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This paper is a study of 14 media houses in Malawi and it looks at coverage of human rights issue from various dimensions. A questionnaire was administered to journalists of diverse levels at these media houses to gather data concerning the research. The targeted media houses are located in the main urban centres of Malawi and include radio, television and newspaper publishers. The findings indicate that training, lack of specialised units in newsrooms, inadequate reference materials and reluctance by officials to give out required information are some of the issues that are hampering coverage of human rights stories in the country. The paper also looks at suggestions made by journalists to help improve reportage of human rights in Malawi. It then makes recommendations based on evidence gathered through the questionnaires on how the media and other concerned stakeholders can work together for better human rights reporting in the country. [ABSTRACT FROM AUTHOR]

Temptation plays a key role in theoretical work on spending and saving in developing countries. The limited empirical evidence on its importance, however, suggests that cash transfers do not induce increases in temptation spending. This paper expands the evidence base by studying the effect of randomized exposure to temptation on spending decisions in rural Malawi. Consistent with the cash transfer literature, a more tempting environment does not induce significant changes in temptation spending. However, the magnitudes of both temptation spending levels and the treatment effects are somewhat sensitive to the definition of temptation spending used. This paper examines the potential factors that may be driving these null results, and suggests that future research may find a limited role for temptation in the economic decisions of the poor. [ABSTRACT FROM AUTHOR]

The paper contributes to the scarce literature on the negative effect of coronavirus 2019-induced income and food price shocks on household economic access to food, focusing on Malawi during the first two pandemic waves and using a country representative sample. We find that household income reduction, as explained by income source shocks and health mitigation measures, has a wave-specific and persistent effect on ordinal categories of food security perception. Our evidence supports the implementation and monthly scaling-up of nutrition-sensitive social protection programmes and health measures at the household level to address these adverse effects. [ABSTRACT FROM AUTHOR]

High human immunodeficiency virus (HIV)–prevalence countries in Southern and Eastern Africa continue to receive substantial external assistance (EA) for HIV programming, yet countries are at risk of transitioning out of HIV aid without achieving epidemic control. We sought to address two questions: (1) to what extent has HIV EA in the region been programmed and delivered in a way that supports long-term sustainability and (2) how should development agencies change operational approaches to support long-term, sustainable HIV control? We conducted 20 semi-structured key informant interviews with global and country-level respondents coupled with an analysis of Global Fund budget data for Malawi, Uganda, and Zambia (from 2017 until the present). We assessed EA practice along six dimensions of sustainability, namely financial, epidemiological, programmatic, rights-based, structural and political sustainability. Our respondents described HIV systems' vulnerability to donor departure, as well as how development partner priorities and practices have created challenges to promoting long-term HIV control. The challenges exacerbated by EA patterns include an emphasis on treatment over prevention, limiting effects on new infection rates; resistance to service integration driven in part by 'winners' under current EA patterns and challenges in ensuring coverage for marginalized populations; persistent structural barriers to effectively serving key populations and limited capacity among organizations best positioned to respond to community needs; and the need for advocacy given the erosion of political commitment by the long-term and substantive nature of HIV EA. Our recommendations include developing a robust investment case for primary prevention, providing operational support for integration processes, investing in local organizations and addressing issues of political will. While strategies must be locally crafted, our paper provides initial suggestions for how EA partners could change operational approaches to support long-term HIV control and the achievement of universal health coverage. [ABSTRACT FROM AUTHOR]

Introduction: Diversification away from tobacco production has been identified as a priority for Malawi, historically one of the world's most tobacco-reliant countries.Methods: This paper refers to a nationally representative data set to characterize broad trends in production since 2000 to understand whether Malawi is shifting away from tobacco and how production has changed over time.Results: From 2004 to 2019, the share of Malawian crop farmers producing tobacco fell from 16% to 5%, and tobacco's share of the total value of crop production also declined sharply. Tobacco farms are generally growing larger (in size and scale of production) over time. However, land productivity remains low, with net returns of 93 000 MWK (128 USD) per hectare at the median. Farm-gate prices for tobacco have declined relative to the prices of maize or fertilizer, rendering tobacco a less lucrative avenue to generate the cash income needed to purchase these key items. In addition, the share of the export price received by farmers has also declined over time, with the median farm-gate price representing 32% of the export price in 2004 and 18% in 2019.Conclusions: In some respects, a transition away from tobacco has already occurred. Additional research is needed to understand why the farm-gate share of tobacco export prices has declined over this period and how the livelihoods of smallholder farm-households that exited tobacco production have been affected.Implications: To the extent that tobacco prices appear to be declining, there is a need to rigorously assess whether farmers have suitable crop alternatives (with established markets) and other livelihood options. Likely, investments are yet needed to foster strong alternatives to tobacco; such investments include research and development in on-farm technologies to raise the productivity of non-tobacco crops, as well as improvements in non-tobacco value chains to reduce transportation costs and promote private investment. [ABSTRACT FROM AUTHOR]

In recent decades, qualitative research from across sub-Saharan Africa has shown how young men are often unable to marry because they lack wealth and a stable livelihood. With survey data, researchers have begun to study how men's economic circumstances are related to when they marry in the continent's capitals and larger urban centers. However, our understanding of these dynamics outside of large cities remains limited. Drawing on longitudinal survey data, this paper examines how men's economic standing, both at the individual and household level, relates to their marriage timing in rural and semi-urban communities in the Salima district of Malawi. The findings show that men who have higher earnings, work in agriculture, and come from a household that sold cash crops were more likely to marry. In contrast, students as well as men from households owning a large amount of land were substantially less likely to marry. Additionally, men living in the semi-urban communities were around half as likely to marry as their rural counterparts. This negative association is largely explained by the greater proportion of men who are students in towns and trading centers and also the relatively less agricultural nature of these communities. These findings show the value of considering both individual and family characteristics in studies of marriage timing and also suggest that as sub-Saharan Africa urbanizes, the age of marriage for men will likely rise. [ABSTRACT FROM AUTHOR]

In Malawi, there has been an unprecedented increase in the number of foreign companies looking to invest in the mining sector. However, in a country where mining sector regulations are woefully inadequate but where the government seems determined to attract overseas investors, it is important to adopt approaches which ensure that the benefits of mining are maximized and that its adverse community-level impacts are minimized. Focusing on the experiences of the Kayerekera Uranium and Chimwadzulu Ruby projects, this paper critically examines how the rapid increase in mining activities in Malawi is affecting local livelihoods. In doing so, the paper explores how civil society has influenced the development of the corporate social responsibility strategies of incoming companies and how well the needs of communities are being met. Given the inadequacies of mining regulations, greater participation from civil society actors and the communities themselves in decisions pertaining to mine development is a key to effective community development in emerging mineral economies such as Malawi. [ABSTRACT FROM PUBLISHER]

This paper studies the relationship between group size and informal risk sharing. It shows that under limited commitment with coalitional deviations, this relationship is theoretically ambiguous. It investigates this question empirically using data on sibship size of household heads and spouses from rural Malawi, exploiting a social norm among the main sample ethnic group to define the potential risk‐sharing group. We uncover evidence of worse risk sharing of crop losses in larger potential risk‐sharing groups, and rule out alternative explanations for the findings. A simple calibration exercise indicates that our empirical findings are consistent with the theory. [ABSTRACT FROM AUTHOR]

