Search

Background In Malawi, abortion is legal only if performed to save a woman’s life; other attempts to procure an abortion are punishable by 7–14 years imprisonment. Most induced abortions in Malawi are performed under unsafe conditions, contributing to Malawi’s high maternal mortality ratio. Malawians are currently debating whether to provide additional exceptions under which an abortion may be legally obtained. An estimated 67,300 induced abortions occurred in Malawi in 2009 (equivalent to 23 abortions per 1,000 women aged 15–44), but changes since 2009, including dramatic increases in contraceptive prevalence, may have impacted abortion rates. Methods We conducted a nationally representative survey of health facilities to estimate the number of cases of post-abortion care, as well as a survey of knowledgeable informants to estimate the probability of needing and obtaining post-abortion care following induced abortion. These data were combined with national population and fertility data to determine current estimates of induced abortion and unintended pregnancy in Malawi using the Abortion Incidence Complications Methodology. Results We estimate that approximately 141,044 (95% CI: 121,161–160,928) induced abortions occurred in Malawi in 2015, translating to a national rate of 38 abortions per 1,000 women aged 15–49 (95% CI: 32 to 43); which varied by geographical zone (range: 28–61). We estimate that 53% of pregnancies in Malawi are unintended, and that 30% of unintended pregnancies end in abortion. Given the challenges of estimating induced abortion, and the assumptions required for calculation, results should be viewed as approximate estimates, rather than exact measures. Conclusions The estimated abortion rate in 2015 is higher than in 2009 (potentially due to methodological differences), but similar to recent estimates from nearby countries including Tanzania (36), Uganda (39), and regional estimates in Eastern and Southern Africa (34–35). Over half of pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.

Population health needs in developing countries are great and countries are scaling up health professional education to meet these needs. Marginalized populations, in particular, are vulnerable to poor health and health care. This paper presents a culturally appropriate diversity training program delivered to Global Health Fellows who are educators and leaders in health professions in Malawi and Zambia. The purpose of this interprofessional education experience was to promote culturally competent and humble care for marginalized populations.

This study examined factors that determine utilization of postpartum family planning services at Ntchisi District Hospital in Malawi. The study design was descriptive and utilized quantitative methods of data collection and analysis. A random sample of 383 postpartum women was interviewed using a structured questionnaire. Data were analysed using SPSS version 16.0. Chi-square tests were used to establish relationships between utilization of Post Partum Family Planning services and demographic variables. Knowledge about family planning services was almost universal at 94.3% among the women. About 75% of the women were using the contraceptives within the first year after delivery however they started taking the contraceptives after they had already resumed sex. There was a significant association (P < 0.05) between utilization of post partum family planning services and the following: clarity of family planning information given, level of education, period for resuming sex, husband’s approval of family planning method, counselling on fertility intention, duration of lactation amenorrhoea, maternal age and parity. There is therefore a need to promote these factors to increase uptake of postpartum services.

This study explored beliefs and actual practices of young women on utilization of Prevention of Mother to Child Transmission (PMTCT) of HIV services in Balaka district of Southern Malawi. The study design wascross sectional which utilized qualitative data collection and analysis methods. In-depth interviews were conducted on 12 young mothers of 15 to 24 years old. The respondents were drawn from 6 health centres in the district during their visits to either the under-five clinic, HIV and AIDS support groups or HIV follow up clinics. Data were analyzed using thematic analysis approach. Overall the respondents had positive beliefs on utilization of PMTCT services. They believed that adherence to PMTCT guidelines such as condom use, taking of Nevirapine (NVP) and exclusive breastfeeding protected the baby from contracting the virus. Nevertheless, all respondents believed that HIV testing was mandatory and that early weaning caused malnutrition and death of babies. Actual practice was very low. Very few young mothers breastfed exclusively, weaned their babies abruptly and took NVP as recommended. Not all positive beliefs translated into positive behavior. Lack of male support, inability of the midwives to provide comprehensive care to HIV infected mothers and their infants, and fear of stigma and discrimination were other factors that hindered utilization of PMTCT services. Culture was also a major barrier because traditionally babies are expected to be breastfed and supplements are fed to babies too. Therefore, there is a need to mobilize communities on PMTCT of HIV. Education programmes in HIV should emphasize behavior change interventions and should focus on both men and women and significant others. There is also need to intensify monitoring and evaluation of health workers’ activities to ensure that beliefs translate into positive behavior.

