Artículos de revistas sobre el tema "Personnel management – Malawi"

Pesticides pose a significant risk to humans and the environment. This paper analyzes the measures used to manage pesticides in Malawi. Malawi’s regulatory authority of pesticides, the Pesticides Control Board (PCB), faces a number of challenges including lack of facilities for analyzing pesticides and inadequate personnel to conduct risk assessment of pesticides. The PCB needs to provide access to information and opportunities among the public to make contributions regarding requirements, processes and policies for assessing pesticide risk and efficacy. There is also a need to enhance the capacity of PCB to assess pesticide poisoning in workers, monitor pesticide residues in food and environmental contamination, as well as to control the illegal importation and sale of pesticides. Just like in other countries such as South Africa, India and Sri Lanka, Malawi urgently needs to implement measures that can restrict the importation, production, sale and use of very toxic pesticides. Malawi also needs to develop measures for the effective management of pesticide waste containers as well as obsolete pesticides, where potential solutions include reducing the purchase of (unneeded) pesticides, treatment of obsolete pesticides in high-temperature cement kilns, as well as requesting pesticide dealers to adopt life-cycle management of their products.

This study assessed e-records readiness at Karonga District Council (KDC) as one of the local government authorities in Malawi. The study employed a descriptive survey design where a survey questionnaire was used to collect data. Altogether, 56 staff were sampled randomly and purposively. The staff comprised principal officers, records clerks, ICT personnel and other action officers. The study revealed that e-records readiness at KDC was low and evolving as evident by the presence of e-record products and technologies, which were largely inadequate and obsolete. The study also established that there was inadequate and poor adherence to policies, standards and procedures for e-records management practices. Furthermore, responsibilities for e-records management were not clear. There was no established records management programme. Therefore, the study recommends the development of e-records management policy; recruitment of more staff; regular training in e-records products and other emerging technologies; mobilization of more resources required for management of records; and increasing awareness of the role of records management. This should be supported by the top management at the District Council and the Ministry of Local Government at large.

SUMMARYA computer crop simulation model of the growth and development of maize was validated using data sets obtained from field experiments run at various sites in the mid-altitude maize zone of central Malawi between 1989 and 1992. The model was used to provide information concerning management options such as the timing and quantity of nitrogen fertilizer applications and to quantify the weather-related risks of maize production in the region. It was linked to a Geographic Information System to provide information at a regional level that could ultimately be of value to policy makers and research and extension personnel.

Résumé L'article abordera les aspects suivants : les principes et les valeurs à la base du schème d'intervention préconisé pour le patient violent, ainsi que la description de l'encadrement clinique des bénéficiaires et du personnel. L'encadrement clinique s'effectue à deux niveaux : celui du malade vise l'autonomie et la responsabilisation. Pour ce faire, nous avons développé différents mécanismes ou outils que nous exposerons. Ce sont : le plan de soins individualisé, la personne de référence, la personne ressource, le milieu de vie et les activités rééducatives, l'intervention clinique spécifique à l'agressivité (l'intervention physique et psychologique auprès du résidant et du personnel lors d'acting-out). Le deuxième niveau d'encadrement concerne le personnel soignant et poursuit l'objectif de développer chez lui des moyens pour composer avec la violence manifestée par le malade. Nous mentionnerons les moyens préconisés pour aider le personnel dans cette tâche difficile.

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.

Purpose The purpose of this paper is to identify the factors that affect TQM implementation in construction companies and it suggests solutions for TQM implementation in a difficult environment. Design/methodology/approach Studies were carried out at six large construction companies who ply their trade in Southern Africa and in-depth investigations were conducted to assess TQM implementation practices and associated TQM barriers. Interviews were conducted on directors and key personnel that play important roles in TQM implementation in their respective organisations. The empirical study also utilised a number of organisational documents which added rigour to the findings. Findings This study identified three core categories and ten main barriers affecting TQM implementation in Southern Africa construction companies. The core categories are motivation, infrastructure and penchants and tendencies while the factors are lack of quality support, poor TQM knowledge and TQM awareness, poor information sharing, temporary workers, overdependence on contract document, poor data collection measurement, undefined TQM roles and responsibilities, award to lowest bidder tendency, poor business environment and corruption. Research limitations/implications The study was conducted based on companies plying their trade in Southern Africa and mostly around Malawi, Zambia and Mozambique. It does not study companies in Namibia, Zimbabwe, Angola, South Africa and Botswana. Practical implications TQM cannot be exported wholly from another region to a new setting without taking into consideration the local factors associated with that setting. For successful TQM implementation in construction in Southern Africa, characteristics of this region have to be known. This study illuminates a number of TQM implementation barriers associated with construction especially applied to this difficult environment. Application of this knowledge would enhance TQM and heighten competitive advantage initiatives. The proportions highlighted in this study therefore help build up the TQM implementation awareness. Social implications At society level, the findings of this study indicate societal problems such as corruption and business environment which require wide level approaches to deal with these barriers. In addition, if TQM applied in road construction projects, the quality of the roads will be improved, this in turn will have direct impact on quality of life in the society, better roads means easier access to hospitals, schools and public places, better transport and movements of goods and services, etc. It can also save money for the country in long run and economic benefits to the society. Originality/value The factors identified in this study are based on current TQM implementation practices at established construction companies in Southern Africa. They provide a practical basis for guiding TQM in construction companies operating in difficult environments.