This paper considers, the significance which the UN Convention on the Rights of the Child has for poor children. It does this by setting out a series of issues which would need to form part of a research agenda in evaluating the implication of the Convention for Malawi. In doing this, the paper provides a blueprint for action in all countries which experience a similar degree of economic deprivation as Malawi. It is concluded that the Convention could play a crucial role in advancing the interests of children in such countries. [ABSTRACT FROM AUTHOR]

It is well known that many victims of crime do not notify the police. Research suggests that factors related to the victim, crime event and wider community are all implicated in the decision to report victimization. Few studies have investigated the correlates of victim reporting in developing countries, mainly owing to a lack of relevant data. It is therefore unclear whether the determinants of victim reporting in Western industrialized countries are generalizable to low-income developing settings. This paper explores the factors associated with victims reporting assault to the police in the African context of Malawi, using data from a nationally representative household survey. Results of a multilevel logistic regression indicate some similarities with the Western criminological literature, such as age of the victim and crime seriousness positively correlating with crime reporting. Other results seem to reflect the distinctive characteristics of Malawi, with victims more likely to report being assaulted if they are male, have access to a working phone or live in urban areas. The results illustrate the importance of studying criminological phenomena across a diverse range of settings. Implications of the findings for future research and crime prevention are discussed. [ABSTRACT FROM PUBLISHER]

This study employs a difference-in-differences estimation strategy to study the causal impacts of free primary education (FPE) on women's schooling and fertility-related outcomes using the 1990s FPE reform of Malawi. The results show that full exposure to FPE at the mean value of the reform's potential impact led to an 18.5 percentage points increase in the probability of ever enrolling in school and 1.2 years of additional schooling. Furthermore, the reduced form estimates suggest that full exposure to FPE increased age at first marriage and at first childbirth by almost 0.79 and 0.98 years respectively. The study also finds statistically significant reductions at all ages between age 14 and 24 in the total number of children to which women give birth. By age 24, for example, full exposure to FPE at the mean value of the reform's potential impact led to 0.28 fewer children. In addition, there is evidence showing that exposure to FPE led to increased spacing between the first two births (about six additional months) if the first child is female. The study explores several channels through which FPE may affect fertility-related outcomes. Postponement of marriage and first childbirth, increased contraceptive use, and changes in mate characteristics all play a role. [ABSTRACT FROM AUTHOR]

High-quality data are essential to monitor and evaluate community health worker (CHW) programmes in low- and middle-income countries striving towards universal health coverage. This mixed-methods study was conducted in two purposively selected districts in Kenya (where volunteers collect data) and two in Malawi (where health surveillance assistants are a paid cadre). We calculated data verification ratios to quantify reporting consistency for selected health indicators over 3 months across 339 registers and 72 summary reports. These indicators are related to antenatal care, skilled delivery, immunization, growth monitoring and nutrition in Kenya; new cases, danger signs, drug stock-outs and under-five mortality in Malawi. We used qualitative methods to explore perceptions of data quality with 52 CHWs in Kenya, 83 CHWs in Malawi and 36 key informants. We analysed these data using a framework approach assisted by NVivo11. We found that only 15% of data were reported consistently between CHWs and their supervisors in both contexts. We found remarkable similarities in our qualitative data in Kenya and Malawi. Barriers to data quality mirrored those previously reported elsewhere including unavailability of data collection and reporting tools; inadequate training and supervision; lack of quality control mechanisms; and inadequate register completion. In addition, we found that CHWs experienced tensions at the interface between the formal health system and the communities they served, mediated by the social and cultural expectations of their role. These issues affected data quality in both contexts with reports of difficulties in negotiating gender norms leading to skipping sensitive questions when completing registers; fabrication of data; lack of trust in the data; and limited use of data for decision-making. While routine systems need strengthening, these more nuanced issues also need addressing. This is backed up by our finding of the high value placed on supportive supervision as an enabler of data quality. [ABSTRACT FROM AUTHOR]

Background This study aimed to determine the key mental health indicators affecting people affected by lymphatic filariasis (LF) lymphoedema by assessing the prevalence of depressive symptoms and quality of life (QOL), identifying associated sociodemographic and clinical risk factors, and evaluating the impact of an enhanced self-care intervention for lymphoedema management. Methods A prospective cohort study of adults with filarial lymphoedema from two regions of Malawi was conducted over six months in 2021. Depressive symptoms and QOL were assessed using Patient Health Questionnaire (PHQ-9) and LF Specific QOL Questionnaire, respectively, at baseline (pre-intervention), 3- and 6-months (postintervention). Beta regression analysis identified risk factors, and assessed the impact of the intervention. Results Three hundred eleven affected individuals were surveyed with 23% (95% CI 18%–29%) reporting mild/moderate depressive symptoms and 31% (95% CI 26%–37%) reporting moderately low/low QOL. Higher depressive symptom scores were associated with high frequency of acute filarial attack episodes. Individuals with higher depressive symptoms (Adjusted Odds Ratios (AOR) 0.93, 95% CI 0.93–0.93) and lower QOL (AOR 0.98, 0.98–0.98) showed greatest improvement in mental health indicators over 3-months but was not sustained to the same level at 6-months. Conclusions Sustained morbidity management and psychological support is recommended for affected persons to ensure long-term positive mental health and clinical outcomes. Contexte Cette étude vise à déterminer les principaux indicateurs de santé mentale affectant les personnes atteintes de lymphœdème dû à la filariose lymphatique (FL) en évaluant la prévalence des symptômes dépressifs et la qualité de vie (QV), en identifiant les facteurs de risque sociodémographiques et cliniques associés, et en évaluant l'impact d'une intervention améliorée d'autosoins pour la gestion du lymphœdème. Méthodes Une étude de cohorte prospective d'adultes atteints de lymphoedème filaire dans deux régions du Malawi a été menée pendant six mois en 2021. Les symptômes dépressifs et la qualité de vie ont été évalués à l'aide du questionnaire sur la santé des patients (PHQ-9) et du questionnaire sur la qualité de vie spécifique au lymphœdème, respectivement, au début de l'étude (avant l'intervention), et à 3 puis 6 mois après l'intervention. Une analyse de régression beta a permis d'identifier les facteurs de risque et d'évaluer l'impact de l'intervention. Résultats Trois cent onze personnes affectées ont été interrogées, dont 23% (95% CI 18%–29%) ont déclaré des symptômes dépressifs légers/modérés et 31% (95% CI 26%–37%) ont déclaré une qualité de vie modérément faible/faible. Des scores élevés de symptômes dépressifs ont été associés à une fréquence élevée d'épisodes de crises filariennes aiguës. Les personnes présentant des symptômes dépressifs plus élevés (rapport de cotes ajusté (RCA) 0.93, IC à 95 % 0.93–0.93) et une qualité de vie plus faible (RCA 0.98, 0.98–0.98) ont montré la plus grande amélioration des indicateurs de santé mentale au cours des trois mois, mais cette amélioration ne s'est pas maintenue au même niveau au cours des six mois suivants. Conclusion Gestion de la morbidité et soutien psychologique sont des éléments clés pour garantir une santé mentale et des résultats cliniques satisfaisants de personnes atteintes sur le long terme. Antecedentes Este estudio tuvo como objetivo determinar los indicadores clave de salud mental que afectan a las personas afectadas por linfedema por filariasis linfática (FL) mediante la evaluación de la prevalencia de síntomas depresivos y calidad de vida (CdV), la identificación de factores de riesgo sociodemográficos y clínicos asociados, y la evaluación del impacto de una intervención de autocuidado mejorada para el manejo del linfedema. Métodos Se realizó un estudio prospectivo de cohortes de adultos con linfedema filarial de dos regiones de Malawi durante seis meses en 2021. Los síntomas depresivos y la calidad de vida se evaluaron mediante el Cuestionario de Salud del Paciente (PHQ-9) y el Cuestionario de Calidad de Vida específico para el LF Cuestionario, respectivamente, al inicio (preintervención) y a los 3 y 6 meses (posintervención). El análisis de regresión beta identificó los factores de riesgo y evaluó el impacto de la intervención. Resultados Se encuestó a 311 afectados, de los cuales el 23% (IC 95%, 18%–29%) presentaba síntomas depresivos leves/moderados y el 31% (IC 95%, 26%–37%) una CdV moderadamente baja/baja CdV. Las puntuaciones más altas de síntomas depresivos se asociaron con una alta frecuencia de episodios de ataques agudos de filarias. Los individuos con mayores síntomas depresivos (Odds Ratios Ajustados [ORA] 0.93; IC 95%: 0.93–0.93) y menor CdV (ORA 0.98; 0.98–0.98) mostraron la mayor mejoría en los indicadores de salud mental a los 3 meses, pero no se mantuvo al mismo nivel a los 6 meses. Conclusiones Se recomienda el manejo sostenido de la morbilidad y el apoyo psicológico a las personas afectadas para garantizar resultados clínicos y de salud mental positivos a largo plazo. [ABSTRACT FROM AUTHOR]