This study was conducted to assess quality of postnatal care that midwives provide to women seeking postnatal services in health facilities in Dedza district, the central region ofMalawi. The study design was descriptive cross sectional and utilized quantitative data collection and analysis method to determine structural, process and outcome components of postnatal care in two facilities that offer emergency obstetric and neonatal care and five that offer basic emergency obstetric and neonatal care. All 60 midwives who were providing postnatal care during the time of study in the district were interviewed using a structured questionnaire. In addition, the midwives actual practice was observed and compared to a standard checklist on postnatal care practice which was developed by the Malawi Ministry of Health. Data were analyzed using SPSS version 16.0. Results show that structure for providing postnatal counseling services was inappropriate and inadequate. Furthermore, the contents of postnatal services were below reproductive health standards because the clients were neither monitored nor examined physically on discharge. On average, all the seven facilities scored 48% on postnatal services rendered which is far below the recommended 80% according to the Reproductive Health Standards. There is a need to provide basic infrastructure in all the basic emergency obstetric and neonatal care facilities. In addition, refresher training courses for midwives in maternal and neonatal health with emphasis on postnatal care are recommended. There is also a need to restructure the maternal and neonatal health departments in the facilities so that the postnatal care units become stand-alone priority sites to improve the quality of the postnatal care services rendered.

Background Malawi continues to experience critical shortages of key health technical cadres that can adequately respond to Malawi’s disease burden. Difficult working conditions contribute to low morale and frustration among health care workers. We aimed to understand how obstetric care staff perceive their working relationships with managers. Methods A qualitative exploratory study was conducted in health facilities in Malawi between October and December 2008. Critical Incident Analysis interviews were done in government district hospitals, faith-based health facilities, and a sample of health centres’ providing emergency obstetric care. A total of 84 service providers were interviewed. Data were analyzed using NVivo 8 software. Results Poor leadership styles affected working relationships between obstetric care staff and their managers. Main concerns were managers’ lack of support for staff welfare and staff performance, lack of mentorship for new staff and junior colleagues, as well as inadequate supportive supervision. All this led to frustrations, diminished motivation, lack of interest in their job and withdrawal from work, including staff seriously considering leaving their post. Conclusions Positive working relationships between obstetric care staff and their managers are essential for promoting staff motivation and positive work performance. However, this study revealed that staff were demotivated and undermined by transactional leadership styles and behavior, evidenced by management by exception and lack of feedback or recognition. A shift to transformational leadership in nurse-manager relationships is essential to establish good working relationships with staff. Improved providers’ job satisfaction and staff retentionare crucial to the provision of high quality care and will also ensure efficiency in health care delivery in Malawi. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1694-x) contains supplementary material, which is available to authorized users.

Critical Incident Analysis Instrument. (DOC 30 kb)

The present study explored the challenges faced in the implementation of inclusive education in Malawi. The study was constructed within Bronfenbrenner’s ecological systems theory. The theory maintains that children grow, develop and learn in a complex environment that impacts them negatively and positively. An exploratory qualitative case study research design was adopted for the study. Purposive sampling technique was used to pick on the study sites as well as the research participants. Montfort Special Needs Education College and a few selected primary schools formed the cases for the study. Semi-structured interviews and focus group discussion were used to collect data and results analyzed using themes with a clear focus on the research questions.

PURPOSE:To determine knowledge and practices of young women on utilization of prevention of mother-to-child transmission (PMTCT) of HIVservices.DESIGN:A cross-section descriptive study that used quantitative and qualitative data analysis methodologies.FINDINGS:Knowledge of PMTCT of HIV among respondents was universal. All respondents (100%,N= 184) stated that utilization of PMTCT services reduces transmission of HIV from mother to child. Respondents knew that HIV transmission can be reduced with exclusive breastfeeding (93%,n= 172), abrupt weaning at 6 months (44%,n= 81), taking single-dose nevirapine (SD-NVP; 43%,n= 79), and giving NVP to the baby (65%,n= 120). Very few respondents (4%,n= 7) stated that avoiding pregnancy is one way of preventing HIV transmission and that a mother who is HIV positive who has received SD-NVP or antiretroviral (ARV) therapy can still deliver a baby who is HIV positive. Actual practice was very low; only 14% breastfed exclusively and only 3% weaned their babies abruptly. Although all the 184 mothers were given NVP to take at onset of labor, very few respondents (22%) took NVP as recommended. Although it was recommended that all babies take NVP at birth and within 72 hr of birth, only 58% of the babies received NVP as recommended and only 3% of the women avoided pregnancy.CONCLUSION:There was a big discrepancy between knowledge and practice of PMTCT services. Culture was the major barrier because traditionally, babies are expected to be breastfed and supplements are fed to babies, too. Most mothers did not adhere to the taking of NVP at onset of labor. Therefore, there is a need to mobilize communities on PMTCT of HIV. The HIV education programmes should emphasize behavior-change interventions and should focus on both men and women, their partners, and significant others. There is also need to intensify monitoring and evaluation of health workers’ activities to ensure that knowledge is put into practice.