Résumé Cet article rend compte des principaux résultats d'un projet du CLSC des Faubourgs1 portant sur l'intervention auprès des personnes itinérantes souffrant de troubles mentaux graves et persistants. Le projet comporte deux volets : une recherche qui décrit les personnes itinérantes fréquentant les urgences psychiatriques de garde à Montréal et les services qui leur sont dispensés et un projet pilote d'intervention auprès d'un échantillon de la population. La première partie de l'article présente les résultats de la recherche et aborde la question de l'accessibilité de la population aux services psychiatriques et les multiples difficultés reliées, d'une part, aux personnes, à leur maladie, à leurs conditions de vie et à leur résistance aux soins et, d'autre part, à l'organisation des services du réseau de la santé et des services sociaux et à l'existence de ressources dans la communauté pour cette population. La deuxième partie de l'article décrit et évalue sommairement une expérimentation de suivi systématique individuel (case management) et s'intéresse à la question de l'approche d'intervention à privilégier auprès de la population compte tenu de ce qui précède.

The pandemic is not new in the history of humanity. The pandemic called COVID-19 disease has a great impact on the actions and activities of humanity and consequently on the Environment. Food demand and thus food security are greatly affected due to mobility restrictions, reduced purchasing power and with a greater impact on the most vulnerable population groups. The COVID-19 crisis has threatened the livestock production, food security and nutrition of millions of people, many of whom were already suffering. This review paper highlights these effects and proffered solutions to the problems. La pandémie n'est pas nouvelle dans l'histoire de l'humanité. La pandémie appelée maladie COVID-19 a un grand impact sur les actions et les activités de l'humanité et par conséquent sur l'environnement. La demande alimentaire et donc la sécurité alimentaire sont fortement affectées en raison des restrictions de mobilité, de la réduction du pouvoir d'achat et d'un impact plus important sur les groupes de population les plus vulnérables. La crise du COVID-19 a menacé la production animale, la sécurité alimentaire et la nutrition de millions de personnes, dont beaucoup souffraient déjà. Cet article de synthèse met en évidence ces effets et propose des solutions aux problèmes.

ObjectiveTo review for Canadian physicians the latest pharmacological options for obesity management. Quality of EvidenceA literature search was conducted in PubMed with no time restriction. Canadian and international guidelines referenced. National and international statistics databases quoted for epidemiological data. Levels of evidence range from I to III. Main MessageAs a chronic progressive disease affecting over 7.2 million Canadians, obesity requires early identification and treatment by primary care practitioners. Three anti-obesity medications are approved for use in Canada under the tradenames Xenical®, Saxenda®, and Contrave® which help bridge the gap between non-pharmacological and surgical options for the treatment of obesity. Family physicians are front-line members of the obesity management team and should remain updated on the pharmacological options for weight management. ConclusionAnti-obesity medications lead to greater average weight loss when combined with behavior modifications and provide individuals with excess weight a sustainable option for obesity management. RESUMEObjectifExaminer, à l’intention des médecins canadiens, les dernières options pharmacologiques pour la gestion de l’obésité. Qualité des preuvesUne recherche documentaire a été effectuée dans PubMed sans restriction de temps. Les lignes directrices canadiennes et internationales sont référencées. Bases de données statistiques nationales et internationales citées pour les données épidémiologiques. Les niveaux de preuve vont de I à III. Message principal En tant que maladie chronique progressive touchant plus de 7,2 millions de Canadiens, l’obésité nécessite un dépistage et un traitement précoces par les praticiens de soins primaires. Trois médicaments contre l’obésité sont approuvés au Canada sous les noms commerciaux Xenical®, Saxenda® et Contrave®, qui aident à combler le fossé entre les options non pharmacologiques et chirurgicales pour le traitement de l’obésité. Les médecins de famille sont des membres de première ligne de l’équipe de gestion de l’obésité et doivent se tenir au courant des options pharmacologiques pour la gestion du poids. ConclusionLes médicaments contre l’obésité entraînent une perte de poids moyenne plus importante lorsqu’ils sont associés à des modifications du comportement et offrent aux personnes en surpoids une option durable pour la gestion de l’obésité.

