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Lucky Mhango,1,2 Masumbuko Baluwa,1 Ellen Chirwa2 1Mzuzu University, Department of Nursing and Midwifery, Mzuzu, Malawi; 2University of Malawi, Kamuzu College of Nursing, Blantyre, MalawiCorrespondence: Lucky MhangoMzuzu University, Department of Nursing and Midwifery, Mzuzu, MalawiTel +265 995421648Fax +265 1320568Email mhango2014lucky@kcn.unima.mwPurpose: Malawi trains registered nurses as clinical preceptors to facilitate quality clinical teaching to nursing students. The concept of preceptorship is new in Malawi, and as such data about its contribution and challenges are scanty. It is for this reason that this study was undertaken to explore the challenges that preceptors face as they teach students.Methods: This exploratory-descriptive qualitative study was conducted at Malawi’s four major referral hospitals utilised by nursing training institutions as clinical sites. A sample of 12 participants was purposively selected to provide data regarding challenges encountered during preceptorship activities. In-depth interviews were conducted in order to collect data on challenges experienced by these facilitators. The data were later categorised and analysed into themes.Results: From the analysed data, three key themes emerged including preceptorship as time-consuming, lack of support from faculty members and lack of teamwork among preceptors.Conclusion: The study concluded that preceptors face several challenges that affect the quality of clinical teaching. The study recommends that there should be an improvement in the working relationship among those involved in clinical teaching to enhance clinical learning experiences among student nurses. It also recommends that more registered nurses should be trained as preceptors to improve the student–preceptor ratio.Keywords: preceptorship, preceptor, clinical teaching, nursing, clinical learning

Background Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries. Methods and findings We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial’s design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions’ socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants’ health costs. Conclusions We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.

Urinary tract infections caused by Extended Spectrum Beta-Lactamase producing Escherichia coli are increasing globally and yet treatment still remains a challenge due to antibiotic resistance of the causative agent. The aim of the study was to determine the antimicrobial susceptibility pattern and detect the presence of blaCTX-M gene in Escherichia coli isolated from urinary tract infection patients at the University Teaching Hospital, Lusaka, Zambia. This was a cross-sectional study that involved the collection of urine samples from patients who were diagnosed with urinary tract infections. The samples were cultured on MacConkey agar complemented with cefotaxime and Polymerase Chain Reaction was performed to confirm the Extended-Spectrum Beta-Lactamase producers by detecting the CTX-M gene. Antimicrobial susceptibility tests were conducted using standard methods. A total of 327 urine samples were cultured and 15 (4.6%) of these samples were positive ESBL producers. The isolates showed complete resistance to ampicillin and cotrimoxazole. Multi drug-resistant Extended Spectrum Beta-Lactamase producing Escherichia coli was detected in 4.6 % of UTI patients at the University Teaching Hospital.

Background: Health Surveillance Assistants (HSAs) are community-based health workers in Malawi, responsible for health services delivery at the community level. The prevalence of high role stressors among health surveillance assistants (HSAs) is a very important issue to strengthen the delivery of the essential health package at the community level; however, data on the prevalence of these role stressors to help understand more about the role stressors among HSAs is unavailable. This study aimed to investigate the prevalence of role stressors and its associated factors among HSAs. Methods: A cross-sectional study design was used in this study to collect data from January 2017 to December 2017. Data were collected from 430 HSAs from the districts of Mangochi, Lilongwe and Mzimba using a self-administered structured questionnaire was hand delivered to a total of 455 HSAs (response rate of 94.5%). Role ambiguity and role conflict was measured using a 13-item Rizzo et al. role conflict and ambiguity (RCA) scale; role overload was measured using a 9-item Reilly role overload scale and the job tasks for HSAs were measured using Burgal et al. modified version of the task inventory scale. Factors for role stressors were analyzed using the principal component analysis (PCA) and multiple linear regression model. Results: Of the respondents 3% had high risk for RA, 51.20% RC and 49% RO. Role stressors are prevalent among HSAs in Malawi. HSAs who were resident in rural areas, female, and performing additional clinical roles experienced significant levels of role stressors. Interestingly, no statistically significant associations were found between role stressors and the years at service post, age and the district of work. Conclusion: This is the first study of occupational role stressors in Malawi. Role stressors are prevalent among HSAs. Interventions aimed at improving supervision, training and task regulation by an independent regulatory body may support to reduce role stressors among HSAs. Keywords : health surveillance assistants, role ambiguity, role conflict, role overload, role stressors