This study aimed to determine the factors that influence the use of prevention of mother to child transmission of HIV (PMTCT) services among young HIV-positive adults in the Balaka district of Malawi. A questionnaire was given to 184 HIV-positive young mothers aged 15–24 years who met the inclusion criteria and who consented to the study. The participants were selected from six health centres in the Balaka district during their visits to the under 5 clinic, HIV and AIDS support groups and HIV follow up clinic. Results showed that the participants’ knowledge of mandatory HIV testing, stigma and discrimination, and poverty influenced their use of PMTCT services. There is a need to mobilise the communities to promote PMTCT awareness and reduce stigma and discrimination towards HIV-positive mothers. Monitoring and evaluation activities and in-service education for health workers is also recommended to promote utilisation of PMTCT services in the district.

Cervical cancer is a curable disease if diagnosed early. However, many women in Malawi seek treatment when the disease has reached inoperable stage. This study was conducted to explore factors that contribute to delay in seeking early diagnosis and treatment of cervical cancer among women in Malawi. The study was exploratory and utilized qualitative data collection and analysis method. In-depth interviews were conducted using a semi-structured interview guide on a purposive sample of 24 women who were diagnosed of cervical cancer at the gynaecological wards of Zomba and Queen Elizabeth Central Hospitals in Malawi between July and September, 2011. Thematic content analysis was used to analyze the qualitative data. Two major themes (individual and health facility) emerged from the participants’ narratives as factors that contributed to their delay in seeking early diagnosis and treatment. The individual factors included; limited knowledge on symptoms and signs and limited financial resources. The health facilities factors included; limited accessibility and unavailability of cancer screening facilities in the health centres. Results show that there is a need to strengthen the screening of cervical cancer among women in the country. In addition, there is a need to create community awareness on the signs and symptoms of cervical cancer and the merits of seeking early diagnosis and treatment.

Objectives Zimbabwe has started to scale up Option B+ for the prevention of mother-to-child transmission of HIV, but there is little published information about uptake or retention in care. This study determined the number and proportion of pregnant and lactating women in rural districts diagnosed with HIV infection and started on Option B+ along with six-month antiretroviral treatment (ART) outcomes. Methods This was a retrospective record review of women presenting to antenatal care or maternal and child health services at 34 health facilities in Chikomba and Gutu rural districts, Zimbabwe, between January and March 2014. Results A total of 2728 women presented to care of whom 2598 were eligible for HIV testing: 76% presented to antenatal care, 20% during labour and delivery and 4% while breastfeeding. Of 2097 (81%) HIV-tested women, 7% were HIV positive. Lower HIV testing uptake was found with increasing parity, late presentation to antenatal care, health centre attendance and in women tested during labour. Ninety-one per cent of the HIV-positive women were started on Option B+. Six-month ART retention in care, including transfers, was 83%. Loss to follow-up was the main cause of attrition. Increasing age and gravida status ≥2 were associated with higher six-month attrition. Conclusion The uptake of HIV testing and Option B+ is high in women attending antenatal and post-natal clinics in rural Zimbabwe, suggesting that the strategy is feasible for national scale-up in the country.

This report describes the effects of a peer-group intervention on Malawian urban hospital workers’ HIV-related personal knowledge, attitudes, and behaviors. More than 850 clinical and nonclinical hospital workers received the intervention. Evaluation used independent surveys of a sample of workers at baseline (N = 366) and postintervention (N = 561). Compared with the baseline survey, after the intervention, workers had higher knowledge of HIV transmission and prevention; more positive attitudes including more hope, less stigmatization of persons with HIV, more positive attitudes toward HIV testing and condom use, and higher self-efficacy for practicing safer sex and for community prevention; more reported recent personal HIV tests, more discussion of safer sex with partners, and more reported community HIV prevention activities. However, health workers’ risky sexual behaviors did not differ at baseline and postintervention. The intervention should be strengthened to support more sexual risk reduction and be made available to all health workers in Malawi.