Indemnifying smallholder farmers against crop loss is thought to play an important role in encouraging the adoption of new technologies and facilitating productivity growth, but to be infeasible due to information problems. Consequently there is interest in developing alternative, partial, insurance products. Examples include rainfall insurance and the limited liability inherent in credit contracts. I argue that although these products may reduce information asymmetry, ambiguity averse farmers struggle to assess whether the contracts reduce risk. This problem is most pronounced when the production technology is ambiguous, as is likely the case for new technologies. I formalize this argument and test the theory using data from two RCTs, conducted in Malawi and Kenya. Comparative statics from the theory are consistent with both sets of data, and I argue that income losses from ambiguity aversion may be substantial. [ABSTRACT FROM AUTHOR]

This paper reports the process evaluation of a peer group intervention for human immunodeficiency virus (HIV) prevention which had positive outcomes for three target groups in Malawi: rural adults, adolescents and urban hospital workers. The six-session intervention was delivered to small groups of 10–12 participants by 85 trained volunteer peer leaders working in pairs. A descriptive, observational mixed methods design was used with a convenience sample of 294 intervention sessions. Using project records and a conceptually based observation guide, we examined five aspects of the implementation process. The context was favorable, but privacy to discuss sensitive issues was a concern for some groups. In study communities, program reach was 58% of rural adults, 70% of adolescents and nearly all hospital workers. Session records confirmed that all peer groups received the intended six sessions (dose delivered). The dose received was high, as evidenced by high participant engagement in peer group activities. Peer leaders were rated above the median for three indicators of peer group content and process fidelity: session management skills, interpersonal facilitation skills and whether more like a peer group than classroom. Documenting that this HIV prevention peer group intervention was delivered as intended by trained peer volunteers supports widespread dissemination of the intervention. [ABSTRACT FROM PUBLISHER]

The paper presents a hierarchical discrete time survival model for the analysis of the 2000 Malawi Demographic and Health Survey data to assess the determinants of transition to marriage among women in Malawi. The model explicitly accounts for the unobserved heterogeneity by using family and community random effects with cross-level correlation structure. A nonparametric technique is used to model the base-line discrete hazard dynamically. Parameters of the model are computed by using a Markov chain Monte Carlo algorithm. The results show that rising age at marriage is a combination of birth cohort and education effects, depends considerably on the family and to some extent on the community in which a woman resides and the correlation between family and community random effects is negative. These results confirm a downward trend in teenage marriage and that raising women's education levels in sub-Saharan Africa has the beneficial effect of increasing age at marriage, and by implication reducing total fertility rates. The negative correlation between family and community random effects has policy implications in that targeting communities with an intervention to increase age at first marriage may not necessarily yield reduced fertility levels in individual families. A campaign that is geared towards individual families would achieve the desired goals. Overall, the findings point to the need for the Government in Malawi to enact public policies which are geared at vastly improving women's education at higher levels. The variation in marriage rates over families poses problems in delivering the policy, since particular policies must be devised for specific groups of families to accomplish the required social and health objectives. [ABSTRACT FROM AUTHOR]

Largely inspired by western donor good governance agenda, the current African parliaments literature has overlooked the significance of new parliament buildings that have been constructed by China and tends to place a premium on appraising the performance of parliaments and parliamentarians in executing their legislative, representation, oversight and constituency support. While understanding how parliaments perform is important and necessary, it does not sufficiently address all the ways in which these parliaments are establishing themselves as sustainable political institutions. By disregarding the new parliament buildings, the literature potentially undermines prospects of a wider understanding of the development of African parliamentary institutions. This article leverages the Chinese government donated parliament buildings in Lesotho and Malawi to make a theoretical and comparative case for the utility of discussing the concept of African legislative institutionalisation through and in juxtaposition to, the parliamentary built environment. I find that although there are stylistic and operational differences, the new parliament buildings in Lesotho and Malawi have provided a bespoke parliamentary built environment, enabled the expansion of a cohort of public officials working on legislative business and facilitated the procedural activities of the institution. [ABSTRACT FROM AUTHOR]

Health rights of prisoners has long been a neglected political issue in Africa, where over one million people are detained, and almost half of whom are in pre-trial detention. African prisons constitute high-risk environments for communicable disease transmission. During the COVID-19 pandemic, the public health literature on African prison responses focused on preparedness as it related to testing capacity, quarantine practices and personal protective measures to mitigate disease spread. This article combines the right to health as narrowly defined by a prisoner's right to access non-discriminatory equivalent health care, with a broader focus on assessing normative standards of detention. A comparative legal realist assessment of prison operations in South Africa, Malawi and Zimbabwe during COVID-19 state disaster measures is presented, focusing on the environmental determinants of health (ventilation, minimum floor space, water, sanitation, hygiene and nutrition) in prisons. It reveals the inherent tensions in ensuring a balance between respecting the fundamental rights of people living and working in prisons, ensuring adequate environmental health standards and mitigating disease during public health emergencies. Despite insufficient government resourcing and inadequate coverage of COVID-19 responses, few severe outbreaks were reported. This could be due to lack of testing, reporting or other factors (asymptomatic infection, acquired immunity). Prison congestion and unrest however affected prisoners and staff fearful of hazardous living and occupational health conditions. COVID-19 as public health emergency amplifies the need to address systemic deficits in infrastructure, resourcing and efficiency of criminal justice systems. Policy level and pragmatic recommendations for enhanced human rights practice are outlined. [ABSTRACT FROM AUTHOR]