Background: von Hippel–Lindau (VHL) disease is an autosomaldominant condition characterized by the development of benignand malignant tumours, including cases of renal cell carcinoma(RCC). Early detection of RCC through routine surveillance canlead to decreased morbidity and mortality. Data on the numberof patients in Nova Scotia (NS) who have VHL disease, diseasemanifestations and the frequency and mode of the surveillancehave not previously been collected or reported. This project wasdesigned to obtain that information.Methods: The number and management of patients with VHL diseasewas determined by multiple sources: the Maritime MedicalGenetics Service, patient charts, and pathology, radiology and laboratorydata. The actual surveillance being performed was comparedwith that recommended in the literature.Results: Twenty-one patients from 11 families in NS were identified.Manifestations included cases of RCC (31.6%), central nervoussystem (CNS) hemangioblastoma (73.7%), retinal hemangioma(47.4%), renal cyst (47.4%) and pheochromocytoma (10.5%).Of the 6 patients with RCC, 4 had bilateral tumours, 2 requiredkidney transplants and 1 developed metastatic disease. Routinesurveillance was being done for the CNS in 62.5% of patients,retina in 47.4%, abdomen in 43.8% and urine catecholaminesin only 10.5%. Only 1 of the 6 patients who developed RCCwas undergoing routine abdominal imaging. Surveillance investigationswere ordered by a number of different specialists.Conclusion: Patients with VHL disease in NS have a number of manifestationsassociated with their disease, including RCC, in a similarfrequency to that reported in the literature. The surveillanceof these patients is suboptimal in frequency and coordination.von Hippel–Lindau disease is a complex condition that requiresa coordinated approach to care to ensure proper surveillance andtreatment. Our study highlights current deficiencies and offersan enormous opportunity for improvement.Généralités : La maladie de von Hippel-Lindau (VHL) est une maladieà transmission autosomique dominante caractérisée par la formationde tumeurs bénignes et malignes, dont l’hypernéphrome.Le dépistage précoce de l’hypernéphrome par des examens régulierspeut amener une réduction de la morbidité et de la mortalité. Onne sait pas combien de personnes sont atteintes de VHL enNouvelle-Écosse, quelles sont les manifestations de la maladie chezces patients et quels tests de dépistage sont effectués et à quellefréquence. Le projet décrit ici visait à obtenir ces renseignements.Méthodologie : Le nombre et la méthode de prise en charge despatients atteints de VHL ont été établis à l’aide de plusieurs sources :la Clinique de génétique médicale des Maritimes, des dossiers depatients, des rapports de pathologie et de radiologie et des analysesde laboratoire. Les méthodes de surveillance mises en placeont été comparées aux méthodes recommandées dans la littératuremédicale.Résultats : Vingt et un patients de 11 familles de Nouvelle-Écosseont été cernés. Les manifestations incluaient : hypernéphrome(31,6 %), hémangioblastomes siégeant au niveau du SNC (73,7 %),hémangiomes rétiniens (47,4 %), kystes rénaux (47,4 %) etphéochromocytomes (10,5 %). Sur les six patients porteurs d’unhypernéphrome, 4 avaient des tumeurs bilatérales, 2 ont eu besoind’une transplantation rénale et un patient a présenté des métastases.De tous les patients atteints de VHL, 62,5 % ont subi destests réguliers de dépistage au niveau du SNC, 47,4 %, au niveaude la rétine, 43,8 %, au niveau de l’abdomen, et seulement 10,5 %des patients ont subi des tests réguliers de dépistage des catécholaminesurinaires. Sur les 6 cas d’hypernéphrome, un seulementsubissait des épreuves régulières d’imagerie au niveau del’abdomen. Les tests de dépistage avaient été prescrits par différentsspécialistes.Conclusion : Les cas de VHL en Nouvelle-Écosse présentent un certainnombre de manifestations liées à cette maladie, dont l’hypernéphrome,à une fréquence proche de celle mentionnée dansla littérature. La fréquence et la coordination des épreuves dedépistage sont sous-optimales. La maladie de VHL est une affectioncomplexe nécessitant une bonne coordination des soinsafin d’assurer une surveillance et un traitement adéquats. Cetteétude montre les lacunes actuelles et pointe vers des améliorationssubstantielles.

The study was conducted to gather relevant information on turkey management, andprevalent diseases in turkeys, constraints and prospects of turkey production in Enugu state.The study was conducted in nine local government areas in the three senatorial zones of Enugu State, Nigeria covering 297 turkey keepers. A structured questionnaire was administered and information on the socio-economic characteristics of turkey producers, production patterns, management practices, prevalent diseases in turkeys and the common problems facing turkey production in Enugu State were identified and collected. The finding of the study indicated that turkey production was carried out mainly by adult female (53.0%), who were either secondary school holders (40.7%) or degree holders (26.3%). Majority (48.1%) had no previous experience in turkey production, however (52.3% involved in the business were within 36-50 years old. Turkey production in Enugu State was generally a part-time occupation as respondents were engaged in other primary occupation such as crop farming (32.6%), trading (24.6%) and civil service (18.5%). Turkeys were kept in small numbers (1-20) along with local chicken, exotic chicken, guinea fowl and ducks by a large (84.6%) number of the farmers. Majority (44.1%) of the turkey keepers in the study area adopted intensive system of management whereas a few (15.8%) allowed their turkeys to roam around. Constraints to turkey production as identified by the farmers in the study area were high cost of feed (86.5%), early poult mortality (85.2%), inadequate access to veterinary care (78.80%), unavailability and high cost of poult (74.40%), lack of management skills (63.3%) and lack of capital (61.7%).Fowl pox (69.0%) and Newcastle disease (57.6%) were the main disease problem constantly encountered and these diseases limit production in the study area. Turkey farmers affirmed that turkey production is a profitable and promising venture based on turkeys' high survival rate, ability to resist diseases and the cash generated after sale of the turkeys. In conclusion, despite the factors limiting turkey production as outlined by the respondents, turkey production has great potential in bridging the animal protein supply therefore, poultry farmers should be encouraged by government to increase their level of production by establishing reliable breeding centres in the south-east Nigeria which will ensure regular supply of day old poult, prompt disease control by employment of more veterinarians and provide soft loans to farmers. L'étude a été menée pour recueillir des informations pertinentes sur la gestion des dindes et les maladies répandues chez les dindes, les contraintes et les perspectives de la production de dindes dans l'État d'Enugu au Nigeria. L'étude a été menée dans neuf zones de gouvernement local dans les trois zones sénatoriales de l'État d'Enugu, au Nigeria, couvrant 297 éleveurs de dindes. Un questionnaire structuré a été administré et des informations sur les caractéristiques socio-économiques des producteurs de dinde, les modes de production, les pratiques de gestion, les maladies répandues chez les dindes et les problèmes courants auxquels est confrontée la production de dinde dans l'État d'Enugu ont été identifiées et collectées. Les résultats de l'étude ont indiqué que la production de dinde était principalement réalisée par des femmes adultes (53,0%), qui étaient soit titulaires d'une école secondaire (40.7%), soit titulaires d'un diplôme (26.3%). La majorité (48.1%) n'avait aucune expérience antérieure dans la production de dinde, mais (52.3%) impliqués dans l'entreprise avaient entre 36 et 50 ans. La production de dinde dans l'État d'Enugu était généralement une activité à temps partiel, car les personnes interrogées exerçaient d'autres activités primaires telles que l'agriculture (32.6%), le commerce (24.6%) et la function publique (18.5%). Les dindes étaient élevées en petit nombre (1 à 20) avec du poulet local, du poulet exotique, de la pintade et des canards par un grand nombre (84.6%) des agriculteurs. La majorité (44.1%) des éleveurs de dindes de la zone d'étude ont adopté un système de gestion intensif tandis que quelques-uns (15.8%) ont laissé leurs dindes se déplacer. Les contraintes à la production de dindes identifiées par les éleveurs dans la zone d'étude étaient le coût élevé des aliments (86.5%), la mortalité précoce des dindonneaux (85.2%), l'accès insuffisant aux soins vétérinaires (78.80%), l'indisponibilité et le coût élevé des dindonneaux (74.40%).), le manque de compétences en gestion (63.3%) et le manque de capital (61.7%). La variole aviaire (69.0%) et la maladie de Newcastle (57.6%) ont été le principal problème de maladie constamment rencontré et ces maladies limitent la production dans la zone d'étude. Les éleveurs de dindes ont affirmé que la production de dindes était une entreprise rentable et prometteuse basée sur le taux de survie élevé des dindes, leur capacité à résister aux maladies et les revenus générés après la vente des dindes. En conclusion, malgré les facteurs limitant la production de dinde comme indiqué par les répondants, la production de dinde a un grand potentiel pour combler l'approvisionnement en protéines animales.Par conséquent, les aviculteurs devraient être encouragés par le gouvernement à augmenter leur niveau de production en établissant des centres d'élevage fiables dans le sud-est du Nigéria, qui garantira un approvisionnement régulier en dindonneaux d'un jour, un contrôle rapide de la maladie par l'emploi de plus de veterinaries et accordera des prêts à des conditions avantageuses aux agriculteurs.