Introduction Male involvement (MI) is vital for the uptake of Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) interventions. Partner notification (PN) is among the strategies identified for MI in PMTCT services. The purpose of this randomized controlled trial was to evaluate the efficacy of an invitation card to the male partners as a strategy for MI in PMTCT services by comparing the proportion of pregnant women that were accompanied by their partners between the intervention and the non-intervention study groups. Methods Pregnant women attending antenatal care without a male partner at South Lunzu and Mpemba health centres in Blantyre, Malawi, were enrolled in the study from June to December 2013. In an intention-to-treat analysis, we compared all participants that were randomized in the invitation card group with the standard of care (SoC) group. Risk ratios (RR) with 95% confidence intervals (CI) were computed to assess the efficacy of the invitation card. Results Of the 462 randomized women, 65/230 (28.26%) of the women in the invitation card group reported to the antenatal care clinic with their partners compared to 44/232 (18.97%) women in the SoC group. In an unadjusted intention-to-treat analysis women in the invitation card group were 50% more likely to be accompanied by their male partners than those in the SoC group RR: 1.49 (95% CI: 1.06-2.09); p = 0.02. Our random effects analysis showed that there was no clustering by site of recruitment with an inter cluster correlation coefficient (ICC) of 1.98x 10-3, (95% CI: 1.78 x10-7 - 0.96 x 10-1); p =0.403. Conclusion An invitation card significantly increased the proportion of women who were accompanied by their male partners for the PMTCT services. An invitation card is a feasible strategy for MI in PMTCT.

No Abstract

Background Male involvement (MI) in Prevention of mother to child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) services remains low despite the progress registered in the implementation of the PMTCT program. Male involvement in PMTCT is a fairly new concept in Malawi that has not been fully implemented within PMTCT service provision despite its inclusion in the PMTCT guidelines. One of the reasons for the limited MI is the lack of knowledge on both its relevance and the role of men in the program. Currently, men have been encouraged to participate in PMTCT services without prior research on their understanding of the relevance and their role in PMTCT. This information is vital to the development of programs that will require MI in PMTCT. The objective of this study was to explore the views of men, pregnant women and health care providers on the importance and roles of MI in PMTCT services in Blantyre Malawi. Methods An exploratory descriptive qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) and its catchment area in Blantyre, Malawi. We conducted 6 key informant interviews (KIIs) with health care workers and 4 focus group discussions (FGDs) with 18 men and 17 pregnant women. Interviews and discussions were digitally recorded and simultaneously transcribed and translated into English. Data were analyzed using framework analysis approach. Results The major themes that emerged on the relevance of MI in PMTCT were a) uptake of interventions along the PMTCT cascade b) support mechanism and c) education strategy. Lack of MI in PMTCT was reported to result into non-disclosure of HIV test results and non-compliance with PMTCT interventions. Conclusions Male involvement is paramount for the uptake of interventions at the different cascades of PMTCT. The absence of male involvement may compromise compliance with PMTCT interventions.

In rural sub-Saharan Africa, most care for patients with AIDS is provided at home by relatives. Caring for those with AIDS is assumed to be a substantial burden, but little is known from the perspectives of those who provide the care. In this paper we use interviews with caregivers, supplemented with survey data from a larger study in rural Malawi, to investigate this issue. We focus on the caregivers' diagnoses of the illness of their patients, the type and duration of the care they provided, the support they received from relatives and other members of the community, and the extent to which caregiving was experienced as an emotional, physical, and financial burden. Although none of the caregivers knew of a formal diagnosis and few explicitly named their relative's disease as AIDS, most appeared to suspect it. They described the illness using the typical symptoms of AIDS as they are locally understood and sometimes related the illness to their patient's sexual history. The care, typically given by close female relatives of the patient, was limited to the care that would be given to anyone who was seriously ill. What was striking, however, was the compassion of the caregivers and the attempts they made to provide the best care possible in their circumstances. For most caregivers, kin and members of the community provided social, moral, and physical support, as well as modest financial assistance. Caregiving was physically and emotionally demanding and confined the caregivers to their home, but most caregivers did not consider caregiving a problem primarily because the patients were close relatives. The financial impact of caregiving was typically modest because the caregivers had very little income and few possessions to sell.

