Malawi

AbstractBackground: Cervical cancer is the leading cause of cancer incidence and mortality among Malawian women, despite being a largely preventable disease.

The objective of this study was to investigate the role stressors, sociodemographic characteristics and job tasks of health surveillance assistants (HSAs) and to explore major predictors of role stressors and job satisfaction of HSAs in Malawi. Data were collected from health centres and hospitals of three Malawi districts of Mangochi, Lilongwe and Mzimba. Respondents were 430 HSAs. The key findings of this study were role ambiguity and role overload were significantly negatively related to job satisfaction, while role conflict was insignificantly related to job satisfaction. Additionally, the clinical tasks of the HSAs and some of the sociodemographic variables were associated with the role stressors and job satisfaction of the HSAs in Malawi. Since the HSAs' clinical tasks were significantly related to all role stressors, there is need by the government of Malawi to design strategies to control the role stressors to ensure increased job performance and job satisfaction among HSAs. Furthermore, studies may be required in the future to assist government to control role stressors among HSAs in Malawi.

To identify and to assess factors enhancing or hindering the delivery of breast and cervical cancer screening services in Malawi with regard to accessibility, uptake, acceptability and effectiveness, a search of six bibliographic databases and grey literature was executed to identify relevant studies conducted in Malawi in English. One hundred and one unique records were retrieved and 6 studies were selected for final inclusion in the review. Multiple factors affect breast and cervical cancer service delivery in Malawi, operating at three interlinked levels. At the patient level, lack of knowledge and awareness of the disease, location, poor screening environment and perceived quality of care may act as deterrents to participation in screening; at the health facility level, services are affected by the availability of resources and delivery modalities; and at the healthcare system level, inadequate funding and staffing and lack of appropriate monitoring and guidelines may have a negative impact on services. Convenience of screening, in terms of accessibility and integration with other health services, was found to have a positive effect on service uptake. Building awareness of cancer and related services and offering quality screening are significant determinants of patient satisfaction. Capitalising on these lessons is essential to strengthen breast and cervical cancer service delivery in Malawi, to increase early detection and to improve survival of women.

Effective implementation of policies for expanding antiretroviral therapy (ART) requires a well-trained and adequately staffed workforce. Changes in national HIV workforce policies, health facility practices, and provider experiences were examined in rural Malawi and Tanzania between 2013 and 2017. In both countries, task-shifting and task-sharing policies were explicit by 2013. In facilities, the cadre mix of providers varied by site and changed over time, with a higher and growing proportion of lower cadre staff in the Malawi site. In Malawi, the introduction of lay counsellors was perceived to have eased the workload of other providers, but lay counsellors reported inadequate support. Both countries had guidance on the minimum numbers of personnel required to deliver HIV services. However, patient loads per provider increased in both settings for HIV tests and visits by ART patients and were not met with corresponding increases in provider capacity in either setting. Providers reported this as a challenge. Although increasing patient numbers bodes well for achieving universal antiretroviral therapy coverage, the quality of care may be undermined by increased workloads and insufficient provider training. Task-shifting strategies may help address workload concerns, but require careful monitoring, supervision and mentoring to ensure effective implementation.

National HIV testing policies aim to increase the proportion of people living with HIV who know their status. National HIV testing policies were reviewed for each country from 2013 to 2018, and compared with WHO guidance. Three rounds of health facility surveys were conducted to assess facility level policy implementation in Karonga (Malawi), uMkhanyakude (South Africa), and Ifakara (Tanzania). A policy "implementation" score was developed and applied to each facility by site for each round. Most HIV testing policies were explicit and aligned with WHO recommendations. Policies about service coverage, access, and quality of care were implemented in >80% of facilities per site and per round. However, linkage to care and the provision of outreach HIV testing for key populations were poorly implemented. The proportion of facilities reporting HIV test kit stock-outs in the past year reduced over the study period in all sites, but still occurred in ≥17% of facilities per site by 2017. The implementation score improved over time in Karonga and Ifakara and declined slightly in uMkhanyakude. Efforts are needed to address HIV test kit stock-outs and to improve linkage to care among people testing positive in order to reach the 90-90-90 targets.