Appelée « virus chinois » au début de sa propagation, la maladie à coronavirus 2019 (Covid-19) a bouleversé la planète terre à cause de son ampleur sanitaire, socio-économique, culturelle, géopolitique, etc. Au moment où les pays occidentaux et autres contrées du monde, en l’occurrence l’Amérique Latine et quelques pays asiatiques comme la Chine et l’Inde, comptent leurs milliers de morts et millions d’infectés par cette maladie, en Afrique subsaharienne particulièrement au Niger la Covid-19 a eu très peu d’impact sanitaire sur la population. Mais pour des mesures préventives, les gouvernants nigériens ont pris des dispositifs coercitifs semblables à ceux des pays fortement touchés par la pandémie du coronavirus. Ainsi, il est à constater le confinement d’une importante partie de la population et l’instauration d’un couvre-feu nocturne qui restreint ipso facto les libertés individuelles fondamentales. Cette restriction n’a pas été sans conséquence sur le climat social, provoquant ainsi des remous sociaux, des vives contestations voire la désobéissance civile résultant par des violences policières hors normes surtout à Niamey dans la capitale nigérienne. Cette étude est essentiellement basée sur la méthode qualitative à travers l’usage de la grille d’observation et du guide d’entretien semi-dirigé comme outils d’enquête pour analyser les impacts du confinement contre la Covid-19 sur les personnes victimes et témoins des effets du couvre-feu et/ou des violences policières à Niamey. Leurs perceptions déterminent des comportements qui banalisent ou non les gestes barrières contre le coronavirus. Quant aux résultats de l’étude, ils montrent que les violences policières reflètent le caractère conflictuel de la gestion de cette pandémie et freinent l’adhésion pacifique et totale de la population aux mesures préventives contre la Covid-19. Ces résultats montrent aussi que l’absence des mesures d’accompagnement conséquentes des autorités politiques a considérablement contribué à l’inobservance desdites mesures par la population de Niamey. Some people name it "Chinese virus" as it spreads. The 2019 coronavirus disease (Covid-19) disrupts our planet earth because of its health, socio-economic, cultural, geopolitical scale, etc. At a time when Western countries and other parts of the world, in this case Latin America and some Asian countries such as China and India, count their thousands of deaths and millions infected by this disease, in Sub-Saharan Africa particularly in Niger, Covid-19 has very little health impact on the population. But, for preventive measures, nigérien rulers have taken coercive measures similar to those in countries strongly affected by the coronavirus pandemic. Thus, it is to be noted that locking down a large part of the population and setting of a night curfew which ipso facto restrict fundamental individual freedoms. Indeed, this restriction has consequences on social scale by causing for instance social unrest, strong protests and even civil disobedience resulting in extraordinary police violence, especially in Niamey, the capital City of Niger. This study is essentially based on the qualitative method through the use of observation grid and semi-structured interview guide as survey tools to analyze the impacts of locking down against Covid-19 of people who are victims and witnesses of the curfew effects and/or police violence in Niamey. Their perceptions determine behaviors that may or may not trivialize barrier gestures against coronavirus. As for the outcomes of our study, they show that police violence reflects conflictual nature of management of this pandemic and hinders the peaceful and total support of the population for preventive measures against Covid-19. These results also show the absence of subsequent additional measures from political authorities leading considerably to the nonobservance of these measures by the population of Niamey.

The Malawi government established and implemented various talent management practices within public hospitals in the country to enhance accessibility, productivity and energy of its health personnel, and to boost the quality of health service delivery. Innovative work behaviours such as the creation, introduction and application of new ideas are key to achieving productivity, accessibility and energy of health personnel. The sure way of achieving innovative work behaviour is through the implementation of talent management. The purpose of this study was to examine the impact of talent management on innovative work behaviour of registered nurses in public hospitals of Malawi. A quantitative research approach was employed, and an adapted Innovative Work Behaviour Questionnaire (IWB) was administered to a convenience sample of 947 (N=947) registered nurses in public hospitals of Malawi. The results of the study showed that talent management practices did not contribute to innovative work behaviour of registered nurses in public hospitals of Malawi. The study, therefore, recommends that management of public hospitals should pay attention to effective talent management practices of healthcare workers, particularly that of nurses in public hospitals. The implication of this study to management in public hospitals is that the results can be used to improve the application of talent management practices at healthcare facilities and help to advance innovative work behaviour of healthcare workers.