There is a chronic shortage of medical doctors in many Sub-Saharan African countries and indeed many of these countries have very little to spend on healthcare. As a consequence levels of maternal and neonatal mortality still very high and many are struggling to meet the WHO Millennium development goals. Many African countries like Malawi have a cadre of health workers called Non Physician Clinicians (NPCs) who are trained by the Ministry of Health and are often the most experienced health worker in hospitals and health centres across the country. Some of these NPCs specialize in emergency obstetric and neonatal care (EmONC) and are in the frontline providing care for mothers and babies. The value of NPCs cannot be understated, it will take many more years before countries like Malawi have enough doctors, and dedicated, hardworking and loyal NPCs are providing an essential and valuable service. Enhancing Training and Appropriate Technologies for Mothers and Babies in Africa (ETATMBA) was an EC funded (FP7) project managed by The University of Warwick Medical School (WMS) and was being delivered in Tanzania and Malawi. Project partners include the Karolinska Institute (Sweden), The Ministry of Health (Malawi), the College of Medicine (Malawi) and Ifakara Health Institute (Tanzania). The purpose of the project was to train non-physician clinicians (assistant medical officers (AMOs) in Tanzania) as advanced leaders providing them with skills and knowledge in advanced neonatal and obstetric care. Training it is hoped that they would cascade to their colleagues (other NPCs, midwives, nurses). We chose to trial effectiveness of this sort of education on NPCs because they tend not to emigrate and so it was possible to do longer term project work with more durable impact in these countries. The aim of the project was to try and address the high levels of maternal and neonatal mortality. This report is the result of the impact and process evaluation of the ETATMBA project in both Tanzania and Malawi. In both Tanzania and Malawi we carried out an evaluation of impact and a process evaluation. In Tanzania we used a before and after design looking at health indicators in the health facilities where the trainees were to be based for the period leading up to the start of the training and approximately a year after the training. The choice of training areas and centres was determined by the national plan to upgrade remote rural health centres to provide emergency obstetric care. In Malawi we were delivering the intervention in the northern and central regions which contained 14 districts. We chose to randomize the design putting selected trainees in half of the districts. Outcomes were health indicators like in Tanzania. The primary outcome was perinatal mortality (specified as fresh stillbirth plus neonatal death before discharge from the health facility), with secondary outcomes of maternal mortality, obstetric complications and birth complications. In addition, in Tanzania we looked at infrastructure and availability of key items (e.g. electricity, running water, specific equipment and appropriate drugs). In both Tanzania and Malawi we carried out a qualitative process evaluation. Interviews explored perceptions of the training, trainees where we required to provide real evidence that they were implementing their new skills and knowledge into practice. We also interviewed cascadees (colleagues who may have received training from one of our trainees) district medical officers and a number of the trainers involved with the trainees. In both Tanzania and Malawi the training was successfully implemented. In Malawi 54 trainees started and by the end we had 46. In Tanzania, we had dyads of trainees that is an AMO and a nurse or a nurse iv midwife (the plan was to train the nurse in anaesthesia). There were 54 trained and 36 evaluated. Of the 36 at the start (18 of each group) one passed away and two moved into other areas so we ended with 33 trainees. An ongoing initiative in Tanzania suggested that after being trained the trainee dyads would return to updated facilities (e.g. an operating theatre) that allowed them to use the new skills and knowledge. Training in Tanzania was an intensive period away working with the tutors and doctors whilst in Malawi it was more modular with clinical mentors visiting trainees in their own facilities: socalled “on-the-job” training. Both training courses included leadership training. Whilst we were very successful at carrying out an evaluation in both countries problems with data do make us cautious about interpreting the results we have. In Malawi for the primary outcome of neonatal and perinatal mortality we did not demonstrate any difference. In Tanzania we found that it is not routine practice to record neonatal mortality at the facilities making it impossible to calculate perinatal mortality. However, in terms of maternal mortality there is a decline in maternal mortality in Tanzania and may be a trend in Malawi but this needs further statistical modelling to account for confounders. In Malawi the lack of any change in intervention districts compared to control may also reflect the fact that to achieve the BSc, NPCs’ training continued to 2014 and a longer time may be needed to see the effect. In Malawi there is some indication that in intervention districts there are more obstetric complications but this is apparent at baseline. The qualitative data strongly supports that in Malawi the trainees applied new skills such as vacuum extraction and breech delivery, but baseline differences in the quantitative data between groups make it difficult for this to be clear. In Tanzania there is evidence that patients are aware of the new skills with people turning up at facilities that trainees are working in. Similarly, birth complications in Malawi appear to rise but differences at baseline make this difficult to interpret and again this may be a recording issue in the intervention group following training. For example, reported cases of asphyxia at birth have risen in both intervention and control districts. It is possible that training has influenced this; in ETATMBA we did extensive teaching on neonatal resuscitation but an important confounder has been a countrywide initiative called ‘Helping Babies Breathe’ that could have impacted on asphyxia rates in control districts. In both countries it is clear that resources and infrastructure have a huge impact on the ability of health workers, at times, to carry out their work. Basic no expensive drugs are often unavailable equipment is poorly maintained and running (clean) water and electricity are not guaranteed. Roads and vehicles for patient transfer or emergencies again are at times note available or so poorly maintained they are a major barrier to access to emergency obstetric care. Trainees across the study note that they would welcome ongoing support and mentorship as our project closes. Trainers are maintaining some contact but face-to-face is difficult. In Tanzania the pattern of shortages of medical doctors is different to Malawi (where the shortage is urban as well as rural). In Tanzania you can find doctors in major centres but as you get into remote areas there are considerably less of them. The trainees note that often they are the only health professional available in these areas yet they are poorly supported with very poor housing and little or no recognition. There were similar feelings of isolation in Malawi with trainees feeling they lack a clear career path. The training and the setting up of a BSc for NPCs has given them some hope. There is evidence from our qualitative study that due to the leadership training trainees in both countries are engaging with local communities and officials and working with the teams and management in the facilities to try and bring about clinical service improvements. This study has demonstrated that up-skilling non-physician clinicians with skills and knowledge in obstetrics, neonatal care and leadership is possible in sub-Saharan Africa. Not only is it possible it can v have a real impact on lives. The project highlights a number of the challenges of working in sub-Saharan Africa. This work provides strong evidence that this cadre are an important and integral part of the future of healthcare in sub-Saharan Africa and more should be done to encourage a future well-educated and supported generation who will have the health of nations in their hands and provide a sustainable solution for many countries in sub-Saharan Africa for the future.