Background Tuberculosis case-finding interventions are critical to meeting World Health Organization End TB strategy goals. We investigated the impact of community-wide tuberculosis active case finding (ACF) alongside scale-up of human immunodeficiency virus (HIV) testing and care on trends in adult tuberculosis case notification rates (CNRs) in Blantyre, Malawi. Methods Five rounds of ACF for tuberculosis (1–2 weeks of leafleting, door-to-door enquiry for cough and sputum microscopy) were delivered to neighborhoods ("ACF areas") in North-West Blantyre between April 2011 and August 2014. Many of these neighborhoods also had concurrent HIV testing interventions. The remaining neighborhoods in Blantyre City ("non-ACF areas") provided a non-randomized comparator. We analyzed TB CNRs from January 2009 until December 2018. We used interrupted time series analysis to compare tuberculosis CNRs before ACF and after ACF, and between ACF and non-ACF areas. Results Tuberculosis CNRs increased in Blantyre concurrently with start of ACF for tuberculosis in both ACF and non-ACF areas, with a larger magnitude in ACF areas. Compared to a counterfactual where pre-ACF CNR trends continued during ACF period, we estimated there were an additional 101 (95% confidence interval [CI] 42 to 160) microbiologically confirmed (Bac+) tuberculosis diagnoses per 100 000 person-years in the ACF areas in 3 and a half years of ACF. Compared to a counterfactual where trends in ACF area were the same as trends in non-ACF areas, we estimated an additional 63 (95% CI 38 to 90) Bac + diagnoses per 100 000 person-years in the same period. Conclusions Tuberculosis ACF was associated with a rapid increase in people diagnosed with tuberculosis in Blantyre. [ABSTRACT FROM AUTHOR]

The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers' ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N  = 112) with government actors, development partners and civil societies in three districts or counties in each country (N  = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach. [ABSTRACT FROM AUTHOR]

Summary: Vision impairment among children is associated with lower levels of educational attainment. School-based eye health programs have the potential to provide high-quality and cost-effective services that assist in the prevention of blindness and uncorrected vision impairment, particularly in low-resources settings. The aim of this study was to identify key factors that inhibit or facilitate the provision of school-based eye health programs, including referral to eye care services, for Malawian children in the Central Region. In-depth interviews (n = 10) and focus groups (n = 5) with children, parents, school staff, eye care practitioners, government and NGO workers (total participants n = 44) in rural and urban contexts within central region, Malawi, were conducted. Taking a rights-based approach, we used the AAAQ (availability, accessibility, acceptability, quality) framework to identify barriers and enablers to school eye health programs. Complex factors shape access to school-based eye health programs. While intersectoral collaboration between ministries was present, infrastructure and resourcing restricted the delivery of school eye health programs. School staff were supportive of being trained as vision screeners. Parents voiced geographic access to follow up eye care, and spectacle cost as a barrier; and children revealed experiences of stigma related to spectacle as barriers to uptake. School-based eye care may be facilitated through teachers, community informants and health workers through; the provision of school vision screening; increased awareness of the impact of vision impairment on education and future employment; and through educational approaches that seek to decrease stigma and misconceptions associated with wearing spectacles. [ABSTRACT FROM AUTHOR]

Global financing for the HIV response has reached unprecedented levels in recent years. Over US$10 billion were mobilized in 2007, an effort credited with saving the lives of millions of people living with HIV (PLHIV). A relatively unexamined aspect of the global HIV response is the role of the private sector in financing HIV/AIDS services. As the nature of the response evolves from emergency relief to long-term sustainability, understanding current and potential contributions from the private sector is critical. This paper examines trends in private sector financing, management and resource consumption related to HIV/AIDS in five sub-Saharan African countries, with a particular emphasis on the effects of recently scaled-up donor funding on private sector contributions. We analysed National Health Accounts HIV/AIDS subaccount data for Kenya, Malawi, Rwanda, Tanzania and Zambia between 2002 and 2006. HIV subaccounts provide comparable data on the flow of HIV/AIDS funding from source to use. Findings indicate that private sector contributions decreased in all countries except Tanzania. With regards to managing HIV/AIDS funds, non-governmental organizations are increasingly controlling the largest share of resources relative to other stakeholders, whereas private for-profit entities are managing fewer HIV/AIDS resources since the donor influx. The majority of HIV/AIDS funds were spent in the public sector, although a considerable amount was spent at private facilities, largely fuelled by out-of-pocket (OOP) payments. On the whole, OOP spending by PLHIV decreased over the 4-year period, with the exception of Malawi, demonstrating that PLHIV have increased access to free or subsidized HIV/AIDS services. Our findings suggest that the influx of donor funding has led to decreased private contributions for HIV/AIDS. The reduction in private sector investment and engagement raises concerns about the sustainability of HIV/AIDS programmes over the long term, particularly in light of current global economic crisis and emerging competing priorities. [ABSTRACT FROM AUTHOR]

Fall armyworm (Spodoptera frugiperda Smith), a serious pest of cereals from the Americas, has spread across sub-Saharan Africa and Asia since 2016, threatening the food security and incomes of millions of smallholder farmers. To measure the impact of S. frugiperda under different management approaches, we established on-farm trials across 12 landscapes (615–1,379 mm mean annual rainfall) in Malawi and Zambia during the 2019/2020 and 2020/2021 seasons. Here we present the results from our conventional tillage, monocrop maize, no pesticide treatment, which served to monitor the background S. frugiperda impact in the absence of control measures. Median plot-level S. frugiperda incidence ranged between 0.00 and 0.52 across landscapes. Considering severe leaf damage (Davis score ≥5), the proportion of affected plants varied between 0.00 and 0.30 at the plot scale, but only 3% of plots had ≥10% severely damaged plants. While incidence and damage severity varied substantially among sites and seasons, our models indicate that they were lower in high tree cover landscapes, in the late season scouting, and in the 2020/2021 season. Yield could not be predicted from S. frugiperda incidence or leaf damage. Our results suggest S. frugiperda impacts may have been overestimated at many sites across sub-Saharan Africa. S. frugiperda incidence and damage declined through the cropping season, indicating that natural mortality factors were limiting populations, and none of our plots were heavily impacted. Long-term S. frugiperda management should be based on Integrated Pest Management (IPM) principles, including minimising the use of chemical pesticides to protect natural enemies. [ABSTRACT FROM AUTHOR]

Background In northern rural Malawi, the majority of households cook using open fires and there is also a high burden of adverse birth outcomes. The use of open fires or highly polluting cookstoves is associated with low birthweight in babies. There is mixed evidence on whether implementation of cleaner burning cookstoves reduces the number of babies born with low birthweight. Methods This is a secondary analysis of a cluster randomized control trial in Malawi, conducted over 2014–17. Households were randomized to receive improved cookstoves or to continue current practices. For this analysis, the primary outcome was low birthweight in households under routine demographic surveillance, among births occurring within the trial time frame (N  = 4010). A subset of data with stricter exposure definitions respecting the original randomized allocation was also analysed (N  = 1050). A causal, forwards modelling approach was used. Results The main dataset showed evidence of effect of the intervention on low birthweight [adjusted odds ratio (aOR) 0.69; 95% CI 0.48–0.99, n  = 2788). The subset analysis lacked power to provide evidence of association between improved cookstoves and low birthweight in the stricter exposure definition (aOR 0.62; 95% CI 0.35–1.09, n  = 932). Conclusions This study provides some evidence that an improved cookstove intervention in rural Malawi reduced the number of babies born with low birthweight by 30%. This direction of the effect was also seen in the subset analysis. The analysis suggests that the intervention reduced the number of infants born prematurely or with intra-uterine growth restriction, indicating that improved cookstoves could be a useful maternal health intervention. [ABSTRACT FROM AUTHOR]