Purpose The purpose of the paper is to report on a study that investigated the critical success factors (CSFs) in the supply chain management of essential medicines in the public health-care delivery system in Malawi. Design/methodology/approach The exploratory and descriptive study followed a qualitative and quantitative research approach. Data were collected by means of semistructured interviews and a questionnaire administered to suppliers of essential medicines, regulators, donors and logistics companies in Malawi. Data was analyzed using SPSS. Findings The findings revealed that the significant CSFs are knowledge of disease patterns and prevalence, skills and experience of personnel, adequate financial resources, collaboration with supply chain partners and an efficient procurement and distribution system. Research limitations/implications There were a number of limitations in this study. Although every effort was made to carefully and purposefully select the participants for the in-depth interviews in the first phase of the study and the respondents for the questionnaire in the second phase of the study, they were not randomly selected. As such, the findings cannot be generalised to all stakeholders in the pharmaceutical supply chain in Malawi. However, they can be used as a basis for further research on the topic. Originality/value No previous studies that deal with the identification of CSFs in the Malawi pharmaceutical supply chain were found. Therefore, this research makes a twofold contribution to the body of knowledge in the field. First, it identifies CSFs; second, it could assist stakeholders in the public health-care service delivery system in Malawi with regard to how they can improve the supply of essential medicines.

Introduction: Uptake of evidence-based interventions for adolescents and young adults living with HIV (AYA-LWH) in sub-Saharan Africa (SSA) is complex, and cultural differences necessitate local adaptations to enhance effective implementation. Few models exist to guide intervention tailoring, yet operationalizing strategies is critical to inform science and implementation outcomes, namely acceptability, appropriateness, feasibility, fidelity, and sustainability. This paper describes operationalizing the ADAPT-ITT framework applied to a manualized trauma-informed cognitive behavioral therapy (TI-CBT) intervention addressing mental and sexual health for AYA-LWH in SSA in preparation for a randomized controlled trial (RCT).Methods: Phase 1 of the RCT focused on operationalizing ADAPT-ITT steps 3–7 to tailor the intervention for use in eight sites across Botswana, Malawi, South Africa, and Zimbabwe. Well-defined processes were developed to supplement the general guidelines for each step to provide clear, consistent direction on how to prepare and conduct each step, including documenting, assessing, and determining adaptations, while maintaining intervention fidelity. The processes provided efficient standardized step-by-step progression designed for future replication. All sites participated in Phase 1 using the created tools and strategies to translate and present the TI-CBT to community stakeholders for feedback informing local adaptations.Results: The research team developed and operationalized materials guiding adaptation. A translation review process verified local adaptability, maintained core concepts, and revealed differing interpretations of words, idioms, and culturally acceptable activities. Strategically designed tools comprised of feedback and translation verification forms resulted in meticulous management of adaptations. Robust collaborations between investigators, research managers, site personnel, and topical experts maximized multidisciplinary expertise, resulting in ~10–15 personnel per site facilitating, collecting, assessing, and integrating local feedback. Processes and tools operationalized in steps 3–7 effectively addressed implementation outcomes during community engagements (n = 108), focus groups (n = 5–8 AYA-LWH and caregivers per group), and strategic training of youth leaders.Discussion: This paper offers a novel generalizable approach using well-defined processes to guide intervention adaptation building on the ADAPT-ITT framework. The processes strengthen the science of implementation and provide much-needed specificity in adaptation steps to optimize and sustain real-world impact and help researchers and community stakeholders maximize existing infrastructure, culture, and resources to inform implementation strategies.

While problem gambling and mental illnesses are highly comorbid, there are few examples of integrated problem gambling and mental illness services. This has meant that it is unclear whether such services are needed, why they may be utilised, and how they operate to support clients impacted by the comorbidity and clinicians providing them care. This study reported on data collected via telephone questionnaire-assisted interviews of 20 clients and 19 referrers who had accessed one such Australian integrated problem gambling and mental illness program between July 2014 and June 2016. Data revealed that clients often were referred in the context of psychiatric or psychosocial crisis, or when clinicians encountered clients who were not making progress and wanted a second opinion about diagnosis and treatment. Improved management of illness symptoms or gambling behaviour were commonly reported benefits and a number of clients reported gaining a feeling of reassurance and hope following assessment due to gaining a deeper understanding of their issues and available treatment options. Access to dual specialist problem gambling and mental illness expertise may therefore enhance treatment planning, management during crises and cross-sector collaboration to enhance access to and the impact of care for people experiencing comorbidity.ResumeBien que le jeu problématique et les maladies mentales aient un taux élevé de comorbidité, il existe peu d’exemples de services intégrés pour le jeu et la maladie mentale. En d’autres termes, il n’est pas clair si de tels services sont nécessaires, à quelles fins ils peuvent être utilisés et la manière dont ils fonctionnent pour aider les clients touchés par cette comorbidité et les cliniciens qui leur fournissent des soins. La présente étude a rendu compte des données recueillies lors d’entretiens assistés par un questionnaire téléphonique menés auprès de 20 clients et de 19 répondants qui avaient eu accès à l’un des programmes australiens intégrés de lutte contre le jeu problématique et la maladie mentale entre juillet 2014 et juin 2016. Les données révèlent que les clients étaient souvent recommandés à d’autres services dans le contexte d’une crise psychiatrique ou psychosociale ou lorsque les cliniciens rencontraient des clients qui n’avaient pas fait de progrès et qui souhaitaient obtenir un deuxième avis sur le diagnostic et le traitement. Une gestion améliorée des symptômes de la maladie ou du comportement de jeu constituait des avantages souvent rapportés, et un certain nombre de clients ont déclaré avoir ressenti du réconfort et de l’espoir après une évaluation, en raison d’une meilleure compréhension de leurs problèmes et des options de traitement disponibles. L’accès à une double expertise en matière de jeu problématique et de maladie mentale peut donc améliorer la planification du traitement, la gestion de crise et la collaboration intersectorielle afin d’améliorer l’accès aux soins et l’incidence des soins pour les personnes souffrant de cette comorbidité.