Background Malawi faces a severe shortage of health workers, a factor that has contributed greatly to high maternal mortality in the country. Most clinical care is performed by mid-level providers (MLPs). While utilization of these cadres in providing health care is a solution to the current shortages, demotivating factors within the Malawian health system are pushing them into private, non-governmental, and other non-health related positions. This study aims to highlight these demotivating factors by exploring the critical aspects that influence MLPs’ intention to leave their jobs. Methods This descriptive qualitative study formed part of the larger Health Systems Strengthening for Equity (HSSE) study. Data presented in this paper were collected in Malawi using the Critical Incident Analysis tool. Participants were asked to narrate an incident that had happened during the past three months which had made them seriously consider leaving their job. Data were subjected to thematic analysis using NVivo 8 software. Results Of the 84 respondents who participated in a Critical Incident Analysis interview, 58 respondents (69%) indicated they had experienced a demotivating incident in the previous three months that had made them seriously consider leaving their job. The most commonly cited critical factors were being treated unfairly or with disrespect, lack of recognition of their efforts, delays and inconsistencies in salary payments, lack of transparent processes and criteria for upgrading or promotion, and death of patients. Conclusion Staff motivation and an enabling environment are crucial factors for retaining MLPs in the Malawian health system. This study revealed key ‘tipping points’ that drive staff to seriously consider leaving their jobs. Many of the factors underlying these critical incidents can be addressed by improved management practices and the introduction of fair and transparent policies. Managers need to be trained and equipped with effective managerial skills and staff should have access to equal opportunities for upgrading and promotion. There is need for continuous effort to mobilize the resources needed to fill gaps in basic equipment, supplies, and medicine, as these are critical in creating an enabling environment for MLPs.

An interview survey was carried out in 20 Malawian lakeside villages from 1999 to 2000 to clarify the relationship between local and scientific names of the fishes in Lake Malawi/Nyasa. Fishermen in various localities responded with 536 local fish names for photographs shown of 106 fish species and color morphs. Similarity analysis of local name usage produced three groups of localities corresponding with the Tonga, Tumbuka, and Nyanja/Yao languages. A single scientific fish species had 10.2 local fish names, while one local fish name covered 2.0 scientific fish species, and 64.3 % of local fish names were used only for one scientific species. A few local fish names were used widely irrespective of language, although 69.5 % of local fish names were collected only from one locality. These facts suggest that lakeside residents identify fish at the biological taxonomy level, although the naming was specific to a particular locality. Most fishes with a high variety of local names were shallow-water dwelling species with low local market values, whereas fishes with fewer local names were mainly offshore species of high commercial value.