Aims: The environment is increasingly recognized as an important reservoir of antimicrobial resistance genes (ARGs), which can be identified using molecular platforms. Yet, environmental surveillance remains an underutilised tool as there is no agreement on the best strategy for sample processing. We aim to develop a low‐cost extraction method independent to commercial kits or reagents. Methods and Results: We present a novel, magnetic bead‐based method for the isolation of ARGs from river water named MagnaExtract. We present this with analytic limit of detection as well as a case study in Southern Malawi. Here we compare the DNA yield from MagnaExtract with commercially available QIAGEN kits and the crude boil and spin method, using a high‐resolution melt analysis PCR panel designed for the detection of third‐generation cephalosporin and carbapenem‐resistant genes from 98 water samples. Conclusion: The MagnaExtract method is comparable, and in some instance's superior to commercially available kits for the isolation of ARGs from river water samples. Significance and Impact of the Study: The MagnaExtract approach offers a simple, affordable, high yielding extraction method that could be used for the detection of ARGs from river water samples in surveillance campaigns in East Africa. [ABSTRACT FROM AUTHOR]

Background: Hepatitis B is the leading cause of cirrhosis and liver cancer in sub-Saharan Africa. To reduce mortality, antiviral treatment programs are needed. We estimated prevalence, vaccine impact, and need for antiviral treatment in Blantyre, Malawi.Methods: We conducted a household study in 2016-2018. We selected individuals from a census using random sampling and estimated age-sex-standardized hepatitis B surface antigen (HBsAg) seroprevalence. Impact of infant hepatitis B vaccination was estimated by binomial log-linear regression comparing individuals born before and after vaccine implementation. In HBsAg-positive adults, eligibility for antiviral therapy was assessed.Results: Of 97386 censused individuals, 6073 (median age 18 years; 56.7% female) were sampled. HBsAg seroprevalence was 5.1% (95% confidence interval [CI], 4.3%-6.1%) among adults and 0.3% (95% CI, .1%-.6%) among children born after vaccine introduction. Estimated vaccine impact was 95.8% (95% CI, 70.3%-99.4%). Of HBsAg-positive adults, 26% were HIV-positive. Among HIV-negative individuals, 3%, 6%, and 9% were eligible for hepatitis B treatment by WHO, European, and American hepatology association criteria, respectively.Conclusions: Infant HBV vaccination has been highly effective in reducing HBsAg prevalence in urban Malawi. Up to 9% of HBsAg-positive HIV-negative adults are eligible, but have an unmet need, for antiviral therapy. [ABSTRACT FROM AUTHOR]

Evidence from several countries in sub-Saharan Africa suggests that the integration of family planning (FP) with childhood immunization services can help reduce the unmet need for FP among postpartum women without undermining the uptake of immunizations. However, the quality and responsiveness of FP services that are integrated with childhood immunizations remain understudied. A qualitative study was conducted in two districts of Malawi, which examined the factors influencing the responsiveness of FP services that were integrated with childhood immunizations in monthly public outreach clinics. Semi-structured interviews with clients (n = 23) and FP providers (n = 10) and a clinic audit were carried out in six clinics. Hardware (material) and software (relational) factors influencing service responsiveness were identified through thematic and framework analyses of interview transcripts, and clinic characteristics were summarized from the audit data to contextualize the qualitative findings. Overall, 13 factors were found to influence service responsiveness in terms of the ease of access, choice of provider, environment, service continuity, confidentiality, communication, dignity and FP counselling afforded to clients. Among these factors, hardware deficiencies, including the absence of a dedicated building for the provision of FP services and the lack of FP commodities in clinics, were perceived to negatively affect service responsiveness. Crucially, the providers' use of their agency to alter the delivery of services was found to mitigate the negative effects of some hardware deficits on the ease of access, choice of provider, environment and confidentiality experienced by clients. This study contributes to an emerging recognition that providers can offset the effect of hardware deficiencies when services are integrated if they are afforded sufficient flexibility to make independent decisions. Consideration of software elements in the design and delivery of FP services that are integrated with childhood immunizations is therefore critical to optimize the responsiveness of these services. [ABSTRACT FROM AUTHOR]

Background: In areas highly endemic for malaria, Plasmodium falciparum infection prevalence peaks in school-age children, adversely affecting health and education. School-based intermittent preventive treatment reduces this burden but concerns about cost and widespread use of antimalarial drugs limit enthusiasm for this approach. School-based screening and treatment is an attractive alternative. In a prospective cohort study, we evaluated the impact of school-based screening and treatment on the prevalence of P. falciparum infection and anemia in 2 transmission settings.Methods: We screened 704 students in 4 Malawian primary schools for P. falciparum infection using rapid diagnostic tests (RDTs), and treated students who tested positive with artemether-lumefantrine. We determined P. falciparum infection by microscopy and quantitative polymerase chain reaction (qPCR), and hemoglobin concentrations over 6 weeks in all students.Results: Prevalence of infection by RDT screening was 37% (9%-64% among schools). An additional 9% of students had infections detected by qPCR. Following the intervention, significant reductions in infections were detected by microscopy (adjusted relative reduction [aRR], 48.8%; P < .0001) and qPCR (aRR, 24.5%; P < .0001), and in anemia prevalence (aRR, 30.8%; P = .003). Intervention impact was reduced by infections not detected by RDT and new infections following treatment.Conclusions: School-based screening and treatment reduced P. falciparum infection and anemia. This approach could be enhanced by repeating screening, using more-sensitive screening tests, and providing longer-acting drugs.Clinical Trials Registration: NCT04858087. [ABSTRACT FROM AUTHOR]

Background Diverse environmental exposures and risk factors have been implicated in the transmission of Salmonella Typhi, but the dominant transmission pathways through the environment to susceptible humans remain unknown. Here, we use spatial, bacterial genomic, and hydrological data to refine our view of typhoid transmission in an endemic setting. Methods A total of 546 patients presenting to Queen Elizabeth Central Hospital in Blantyre, Malawi, with blood culture–confirmed typhoid fever between April 2015 and January 2017 were recruited to a cohort study. The households of a subset of these patients were geolocated, and 256 S. Typhi isolates were whole-genome sequenced. Pairwise single-nucleotide variant distances were incorporated into a geostatistical modeling framework using multidimensional scaling. Results Typhoid fever was not evenly distributed across Blantyre, with estimated minimum incidence ranging across the city from <15 to >100 cases per 100 000 population per year. Pairwise single-nucleotide variant distance and physical household distances were significantly correlated (P  = .001). We evaluated the ability of river catchment to explain the spatial patterns of genomics observed, finding that it significantly improved the fit of the model (P  = .003). We also found spatial correlation at a smaller spatial scale, of households living <192 m apart. Conclusions These findings reinforce the emerging view that hydrological systems play a key role in the transmission of typhoid fever. By combining genomic and spatial data, we show how multifaceted data can be used to identify high incidence areas, explain the connections between them, and inform targeted environmental surveillance, all of which will be critical to shape local and regional typhoid control strategies. [ABSTRACT FROM AUTHOR]

Dolutegravir HIV drug resistance (HIVDR) data from Africa remain sparse. We reviewed HIVDR results of Malawians on dolutegravir-based antiretroviral therapy (November 2020–September 2021). Of 6462 eligible clients, 33 samples were submitted to South Africa, 27 were sequenced successfully, and 8 (30%) had dolutegravir HIVDR. Malawi urgently requires adequate HIVDR testing capacity. [ABSTRACT FROM AUTHOR]