ABSTRACT Introduction Obstetric fistulae are a leading scourge for women in developing countries resulting, in severe individual suffering and devastating socio-economic repercussions for her family and community. The underlying causes of obstetric fistula stem from multiple factors to include poor nutrition, early marriage, insufficient education and inferior social status of women as well as substandard medical care. The US Agency for International Development (USAID) has invested more than $100 million globally since 2004 to address these factors as well as support women suffering with fistulae. The ultimate goal is to eradicate obstetric fistula in Bangladesh in the next 20 years. Despite these efforts, nearly 20,000 women in Bangladesh, still suffer with this malady. Methods To close this gap, USAID and the Department of Defense (DOD) developed a novel Interagency Agreement (IAA) leveraging the surgical skills of military health professionals to scale-up the ongoing fistula care program. The agreement outlined three lines of effort: (1) treat existing fistulae by bolstering surgical capacity of the existing USAID fistula care program; (2) promote fistula mitigation with lectures and hands-on teaching of obstetric care as well as safe gynecologic surgery; and (3) assist with advocacy at higher levels of the Bangladesh government. A Bangladesh Fistula Mission Partnership working group was formed to design and implement this IAA. Critical partners from the US Embassy in Dhaka included USAID (Health, Legal, Contracting), the DOD (Office of Defense Cooperation), and Department of State (Regional Security Officer). Partners from the US Army included United States Army-Pacific Command (Surgeon, Legal, Finance, Security Cooperation, Contracting), Regional Health Command-Pacific (Operations, Legal, Public Affairs), and Tripler Army Medical Center (Department of OBGYN, Operations, Public Affairs). Institutional Review Board approval was not required as the treatments offered were standard of care. Results The Tripler Army Medical Center (TAMC) health professionals executed the IAA with one pre-deployment site survey and two surgical missions in 2016–2017. The military team supported the surgical repair of 40 pelvic fistulae and perineal tears and provided operative management for an additional 25 patients with pelvic organ prolapse. Furthermore, the team conducted 19 professional lectures and multiple educational forums at hospitals in Kumudini, Khulna and the premier medical university in Dhaka for over 800 attendees including physicians, nurses and students to help prevent obstetric and surgical fistulae. Importantly, the team assisted USAID as subject matter experts in its advocacy to the Bangladesh Ministry of Health for improved maternity care and regulatory oversight. During the missions, the team enhanced their readiness by exercising individual and collective tasks while exposing personnel to the cultural context of the region. Conclusion This IAA was the first USAID funded and DoD-executed health mission in the US Indo-Pacific Command Area of Responsibility. Direct participation in the IAA enabled TAMC to support the US Indo-Pacific Command Theater Campaign Plan, the Department of Defense Instruction 2000.30 on Global Health Engagements, the USAID Country Development Cooperation Strategy, and the US Ambassadors Integrated Country Strategy Objectives in Bangladesh. This effort can serve as a model for future cooperation between USAID and the DoD.