Background In sub-Saharan Africa, individuals infected with HIV who are severely immunocompromised have high mortality (about 10%) shortly after starting antiretroviral therapy (ART). This group also has the greatest risk of morbidity and mortality associated with immune reconstitution inflammatory syndrome (IRIS), a paradoxical response to successful ART. Integrase inhibitors lead to significantly more rapid declines in HIV viral load (VL) than all other ART classes. We hypothesised that intensifying standard triple-drug ART with the integrase inhibitor, raltegravir, would reduce HIV VL faster and hence reduce early mortality, although this strategy could also risk more IRIS events. Methods and findings In a 2×2×2 factorial open-label parallel-group trial, treatment-naive adults, adolescents, and children >5 years old infected with HIV, with cluster of differentiation 4 (CD4) 0.7) and despite significantly greater VL suppression with raltegravir-intensified ART at 4 weeks (343/836 [41.0%] versus 113/841 [13.4%] with standard ART, p < 0.001) and 12 weeks (567/789 [71.9%] versus 415/803 [51.7%] with standard ART, p < 0.001). Through 48 weeks, there was no evidence of differences in mortality (aHR = 0.98 [95% CI 0.76–1.28], p = 0.91); in serious (aHR = 0.99 [0.81–1.21], p = 0.88), grade-4 (aHR = 0.88 [0.71–1.09], p = 0.29), or ART-modifying (aHR = 0.90 [0.63–1.27], p = 0.54) adverse events (the latter occurring in 59 [6.5%] participants with raltegravir-intensified ART versus 66 [7.3%] with standard ART); in events judged compatible with IRIS (occurring in 89 [9.9%] participants with raltegravir-intensified ART versus 86 [9.5%] with standard ART, p = 0.79) or in hospitalisations (aHR = 0.94 [95% CI 0.76–1.17], p = 0.59). At 12 weeks, one and two raltegravir-intensified participants had predicted intermediate-level and high-level raltegravir resistance, respectively. At 48 weeks, the nucleoside reverse transcriptase inhibitor (NRTI) mutation K219E/Q (p = 0.004) and the non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations K101E/P (p = 0.03) and P225H (p = 0.007) were less common in virus from participants with raltegravir-intensified ART, with weak evidence of less intermediate- or high-level resistance to tenofovir (p = 0.06), abacavir (p = 0.08), and rilpivirine (p = 0.07). Limitations of the study include limited clinical, radiological, and/or microbiological information for some participants, reflecting available services at the centres, and lack of baseline genotypes. Conclusions Although 12 weeks of raltegravir intensification was well tolerated and reduced HIV viraemia significantly faster than standard triple-drug ART during the time of greatest risk for early death, this strategy did not reduce mortality or clinical events in this group and is not warranted. There was no excess of IRIS-compatible events, suggesting that integrase inhibitors can be used safely as part of standard triple-drug first-line therapy in severely immunocompromised individuals. Trial registration ClinicalTrials.gov NCT01825031.

Background:\ud The Government of Malawi is seeking\ud evidence to improve implementation of its flagship\ud quality of care improvement initiative\ud —\ud the Standards\ud Based Management-Recognition for Reproductive\ud Health (SBM-R(RH)).\ud Objective:\ud This implementation study will assess the\ud quality of maternal healthcare in facilities where the\ud SBM-R(RH) initiative has been employed, identify\ud factors that support or undermine effectiveness of the\ud initiative and develop strategies to further enhance its\ud operation.\ud Methods:\ud Data will be collected in 4 interlinked\ud modules using quantitative and qualitative research\ud methods. Module 1 will develop the programme theory\ud underlying the SBM-R(RH) initiative, using document\ud review and in-depth interviews with policymakers and\ud programme managers. Module 2 will quantitatively\ud assess the quality and equity of maternal healthcare\ud provided in facilities where the SBM-R(RH) initiative\ud has been implemented, using the Malawi Integrated\ud Performance Standards for Reproductive Health.\ud Module 3 will conduct an organisational ethnography\ud to explore the structures and processes through which\ud SBM-R(RH) is currently operationalised. Barriers and\ud facilitators will be identified. Module 4 will involve\ud coordinated co-production of knowledge by\ud researchers, policymakers and the public, to identify\ud and test strategies to improve implementation of the\ud initiative.\ud Potential impact:\ud The research outcomes will\ud provide empirical evidence of strategies that will\ud enhance the facilitators and address the barriers to\ud effective implementation of the initiative. It will also\ud contribute to the theoretical advances in the emerging\ud science of implementation research.

Background: The rapid scale-up of free antiretroviral therapy has lead to decline in adult mortality at the population level and reduction of vertical transmission. Consequently, some couples living with HIV are maintaining their reproductive decisions; marrying and having children. This paper analyses policies and guidelines on HIV, AIDS and sexual and reproductive health in Malawi for content on marriage and childbearing for couples living with HIV.Methods: A qualitative study using interpretive policy analysis approach was conducted from July to December 2010 in two phases. First, data on access to HIV, AIDS and sexual and reproductive health services were collected using in-depth interviews with twenty couples purposively sampled in matrilineal Chiradzulu and patrilineal Chikhwawa communities. Secondly,data were collected from Malawi policies and guidelines on HIV, AIDS and sexual and reproductive health. The documents were reviewed for content on marriage and childbearing for couples living with HIV. Data were analysed using framework approach for applied policy analysis.Results: Four categories emerged from each phase. From the study, we extracted health workers attitudes, weak linkage between HIV, AIDS and sexual and reproductive health services, contradictory messages between media and the hospitals and lack of information as factors directly related to guidelines and policies. Analysis of guidelines and policies showed nonprescriptiveness on issues of HIV, AIDS and reproduction: they do not reflect the social cultural experiences of couples living with HIV. In addition, there is; lack of clinical guidelines, external influence on adoption of the policies and guidelines and weak linkages between HIV and AIDS and sexual and reproductive health services.Conclusion: This synthesis along with more detailed findings which are reported in other published articles, provide a strong basis for updating the policies and development of easy-to-follow guidelines in order to effectively provide services to couples living with HIV in Malawi.