This survey assessed recently pregnant women's knowledge of malaria in pregnancy (MIP) and their experiences with community health workers (CHWs) prior to implementing community delivery of intermittent preventive treatment in pregnancy (cIPTp). Data were collected via a household survey in Ntcheu and Nkhata Bay Districts, Malawi, from women aged 16-49 years who had a pregnancy resulting in a live birth in the previous 12 months. A total of 370 women were interviewed. Women in both districts found their community health workers (CHWs) to be helpful (77.9%), but only 35.7% spoke with a CHW about antenatal care and 25.8% received assistance for malaria during their most recent pregnancy. A greater proportion of women in Nkhata Bay than Ntcheu reported receiving assistance with malaria from a CHW (42.7% vs 21.9%); women in Nkhata Bay were more likely to cite IPTp-SP as a way to prevent MIP (41.0% vs 24.8%) and were more likely to cite mosquito bites as the only way to spread malaria (70.6% vs 62.0%). Women in Nkhata Bay were more likely to receive 3 + doses of IPTp-SP (IPTp3) (59.2% vs 41.8%). Adequate knowledge was associated with increased odds of receiving IPTp3, although not statistically significantly so. Women reported positive experiences with CHWs, but there was not a focus on MIP. Women in Nkhata Bay were more likely to be assisted by a CHW, had better knowledge, and were more likely to receive IPTp3+ . Increasing CHW focus on the dangers of MIP and implementing cIPTp has the potential to increase IPTp coverage.

AbstractMalawi is midway through its current Malaria Strategic Plan 2017–2022, which aims to reduce malaria incidence and deaths by at least 50% by 2022. Malariometric data are available with health surveillance data housed in District Health Information Software 2 (DHIS2) and household survey data from two recent Malaria Indicator Surveys (MIS) and a Demographic and Health Survey (DHS).

The aim of this study was to assess the uptake and determinants of HIV testing among men in Malawi. Secondary data analysis was conducted on cross–sectional household data for 7478 men aged 15 to 54 years drawn from the 2015–16 Malawi Demographic and Health Survey. Secondary data analysis was conducted on cross–sectional household data for 7478 men aged 15 to 54 years drawn from the 2015–16 Malawi Demographic and Health Survey. Descriptive statistics, bivariate and multivariable logistic regression analyses were performed to identify the socio–demographic, behavioral and health service related factors that are associated with HIV testing service utilisation by men in Malawi. All analyses were performed using the complex sample analysis procedure of the Statistical Package for the Social Sciences version 22.0 to account for the multistage sampling used in Demographic Health Survey. Overall, 69.9% of the participants had ever been tested for HIV. The results indicate that age, region of residence, marital status, covered by health insurance, education and age at first sexual debut are significant predictors of HIV testing among men in Malawi. In particular, men who were in the age group 30–39 years, married, those with secondary or above education, and those who had health insurance were more likely to utilise HIV testing service than their counterparts. The findings suggest that HIV testing services and programmes need to target younger unmarried men aged 15–19 and men with low level or no education and expand HIV testing services to the central and southern regions of Malawi. 

Evidence suggests that disclosure of HIV status between partners may influence prevention of maternal-to-child transmission of HIV (PMTCT) outcomes. We report partner disclosure in relation to maternal antiretroviral therapy (ART) uptake and adherence, and MTCT among postpartum HIV-infected Malawian women. A cross-sectional mixed-method study was conducted as part of a nationally representative longitudinal cohort study. Between 2014–2016, all (34,637) mothers attending 54 under-5 clinics with their 4–26 week-old infants were approached, of which 98% (33,980) were screened for HIV; infants received HIV-1 DNA testing. HIV-exposure was confirmed in 3,566/33,980 (10.5%). Among 2882 couples, both partners, one partner, and neither partner disclosed to each other in 2090 (72.5%), 622 (21.6%), and 169 (5.9%), respectively. In multivariable models, neither partner disclosing was associated with no maternal ART, suboptimal treatment adherence and MTCT.  

Malawi has a mature integrated community case management (iCCM) programme that is led by the Ministry of Health (MOH) but that still relies on donor support. From 2013 until 2017, under the Rapid Access Expansion (RAcE) programme, the World Health Organization supported the MOH to expand and strengthen iCCM services in four districts. This paper examines Malawi’s iCCM programme performance and implementation strength in RAcE districts to further strengthen the broader programme. Baseline and endline household surveys were conducted in iCCM-eligible areas of RAcE districts. Care-seeking from HSAs and treatment of fever improved over the project period. At endline, however, less than half of sick children were brought to an HSA, many caregivers reported a preference for providers other than HSAs, and perceptions of HSAs as trusted providers of high-quality, convenient care had decreased. HSA supervision and mentorship were below MOH targets. Stockouts of malaria medicines were associated with decreased care-seeking from HSAs. Additional qualitative research is needed to examine challenges and to inform potential solutions. Malawi’s mature iCCM programme has a strong foundation but can be improved to strengthen the continuity of care from communities to facilities and to ultimately improve child health outcomes.

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