While the definition of high-dose corticosteroids depends on the indication, it is typically defined as greater than 15–20 mg for greater than 2–4 weeks. Corticosteroids have a variety of indications such as autoimmune, gastrointestinal, rheumatologic, respiratory, and hematologic conditions and after organ or hematopoietic stem cell transplantation. They can predispose these patients to infections such as pneumococcal pneumonia, Pneumocystis jirovecii (carinii) pneumonia (PJP), hepatitis B reactivation, active tuberculosis, and disseminated strongyloides infection. This article outlines ways to modify these risks in these patients. Prophylaxis is of utmost importance to those at risk for PJP with trimethoprim/sulfamethoxazole, lamivudine for those at risk of hepatitis B reactivation, isoniazid (INH) for latent tuberculosis and ivermectin for those with positive strongyloides serology. Equally important in mitigating disease risk is the appropriate timing of vaccines to elicit an adequate immune response as well as offering additional vaccines such as the pneumococcal vaccine.RésuméLa notion de dose élevée de corticostéroïdes varie selon les indications, mais elle est généralement définie comme correspondant à plus de 15‑20 mg sur une période de plus de deux à quatre semaines. Les corticostéroïdes sont indiqués dans nombre de conditions auto‑immunes, gastro-intestinales, rhumatologiques, respiratoires et hématologiques, ainsi qu’à la suite d’une transplantation d’organe ou de cellules souches hématopoïétiques. Ils peuvent toutefois prédisposer les patients à diverses infections comme la pneumonie pneumococcique et la pneumonie à Pneumocystis jirovecii (carinii) ou PCP, à une réactivation de l’hépatite B, à une tuberculose active et à une strongyloïdose disséminée. Le présent article passe en revue différentes façons de réduire ces risques chez les patients concernés. Voici des mesures de prophylaxie qui s’avèrent être de la plus haute importance pour les personnes à risque : le triméthoprime ou le sulfaméthoxazole pour celles à risque de PCP; la lamivudine pour celles à risque de réactivation de l’hépatite B; l’isoniazide (INH) dans les cas de tuberculose latente; et l’ivermectine pour les personnes montrant une sérologie positive aux strongyloïdes. De plus, pour réduire le risque de maladie, un calendrier de vaccination approprié est tout aussi important, en vue de susciter une réponse immunitaire adéquate et de pouvoir offrir d’autres vaccins comme le vaccin antipneumococcique.Corticosteroids were first used in clinical practice in 1949 for rheumatoid arthritis.1 The number of patients on high-dose corticosteroids is not well known but the use of corticosteroids is becoming increasingly common for a number of indications: An estimated 1% of the general population in the UK is treated with corticosteroids, and this rate increases with age to almost 2.5% in those aged 70–79. 4“High-dose corticosteroids” as a risk factor for infections is typically defined as greater than 15–20 mg of prednisone (or its’ equivalent) for greater than 2–4 weeks, although this definition does vary slightly depending on the infection considered. Notably, this definition is different from the standard definition of high-dose corticosteroids for treatment purposes used in the literature – which is usually defined as greater than 30 mg but less than 100 mg/day – as this dose results in almost complete cytosolic receptor saturation. 2Corticosteroids are used commonly for their anti-inflammatory effects in many conditions with an element of autoimmune disease. The mechanism is to induce transient lymphocytopenia by altering lymphocyte circulation, inducing lymphocyte death and inhibiting cytokines to prevent T-cell activation.3 For example, they are used to induce remission in inflammatory bowel disease (IBD) or to maintain symptom control in rheumatologic diseases like polymyalgia rheumatica. They are also used to prevent organ rejection in solid organ transplantation. Other indications include autoimmune hepatitis, other rheumatologic diseases such as rheumatoid arthritis, systemic lupus erythematous, vasculitis, respiratory conditions such as interstitial lung disease, sarcoidosis, hematologic disorders such as lymphoma, leukemia, idiopathic thrombocytopenic purpura, hemolytic anemia), endocrine disorders like Graves disease to prevent opthalmopathy and other conditions like multiple sclerosis.The relative risk of bacterial infections was found to be 5-fold higher in IBD patients on corticosteroids alone, 4-fold higher for other infections like strongyloides and tuberculosis, and only 1.5 fold higher for viral infections.5 However, the absolute individual risk of infectious complications from corticosteroid use remains fairly small. Nevertheless, the burden is significant at a population level due to the high frequency of corticosteroid use. 4 Thus, most practitioners eventually come across these complications during their career.VaccinationsOne of the first considerations in patients on high-dose corticosteroids is the timing of the administration of vaccines to be given to these patients. Immunizations with inactivated vaccines can be given up to 2 weeks before high-dose corticosteroids are initiated, whereas live vaccines need to be given 4 weeks before the high-dose corticosteroids are begun. If the vaccines cannot be given prior to the start of a corticosteroid treatment, both live and inactivated vaccines must wait for 4 weeks after the steroids are completed to elicit an adequate immune response and prevent infectious complications with live vaccines.6Equally important to the timing of the vaccines, patients on high-dose corticosteroids (defined as anyone receiving ³ 20 mg/day for 14 days or more) should receive additional vaccines. A single dose of an inactivated pneumococcal conjugate vaccine (Prevnar), at least one year after any previous dose of pneumococcal vaccine polyvalent (Pneumovax), followed by a single dose of Pneumovax 8 weeks later with a booster of Pneumovax 5 years later is recommended for those on high-dose corticosteroids.7,8 Pneumocystis jiroveci infectionThe following patient groups are considered to be at higher risk forPneumocystis jiroveci pneumonia (PJP; formerly known as Pneumocystis carinii pneumonia [PCP])if exposed to prednisone at doses as low as 20 mg/day for at least 4 weeks9: patients with an underlying immunosuppressive disorder (including autologous HSCT and malignancy), or those with chronic obstructive pulmonary disease and interstitial lung disease secondary to polymyositis/dermatomyositis. Also, patients receiving the same dose of prednisone plus TNF-alpha inhibitors, cyclophosphamide, methotrexate, or temsirolimus should also receive PJP prophylaxis. The first-line agent for prophylaxis is trimethoprim/sulfamethoxazole 80/400 mg (single strength) daily or 160/800 mg (double strength) three times per week (e.g., Monday/Wednesday/Friday). While adverse events are rare on such low doses, thrombocytopenia is possible given that this is an idiosyncractic reaction but pancytopenia is usually observed at much higher (i.e., treatment) doses. Also possible are hyperkalemia, increased serum creatinine and aseptic meningitis. A more rare but devastating adverse event is Stevens-Johnson syndrome. A second line agent for PJP prophylaxis is dapsone but this requires glucose-6-phosphate dehydrogenase (G6PD) testing first, as those who are deficient in this erythrocytic enzyme show a two-fold higher predisposition to dapsone-induced hemolytic anemia. Other alternatives for PJP prophylaxis are atovaquone 1500 mg daily, but this is a costly option, or inhaled pentamidine via a nebulizer at 300 mg every month. Correct administration of inhaled pentamidine is crucial and due to the route of administration, disseminated PCP disease is still possible. 