théoriques et le Behaviour Change Wheel ont été utilisés pour guider la collecte des données et l’analyse du cadre conceptuel. Au total, 33 médecins, 7 patients et leurs aidants ont participé à l’étude. Les barrières et les facilitateurs pour l’application des recommandations des GPC liées au diagnostic, à la gestion et à l’utilisation des lignes directrices ont été rapportés. L’insuffisance des données concernant les troubles anxieux et dépressifs dans la démence et la MP constituaient un thème dominant dans les résultats. Ce constat était particulièrement évident en matière de troubles anxieux. Les patients ont aussi mentionné des difficultés à communiquer leurs symptômes et à accéder aux services. Bien que des guides de pratiques soient disponibles, les médecins éprouvent quelques difficultés dans l’application de certaines recommandations, ces difficultés étant surtout dues au manque de données probantes disponibles.
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Neuberger, J. "Community health services." BMJ 305, no. 6867 (December 12, 1992): 1486–88. http://dx.doi.org/10.1136/bmj.305.6867.1486.
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Kerr, David. "Community theatre and public health in Malawi." Journal of Southern African Studies 15, no. 3 (April 1989): 469–85. http://dx.doi.org/10.1080/03057078908708211.
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Changole, Josephine, Ursula Kafulafula, Johanne Sundby, and Viva Thorsen. "Community perceptions of obstetric fistula in Malawi." Culture, Health & Sexuality 21, no. 5 (October 3, 2018): 605–17. http://dx.doi.org/10.1080/13691058.2018.1497813.
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