Background Between 2010 and 2016, the proportion of children 12–23 months of age who received full immunization in Malawi decreased from 81% to 76%. Most studies on immunization have mainly focused on the risk factors of vaccination coverage while data on dropouts and equity gaps is very scanty. Thus the aim of the present study was to describe the trend in immunization coverage, dropout rates and effective immunization coverage (EIC) among children ages 12–23 months in Malawi. Methods Secondary analyses of the cross-sectional data obtained from the three waves of the Demographic and Health Surveys (2004, 2010 and 2015–16) were conducted. Using bottleneck analysis, outputs were generated based on service coverage, demand/equity (service utilization) and quality (full immunization). The World Health Organization benchmarks were used to assess gaps in the immunization coverage indicators. Results The coverage was >90.0% in most of the antigens while full immunization status was estimated at 65%, 84% and 73% in 2004, 2010 and 2015, respectively. The highest coverage was observed in Bacillus Calmette–Guérin (BCG) and lowest in oral polio vaccine 1 (OPV1). OPV1 coverage was <90% in the 2004 cohort year, while pentavalent 3 (Penta3) and measles-containing vaccine 1 (MCV1) coverages were <90% in 2004. Dropout rates of Penta3 and MCV1 were significantly >10% in 2004. The logistic regression analyses showed that children were significantly less likely to be immunized with Penta3 and MCV1 in all cohort years compared with Penta1. Conclusions Although immunization coverage was in line with the national and district targets for various antigens, full vaccination coverage (FVC) is still lagging behind. Furthermore, the dropout rates for Penta3 and MCV1 showed upside U-shaped patterns. Thus health education, supervision and orientation of service providers are urgently needed to address disparities that are existing in FVC. [ABSTRACT FROM AUTHOR]

Unconditional cash transfers have demonstrated widespread, positive impacts on consumption, food security, productive activities and schooling. However, the evidence to date on cash transfers and health-seeking behaviours and morbidity is not only mixed, but the evidence base is biased towards conditional programmes from Latin America and is more limited in the context of Africa. Given contextual and programmatic design differences between the regions, more evidence from Africa is warranted. We investigate the impact of unconditional cash transfers on morbidity and health-seeking behaviour using data from experimental and quasi-experimental study designs of five government cash transfer programs in Ghana, Malawi, Zambia and Zimbabwe. Programme impacts were estimated using difference-in-differences models with longitudinal data. The results indicate positive programme impacts on health seeking when ill and on health expenditures. Our findings suggest that while unconditional cash transfers can improve health seeking when ill, morbidity impacts were mixed. More research is needed on longer-term impacts, mechanisms of impact and moderating factors. Additionally, taken together with existing evidence, our findings suggest that when summarizing the impacts of cash transfers on health, findings from conditional and unconditional programmes should be disaggregated. [ABSTRACT FROM AUTHOR]

Abstract: Hypertension is the most common cause of cardiovascular diseases, accounting for at least half of haemorrhagic and ischaemic strokes, heart failure and renal failure in sub-Saharan Africa. However, population-based data to inform policies are scarce. Using the WHO STEPwise approach to chronic disease risk factor surveillance, a population-based nationwide survey was conducted on participants aged 25–64 years in Malawi. Detailed findings on the burden of hypertension are presented in this paper. Blood pressure (BP) was measured in 3727 participants. The age-standardised prevalence of hypertension (BP ≥140/90mmHg) was 33.2% (95% CI 30.9–35.6%). Hypertension was more frequent in males than females (36.9% vs 29.9%), alcohol drinkers than non-drinkers (40.9% vs 31.6%), overweight than non-overweight (41.5% vs 30.7%) and increased with increasing age (21.4% in 25–34 years old vs 59.2% in 55–64 years old). Three-quarters of the participants said they never had their BP measured before and 94.9% of those with hypertension said they were not aware that they had such a medical problem. High prevalence of hypertension and its risk factors calls for the implementation of primary healthcare approaches such as the WHO package for essential non-communicable diseases to promote healthy lifestyles, early detection, treatment and control. [Copyright &y& Elsevier]

Recent research has begun to highlight the complex connections between colonialism, medical and scientific knowledge-production, and commercial interests. This article analyses colonial ‘bioprospecting’ through a case study of Strophanthus kombe. Used locally as an arrow poison, Strophanthus was ‘discovered’ in Malawi during David Livingstone's Zambesi expedition. After investigation and experimentation it was subsequently used to produce a cardiac drug. The Malawian case study complements previous work on Strophanthus from West Africa. It uncovers the early Scottish-Central African networks that linked the Shire valley (the source of Malawian kombe seeds), with medical research in Edinburgh and Burroughs Wellcome and Co., the first commercial manufacturer of drugs derived from Strophanthus. The article also analyses Burroughs Wellcome's use of scientific and local knowledge in the early marketing of its first original drugs. [ABSTRACT FROM PUBLISHER]

International organizations promote provider-initiated, ‘routine’ HIV testing of pregnant women seeking antenatal care as an effort to curb mother-to-child transmission. We offer an account of the perceptions of HIV testing at antenatal clinics in rural Malawi. Although it is both international and Government of Malawi policy that women must be explicitly informed of their right to refuse testing, analysis of in-depth interviews, focus group discussions and evidence from observational field journals show that rural Malawians do not perceive HIV testing as a choice, but rather as compulsory in order to receive antenatal care. This study illustrates dissonance between global expectations and local realities of the delivery of HIV-testing interventions. [ABSTRACT FROM AUTHOR]

Summary: This paper describes (a) the experience of initiating community involvement in HIV/AIDS and tuberculosis (TB) activities in a rural district in Malawi and (b) some of the different ways in which the community is contributing in the fight against these two diseases and the outcomes of their involvement. During a 2-year period, a total of 21358 (41%) of 52510 HIV tests performed at voluntary counselling and HIV testing (VCT) sites in the district were conducted by lay community counsellors. A team of 465 community volunteers, 1362 trained family caregivers and 9 community nurses provided care and support to 5106 HIV-positive individuals, of whom 2006 (39%) were in WHO stage III or IV. All those in WHO stage III or IV were on co-trimoxazole prophylaxis and 895 (45%) of these were also on antiretroviral treatment. A total of 2714 TB patients, of whom 1627 (60%) were HIV-positive, also received care and support. A total of 1694 orphans were trained in vocational skills. Twelve vegetable gardens and three maize farms were set up, and pre-school activities were organised for 900 orphans. Communities can play an important contributory role in reducing the burden of HIV/AIDS and TB and in mitigating its impact. Despite this, community resources in most settings are often under-exploited and their role remains undefined. [Copyright &y& Elsevier]