9 Hepatitis B ReactivationFurthermore, patients on corticosteroids of at least 20 mg/day for at least 4 weeks, have an 11–20% chance of reactivation if they are hepatitis B surface Ag carriers. An inactive carrier is hepatitis B surface antigen positive for greater than 6 months without detectable hepatitis B e antigen (HbeAg), presence of anti-hepatitis B e antibodies (anti-Hbe), and undetectable or low levels of hepatitis B DNA, repeatedly normal ALT levels, and no or minimal liver fibrosis. Inactive carriers comprise the largest group of chronic hepatitis B infected individuals with an estimated 250 million people worldwide and can convert to active disease under such immunosuppression.Therefore, it is prudent to prescribe hepatitis B prophylaxis to these patients although no high-level evidence supporting this approach is available.11 Lamivudine is considered first choice for these patients if they do not otherwise meet treatment criteria for hepatitis B. Tenofovir is considered first line in areas highly prevalent for resistance to lamivudine, which tends to occur with prolonged lamivudine exposure. For example, lamivudine resistance develops in up to 90% of HBV-HIV co-infected individuals after 4 years of lamivudine therapy.12.In the setting of isolated anti-Hb-core antibody positivity, prophylaxis is not recommendedgiven that the rate of reactivation is less than 1%.10 Instead, patients should have serial measurements of liver function, hepatitis B serology and hepatitis B DNA every 1–3 months during the period of immunosuppressive treatment and if there is any elevation in these markers, antiviral prophylaxis or treatment (depending on the results) should be offered.So, when assessing patients for the need for PCP or hepatitis B prophylaxis, both the intended duration as well as the dose of the corticosteroids need to be considered.Strongyloides stercoralis InfectionStrongyloides stercoralis can persist for several decades and can reactivate with glucocorticoid exposure causing a severe and sometimes fatal disseminated infection. Strongyloides infection can be asymptomatic and can be acquired walking barefoot on soil in the developing world.13 Strongyloides serology is therefore recommended for refugees from low-income countries in Southeast Asia and Africa where strongyloides is endemic before starting high-dose corticosteroid treatement.14 If positive, patients should be treated with 2 doses of ivermectin to prevent the development of hyperinfection. TuberculosisPatients with latent tuberculosis on higher dose and/or longer duration of glucocorticoid use are also at risk of conversion to active disease. A one-step tuberculin skin test (TST) ³ 5 mm is considered positive when a patient is on prednisone doses ³ 15 mg/day for one month or more. First-line treatment for latent tuberculosis is isoniazid over 9 months. Patients should begin therapy ideally at least 4 weeks before starting such immunosuppression to prevent conversion to active disease.15,16. If this is not possible, the recommendation is to start isoniazid and the corticosteroids at the same time. ConclusionsSerious and potentially fatal infections are just one of the many potential complications of being on high-dose corticosteroids for a long period of time – others include diabetes, hypertension, psychosis, osteoporosis, adrenal insufficiency and the development of cushingoid features.17 Infectious diseases that are either latent or inactive may reactivate under high-dose corticosteroids including tuberculosis, pneumocystis jirovecii pneumonia, Strongyloides stercoralis, and hepatitis B. Screening and treatment for such conditions prior to starting high-dose corticosteroids, or at least once the corticosteroids are started, can prevent these complications. Furthermore, the timing of both inactivated and live vaccines is crucial for the patients’ ability to mount an appropriate immune response and to avoid complications from live vaccines. Finally, patients on high-dose corticosteroids are at higher risk for illnesses that may require additional vaccinations not otherwise given to such individuals – for example the pneumococcal vaccine.DisclosureThere are no conflicts of interest for either author on this manuscript. References1. Zoorob RJ and Cender D. A different look at corticosteroids. American Family Physician. 1998 Aug 1; 58(2): 443-450. 2. Buttgereit F, Da Silva JAP, Boers M et al. Standardised nomenclature for glucocorticoid dosages and glucocorticoid treatment regimens: current questions and tentative answers in rheumatology. Ann Rheum Dis 2002; 61: 718-722. 3.Hall BM and Hodgkinson SJ. Corticosteroids in autoimmune diseases. Aust Prescr 1999; 22: 9-11. 4. T.P. van Staa, H.G. Leufkens, L. Abenhaim, B. Begaud, B. Zhang, C. Cooper. Use of oral corticosteroids in the United Kingdom. QJM. 2000 Feb; 93(2): 105–111. 5. Paul Brassard, Alain Bitton, Alain Suissa, Liliya Sinyavskaya, Valerie Patenaude and Samy Suissa. Oral Corticosteroids and the Risk of Serious Infections in Patients With Elderly-Onset Inflammatory Bowel Diseases. The American Journal of Gastroenterology. 2014 Nov; 109: 1795-1802. 6. PHAC: Canadian Immunization Guide - section 3 - Vaccination of specific populations (acquired/secondary immunodeficiency) - http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-07-eng.php#a4. Accessed July 19 2015. Modified December 5th 2013. 7. PHAC: Canadian Immunization Guide – Section 4 – Active Vaccines: Pneumococcal Vaccine - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-pneu-eng.php#tab1. Accessed July 19 2015. Modified March 24th 2015. 8. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012 Oct 12; 61(40): 816. 9. Tomblyn M, Chiller T, Einsele H at al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009; 15(10): 1143. 10. Di Bisceglie AM, Lok AS, Martin P, Terrault N, Perrillo RP, Hoofnagle JH. Recent US Food and Drug Administration warnings on hepatitis B reactivation with immune-suppressing and anticancer drugs: just the tip of the iceberg? Hepatology. 2015; 61(2): 703. 11. Cheng J, Li JB, Sun QL et al. Reactivation of Hepatitis B Virus After Steroid Treatment in Rheumatic Diseases. The Journal of Rheumatology. 2011; 38 (1): 181-182. 12. Benhamou Y, Bochet M, Thibault V, et al. Long-term incidence of hepatitis B virus resistance to lamivudine in human immunodeficiency virus-infected patients. Hepatology. 1999; 30: 1302-1306. 13. Farthing M, Fedail S, Savioli L et al. WGO Practice Guideline: Management of strongyloides. 2004. 14. Khan K, Heidebrecht C, Sears J et al. Appendix 8: Intestinal parasites – Strongyloides and Schistosoma: evidence review for newly arriving immigrants and refugees. CMAJ . 2011; 183(12): E824-925. 15. Pai M, Kunimoto D, Jamieson F, et al. Canadian Tuberculosis Standards – 7th edition. Centre for Communicable Diseases and Infection Control - Public Health Agency of Canada. February 2014: 75. 16. Singh JA, Furst DE, Bharat A et al. 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis. Arthritis Care & Research 2012; 64(5): 625–639. 17. Liu D, Ahmet A, Ward L et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy, Asthma & Clinical Immunology. 2013, 9:30.