Background: Despite the documented benefits of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) services, the uptake remains low in sub-Saharan Africa. The lack of male involvement (MI) may be one of the reasons for this. However, there are limited data on strategies for MI in PMTCT. Objective: The objective of this study was to identify strategies that may promote MI in PMTCT services in antenatal care (ANC) services in Blantyre, Malawi. Study design: An exploratory qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) in Blantyre, Malawi. It consisted of six face-to-face key informant interviews (KIIs) with healthcare workers and four focus group discussions (FGDs) with 18 men and 17 pregnant women attending ANC at SLHC. The FGDs were divided according to sex and age. All FGDs and KIIs were digitally recorded and simultaneously transcribed and translated verbatim into English. Data were analyzed using thematic content analysis. Results: Three major themes with several subcategories emerged. Theme 1 was a gatekeeping strategy with two subcategories: (1) healthcare workers refusing service provision to women accessing antenatal clinic without their partners and (2) women refusing ANC attention in the absence of a partner. Theme 2 comprised extending invitations and had six subcategories: (1) word of mouth, (2) card invites, (3) woman’s health passport book invites, (4) telephonic invites, (5) use of influential people, and (6) home visits. Theme 3 was information education and communication, such as health education forums and advertisements. Of all the strategies, an invitation card addressed to the male partner was most preferred by study participants. Conclusions: There are several strategies by which men may be involved in PMTCT. Healthcare workers should offer a pregnant woman all strategies available for MI for her to select the appropriate one. Further research and consultations with men should continue to achieve higher levels of MI. Keywords: male involvement; HIV and AIDS; PMTCT (Published: 16 December 2013) To access the supplementary material for this article, please see the Supplementary files in the column to the right (under Article Tools) Citation: Glob Health Action 2013, 6 : 22780 - http://dx.doi.org/10.3402/gha.v6i0.22780

The relationship between quality of life (QoL) and antiretroviral treatment (ART) has mainly been studied using quantitative scales often not appropriate for use in other contexts and without taking peoples' lived experiences into consideration. Sub-Saharan Africa has the highest incidence of HIV and AIDS yet there is paucity in research done on QoL. This research report is intended to give an account of the use of a mixed method convergent parallel design as a novice approach to evaluate an instrument's context specificity, appropriateness and usefulness in another context for which it was designed. Data were collected through a qualitative exploration of the experiences of QoL of people living with HIV or AIDS (PLHA) in Africa since being on ART, as well as the quantitative measurements obtained from the HIV/AIDS-targeted quality of life (HAT-QoL) instrument. This study was conducted in three African countries. Permission and ethical approval to conduct the study were obtained. Purposive voluntary sampling was used to recruit PLHA through mediators working in community-based HIV/AIDS organisations and health clinics. Interviews were analysed through open coding and the quantitative data through descriptive statistics and the Cronbach's alpha coefficient. A much wider range and richness of experiences were expressed than measured by the HAT-QoL instrument. Although an effective instrument for use in the USA, it was found not to be sensitive, appropriate and useful in an African context in its present form. The recommendations focus on adapting the instrument using the data from the in-depth interviews or to develop a context-sensitive instrument that could measure QoL of PLHA in Africa http://www.tandfonline.com/doi/full/10.1080/09540121.2013.859651 http://dx.doi.org/10.1080/09540121.2013.859651

This article looks at The Essential Electronic Agricultural Library (TEEAL), an innovative offline database, and its impact on research output in agricultural institutions in Africa. The article also examines some lessons gathered from 10 years of training and outreach on the system in Sub-Saharan Africa. TEEAL, a project of Cornell University’s R. Mann Library, in cooperation with over 50 major scientific publishers, societies, and index providers, is a digital collection of research journals for agriculture and related sciences. Researchers, students, academic staff and librarians can discover and access thousands of full-text PDF articles without the use of the Internet. Through TEEAL, scientists in developing countries now have access to current research; but has this access translated into effective research and teaching? Several studies have been carried out to evaluate whether TEEAL was meeting its objective of contributing to the enhancement of the quality and effectiveness of agricultural research and teaching through improving students’ and researchers’ access to relevant literature. The studies took various approaches in collecting data including a questionnaire, interviews and a bibliometric analysis of publications from institutions that have acquired and are using TEEAL. Results generally show that TEEAL is successfully meeting its objective. Recommendations are made for extending the use of TEEAL sets, particularly the inclusion of more journals from developing countries as a way of further enhancing its appeal to a wider audience.Innovation, No,44, June 2012

Aim This article describes participant outcomes of an interprofessional collaboration between health professionals and faculty in Malawi, Zambia, and the United States (US). Background One strategy critical for improving global health and addressing Millennium Development goals is promotion of interprofessional education and collaboration. Methods Program participants included 25 health professionals from Malawi and Zambia, and 19 faculty/health professionals from Alabama and California. African Fellows participated in a 2 week workshop on Interprofessional Education in Alabama followed by 2 weeks working on individual goals with faculty collaborators/mentors. The US Fellows also spent 2 weeks visiting their counterparts in Malawi and Zambia to develop plans for sustainable partnerships. Results/Conclusions Program evaluations demonstrated participants' satisfaction with the program and indicated that the program promoted interprofessional and cross-cultural understanding; fostered development of long-term sustainable partnerships between health professionals and educators in Zambia and the US; and created increased awareness and use of resources for global health education.