Background: Plasmodium falciparum malaria dominates throughout sub-Saharan Africa, but the prevalence of Plasmodium malariae, Plasmodium ovale spp., and Plasmodium vivax increasingly contribute to infection in countries that control malaria using P. falciparum-specific diagnostic and treatment strategies.Methods: We performed quantitative polymerase chain reaction (qPCR) on 2987 dried blood spots from the 2015-2016 Malawi Demographic and Health Survey to identify presence and distribution of nonfalciparum infection. Bivariate models were used to determine species-specific associations with demographic and environmental risk factors.Results: Nonfalciparum infections had broad spatial distributions. Weighted prevalence was 0.025 (SE, 0.004) for P. malariae, 0.097 (SE, 0.008) for P. ovale spp., and 0.001 (SE, 0.0005) for P. vivax. Most infections (85.6%) had low-density parasitemias ≤ 10 parasites/µL, and 66.7% of P. malariae, 34.6% of P. ovale spp., and 40.0% of P. vivax infections were coinfected with P. falciparum. Risk factors for P. malariae were like those known for P. falciparum; however, there were few risk factors recognized for P. ovale spp. and P. vivax, perhaps due to the potential for relapsing episodes.Conclusions: The prevalence of any nonfalciparum infection was 11.7%, with infections distributed across Malawi. Continued monitoring of Plasmodium spp. becomes critical as nonfalciparum infections become important sources of ongoing transmission. [ABSTRACT FROM AUTHOR]

Background: Intermittent preventive treatment of malaria during pregnancy (IPTp) with dihydroartemisinin-piperaquine (DP) provides greater protection from placental malaria than sulfadoxine-pyrimethamine (SP). Some studies suggest placental malaria alters risk of malaria infection in infants, but few have quantified the effect of IPTp on infant susceptibility to malaria.Methods: Infants born to women enrolled in a randomized clinical trial comparing IPTp-SP and IPTp-DP in Malawi were followed from birth to 24 months to assess effect of IPTp and placental malaria on time to first malaria episode and Plasmodium falciparum incidence.Results: In total, 192 infants born to mothers randomized to IPTp-SP and 195 randomized to IPTp-DP were enrolled. Infants in IPTp exposure groups did not differ significantly regarding incidence of clinical malaria (incidence rate ratio [IRR], 1.03; 95% confidence interval [CI], .58-1.86) or incidence of infection (IRR, 1.18; 95% CI, .92-1.55). Placental malaria exposure was not associated with incidence of clinical malaria (IRR, 1.03; 95% CI, .66-1.59) or infection (IRR, 1.15; 95% CI, .88-1.50). Infant sex, season of birth, and maternal gravidity did not confound results.Conclusions: We did not find evidence that IPTp regimen or placental malaria exposure influenced risk of malaria during infancy in this population. Clinical Trials Registration. NCT03009526. [ABSTRACT FROM AUTHOR]

The United Nations' Sustainable Development Goal 3.2 aims to reduce under‐five child mortality to 25 deaths per 1000 live births by 2030. Child mortality tends to be concentrated in developing regions where information needed to assess achievement of this goal often comes from surveys and censuses. In both, women are asked about their birth histories, but with varying degrees of detail. Full birth history (FBH) data contain the reported dates of births and deaths of every surveyed mother's children. In contrast, summary birth history (SBH) data contain only the total number of children born and total number of children who died for each mother. Specialized methods are needed to accommodate this type of data into analyses of child mortality trends. We develop a data augmentation scheme within a Bayesian framework where for SBH data, birth and death dates are introduced as auxiliary variables. Since we specify a full probability model for the data, many of the well‐known biases that exist in this data can be accommodated, along with space‐time smoothing on the underlying mortality rates. We illustrate our approach in a simulation, showing robustness to model misspecification and that uncertainty is reduced when incorporating SBH data over simply analyzing all available FBH data. We also apply our approach to data from the Central region of Malawi and compare with the well‐known Brass method. [ABSTRACT FROM AUTHOR]

Asymmetric information in the marriage market may cause adverse selection and delay marriage if partner quality is revealed over time. Sexual safety is an important but hidden partner attribute, especially in areas where HIV is endemic. A model of positive assortative matching with both observable (attractiveness) and hidden (sexual safety) attributes predicts that removing the asymmetric information about sexual safety accelerates marriage and pregnancy for safe respondents, and more so if they are also attractive. Frequent HIV testing may enable safe people to signal and screen. Consistent with these predictions, we show that a high-frequency, "opt-out" HIV testing intervention changed beliefs about partner's safety and accelerated marriage and pregnancy, increasing the probabilities of marriage and pregnancy by 26 and 27 |$\%$| for baseline-unmarried women over 28 months. Estimates are larger for safe and attractive respondents. Conversely, a single-test intervention lacks these effects, consistent with other HIV testing evaluations in the literature. Our findings suggest that an endogenous response to HIV risk may explain why the HIV/AIDS epidemic has coincided with systematic marriage and pregnancy delays. [ABSTRACT FROM AUTHOR]

This article discusses the purposes and drivers of handouts in party primaries in Malawi. We argue that existing explanations of handouts are incomplete because they are developed to identify dynamics in presidential or legislative elections. Rules of national elections are constitutionally protected, and their fairness is monitored by both local and international observers. In contrast, rules guiding candidate selection in parties are less institutionalized, and, in some contexts, such as Malawi, a secret ballot cannot be taken for granted. This underlines the need for empirical studies of the logic of handouts at the candidate selection stage to study how differences in institutional context affect the strategic choices behind engaging in the practice. We demonstrate why such an analysis needs to be informed by an in-depth knowledge about the party organizations in which the candidate selection process itself takes place. Through qualitative interviews with members of selectorates and party primary contestants, we find that the institutional environment affects the propensity to use handouts. Mechanisms such as leadership interventions and the opportunity to stand as independent candidates make primary outcomes less final. This reduces the authority of local party organizations to control candidate selection and appropriates the use of patrimonial strategies. [ABSTRACT FROM AUTHOR]

Background Cancer outcomes in sub-Saharan Africa (SSA) remain suboptimal, in part due to poor patient retention. Many patients travel long distances to receive care, and transportation costs are often prohibitively expensive. These are well-known and established causes of delayed treatment and care abandonment in Malawi and across SSA. Methods We sent visit reminder texts and offered upfront money to cover transportation costs through a mobile money transfer (MMT) platform to lymphoma patients enrolled in a prospective cohort in Malawi. The primary aim was to test the feasibility of upfront MMTs. Results We sent 1034 visit reminder texts to 189 participating patients. Of these texts, 614 (59%) were successfully delivered, with 536 (52%) responses. 320/536 (60%) MMTs were sent to interested patients and 312/320 (98%) came to their appointment on time. Of 189 total patients, 120 (63%) were reached via text and 84 (44%) received MMTs a median of three times (IQR 2–5). Median age of reachable patients was 41 (IQR 30–50), 75 (63%) were male, 62 (52%) were HIV+ and 79 (66%) resided outside of Lilongwe. Conclusion MMTs were a feasible way to cover upfront transportation costs for patients reachable via text, however many of our patients were unreachable. Future studies exploring barriers to care, particularly among unreachable patients, may help improve the efficacy of MMT initiatives and guide retention strategies throughout SSA. [ABSTRACT FROM AUTHOR]

Background Although community and health system factors are known to be critical to timely antiretroviral therapy (ART) initiation, little is known about how they affect men and women. Methods We examined community- and health system-level factors associated with ART initiation in Malawi and whether associations differ by gender; 312 ART initiates and 108 non-initiates completed a survey; a subset of 30 individuals completed an indepth interview. Quantitative data were analyzed using univariate and multivariate logistic regressions, with separate models by gender. Qualitative data were analyzed through constant comparison methods. Results Among women, no community-level characteristics were associated with ART initiation in multivariable models; among men, receiving social support for HIV services (adjusted OR [AOR]=4.61; p<0.05) was associated with ART initiation. Two health system factors were associated with ART initiation among men and one for women: trust that accessing ART services would not lead to unwanted disclosure (women: AOR=4.51, p<0.01; men: AOR=1.71, p<0.01) and trust that clients were not turned away from ART services (men: 12.36, p=0.001). Conclusions Qualitative data indicate that men were concerned about unwanted disclosure due to engaging in ART services and long waiting times for services. Interventions to remove health system barriers to ART services should be explored to promote social support among men. [ABSTRACT FROM AUTHOR]