Objective. To examine the changes in clients’ health-care ratings before and after hospital workers received an HIV prevention intervention in Malawi, which increased the workers’ personal and work-related HIV prevention knowledge, attitudes and preventive behaviors. Design. Pre- and post-intervention client surveys. Setting. A large urban referral hospital in Malawi. Participants. Clients at purposefully selected inpatient and outpatient units on designated days (baseline, n ¼ 310 clients; final, n ¼ 683). Intervention. Ten-session peer-group intervention for health workers focused on HIV transmission, personal and workrelated prevention, treating clients and families respectfully and incorporating HIV-related teaching. Main Outcome Measures. Brief face-to-face clients’ interview obtaining ratings of confidentiality of HIV, whether HIVrelated teaching occurred and ratings of service quality. Results. Compared with baseline, at the final survey, clients reported higher confidence about confidentiality of clients’ HIV status (83 vs. 75%, P , 0.01) and more clients reported that a health worker talked to them about HIV and AIDS (37 versus 28%, P , 0.01). More clients rated overall health services as ‘very good’ (five-item mean rating, 68 versus 59%, P , 0.01) and this was true for both inpatients and outpatients examined separately. However, there was no improvement in ratings of the courtesy of laboratory or pharmacy workers or of the adequacy of treatment instructions in the pharmacy. Conclusions. HIV prevention training for health workers can have positive effects on clients’ ratings of services, including HIV-related confidentiality and teaching, and should be scaled-up throughout Malawi and in other similar countries. Hospitals need to improve laboratory and pharmacy services.

IntroductionThe objective of the study was to find out factors that affect the intentions of men and women to use family planning methods.MethodsThe study was conducted in Mangochi district, the southern regionof Malawi in 2006. About 60 Focus group discussions were conducted to identify the attitudes and beliefs of 30 male and 30 female participantsregarding family planning methods. The data was then transcribed and analyzed manually identifying central themes and relationships across the cases and narratives.ResultsMost of the respondents knew the different types of family planning methods and reported that health facilities had adequate stock of family planning supplies. However, it was found that most of the women and men were not using any modern family planning methods. Reasons included: family planning methods were perceived side effects, such as prolonged menstruation, men’s concerns about impotence and genital sores, weight gain or loss, and subsequent infertility. Traditional family planning methods were mostly used for infertility problems.ConclusionDespite knowing about the different types of family planning methods, and awareness of their ready availability in health facilities, use of these methods is low because considerable misinformation still prevails regarding contraceptive methods’ side effects.

The use of simplified methods for viral load determination could greatly increase access to treatment monitoring of HIV patients in resource-limited countries.The aim of the present study was to optimize and evaluate the performance of the Roche COBAS Taqman assay in HIV-RNA quantification from dried blood spots (DBS) and dried plasma spots (DPS).EDTA blood samples from 108 HIV-infected women were used to prepare 129 DBS and 76 DPS on Whatman 903 card. DBS and DPS were stored at -20 degrees C. HIV-1 RNA was extracted from DBS/DPS using the MiniMAG system (bioMerieux). Amplification and detection were performed using the Roche COBAS TaqMan assay. Plasma viral load results were used as standard.There was a high correlation between measures of viral load in plasma and in DBS/DPS (r=0.96 and 0.85 respectively, P0.001). Overall, viral load values in DBS and DPS tended to be lower than in plasma with mean (SD) differences of 0.32 log(0.22) for DBS and of 0.35 (0.33) for DPS. Detection rates were 96.4% for DBS and 96.1% for DPS in samples with corresponding plasma values3.0 log copies/ml. Samples with HIV-RNA below 50 copies/ml were correctly identified in 18/19 DBS and in 7/7 DPS.Both DBS and DPS provided results highly correlated to the plasma values. High detection rate was obtained with both DBS and DPS when HIV-RNA was3.0 log copies/ml. Our results support the use of DBS/DPS to detect virologic failure in resource-limited settings.

Health workers can contribute to HIV prevention by minimizing HIV transmission in health facilities and increasing client teaching. We offered a peer-group intervention for Malawian rural health workers to build their universal precautions and teaching skills. A quasi-experimental design using independent sample surveys and observations compared health workers in an intervention and delayed intervention control district at baseline and at 15 and 30 months post-intervention. Controlling for demographic factors, the intervention district had more reported HIV teaching at 15 and 30 months and also had higher universal precautions knowledge and fewer needle stick injuries at 30 months. Observations at 15 and 30 months post-intervention showed higher levels of teaching in the intervention district. Observed glove wearing and hand washing were also higher at 30 months. This intervention should be made available for health workers in Malawi and provides a potential model for other high-HIV prevalence countries.