This paper investigates how the language in which formal education is conducted affects learners' reading ability Malawi and Zambia offer a suitable context for such an investigation in that in Malawi, Chichewa is the medium of instruction for years 1 to 4, with English a taught subject, whereas in Zambia, English is the medium of instruction from year 1, with one of seven local languages as a taught subject An English language reading test, and a local language reading test (Chichewa in Malawi, and the almost identical Nyanja in Zambia) were administered to the same year 5 learners from 6 schools in each country The results indicate there is no significant difference in English language reading ability between learners in each country, but large differences in favour of Malawi in local language reading ability These results are consistent with research on minority groups suggesting that instruction in L1 reading leads to improved results in L1 with no retardation in L2 reading in both countries, however, reading ability in English is unlikely to be at a level to allow learning through the medium of English for most pupils This is related to pedagogic practices which give insufficient attention to meaning The role of English in these countries is largely driven by political perceptions of effective strategies for unification and modernization However, its dominance in the education system may work against the individual primary school child's cognitive development in general, and their reading proficiency in particular [ABSTRACT FROM AUTHOR]

Focuses on politics in Malawi. Portrayal of democratization; Regional fragmentation; Consensus politics; Registration and turnout in 1993 and 1994 Malawian elections; Search for a maximum coalition combining all regional forces; Role for personality politics.

The share of household resources devoted to a child may depend on their gender, birth order, or relationship to the household head. However, it is challenging to determine whether parents favour certain children over others as consumption data are collected at the household level and goods are shared among family members. I develop a new methodology using the collective household framework to identify consumption inequality between different types of children. I apply this method to child fostering in Malawi. I find little evidence of inequality between foster and non-foster children. [ABSTRACT FROM AUTHOR]

To eliminate lymphatic filariasis (LF) by 2020, the World Health Organization (WHO) has launched a campaign against the disease. Since the launch in 2000, significant progress has been made to achieve this ambitious goal. In this article we review the progress and status of the LF programme in Africa through the WHO neglected tropical diseases preventive chemotherapy databank, the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) portal and other publications. In the African Region there are 35 countries endemic for LF. The Gambia was reclassified as not requiring preventive chemotherapy in 2015, while Togo and Malawi eliminated LF as a public health problem in 2017 and 2020, respectively. Cameroon discontinued mass drug administration (MDA) and transitioned to post-MDA surveillance to validate elimination. The trajectory of coverage continues to accelerate; treatment coverage increased from 0.1% in 2000 to 62.1% in 2018. Geographical coverage has also significantly increased, from 62.7% in 2015 to 78.5% in 2018. In 2019, 23 of 31 countries requiring MDA achieved 100% geographic coverage. Although much remains to be done, morbidity management and disability prevention services have steadily increased in recent years. Vector control interventions conducted by other programmes, particularly malaria vector control, have had a profound effect in stopping transmission in some endemic countries in the region. In conclusion, significant progress has been made in the LF programme in the region while we identify the key remaining challenges in achieving an Africa free of LF. [ABSTRACT FROM AUTHOR]

Introduction: Tobacco production continues to increase in low- and middle-income countries creating complications for tobacco control efforts. There is the need to understand and address the global tobacco leaf supply as a means of decreasing tobacco consumption and improving farmers livelihoods in line with Article 17 of the WHO Framework Convention on Tobacco Control. This study aims to understand the reasons why farmers grow tobacco and identify factors that influence these reasons.Methods: Primary survey data (N = 1770) collected in Kenya, Malawi, and Zambia in the 2013-2014 farming season. Data analysis uses both descriptive and multinomial logistical regression methods.Results: Majority of farmers started and are currently growing tobacco because they believed it was the only economically viable crop. Compared with Malawi, farmers in Kenya and Zambia have a 0.2 and 0.4 lower probability of growing tobacco, respectively because they perceive it as the only economically viable crop, but a 0.04 and 0.2 higher probability of growing tobacco, respectively because they believe it is highly lucrative. There are district/county differences in the reasons provided with some districts having a majority of the farmers citing the existence of a ready market or incentives from the tobacco industry. Statistically significant factors influencing these reasons are the educational level and age of the household head, land allocated to tobacco and debts.Conclusion: There is the need to address the unique features of each district to increase successful uptake of alternative livelihoods. One consistent finding is that farmers' perceived economic viability contributes to tobacco growing.Implications: This study finds that perceived economic viability of tobacco is the dominant factor in the decisions to grow tobacco by smallholder farmers in Malawi, Kenya, and Zambia. There is the need to more deeply understand what contributes to farmers' perceived viability of a crop. Understanding and addressing these factors may increase the successful uptake of alternative livelihoods to tobacco. Furthermore, this study demonstrates that a one-size fits all alternative livelihood intervention is less likely to be effective as each district has unique features affecting farmers' decisions on growing tobacco. [ABSTRACT FROM AUTHOR]

Background Compensation for research participants can be provided for reasons including reimbursement of costs; compensation for time lost, discomfort or inconvenience; or expression of appreciation for participation. This compensation involves numerous ethical complexities, at times entailing competing risks. In the context of transnational research, often incorporating contexts of economic inequality, power differentials and post-colonialism, these issues extend into wider questions of ethical research conduct. Methods We describe experiences of conducting a community-based study of air pollution in southern Malawi incorporating ethnographic, participatory and air quality monitoring elements. Decisions surrounding participant compensation evolved in response to changing circumstances in the field. Results Attention to careful researcher–participant relationships and responsiveness to community perspectives allowed dynamic, contextualised decision-making around participant compensation. Despite widely cited risks, including but not restricted to undue influence of monetary compensation on participation, we learned that failure to adequately recognise and compensate participants has its own risks, notably the possibility of 'ethics dumping'. Conclusions We recommend active engagement with research participants and communities with integration of contextual insights throughout, including participant compensation, as for all elements of research conduct. Equitable research relationships encompass four central values: fairness, care, honesty and respect. [ABSTRACT FROM AUTHOR]

Poor mental health is a pressing global health problem, with high prevalence among poor populations from low-income countries. Existing studies of conditional cash transfer (CCT) effects on mental health have found positive effects. However, there is a gap in the literature on population-wide effects of cash transfers on mental health and if and how these vary by the severity of mental illness. We use the Malawian Longitudinal Study of Family and Health containing 790 adult participants in the Malawi Incentive Programme, a year-long randomized controlled trial. We estimate average and distributional quantile treatment effects and we examine how these effects vary by gender, HIV status and usage of the cash transfer. We find that the cash transfer improves mental health on average by 0.1 of a standard deviation. The effect varies strongly along the mental health distribution, with a positive effect for individuals with worst mental health of about four times the size of the average effect. These improvements in mental health are associated with increases in consumption expenditures and expenditures related to economic productivity. Our results show that CCTs can improve adult mental health for the poor living in low-income countries, particularly those with the worst mental health. [ABSTRACT FROM AUTHOR]