Districts In Malawi Research Articles

First report of dog ticks and tick-borne pathogens they are carrying in Malawi.

Ticks are vectors for transmitting tick-borne pathogens (TBPs) in animals and humans. Therefore, tick identification is necessary to understand the distribution of tick species and the pathogens they carry. Unfortunately, data on dog ticks and the TBPs they harbor in Malawi are incomplete. This study aimed to identify dog ticks and the TBPs they transmit in Malawi. One hundred thirty-two ticks were collected from 87 apparently healthy but infested domestic dogs in four districts of Malawi, which were pooled into 128 tick samples. The ticks were morphologically identified under a stereomicroscope using identification keys, and species identification was authenticated by polymerase chain reaction (PCR) through the amplification and sequencing of 12S rRNA and cytochrome c oxidase subunit I (CO1) genes. The tick species identified were Rhipicephalus sanguineus sensu lato (58.3%), Haemaphysalis elliptica (32.6%), and Hyalomma truncatum (9.1%). Screening for TBPs using species-specific PCR assays revealed that 48.4% of the ticks were infected with at least one TBP. The TBP detection rates were 13.3% for Anaplasma platys, 10.2% for Babesia rossi, 8.6% for B. vogeli, 6.3% for Ehrlichia canis, 3.9% for A. phagocytophilum, 3.1% for B. gibsoni, 2.3% for B. canis and 0.8% for Hepatozoon canis. Co-infections of up to three pathogens were observed in 48.4% of the positive samples. This is the first study to identify dog ticks and the TBPs they harbor in Malawi. These findings provide the basis for understanding dog tick distribution and pathogens they carry in Malawi. This study necessitates the examination of ticks from more study locations to have a better picture of tick challenge, and the development of ticks and tick-borne disease control methods in Malawi.

Is the concentration of heavy metals in sun-dried Engraulicypris sardella (Günther, 1868) in Malawi, a human health risk?

The effects of trophic cascades have made small-size pelagic fish species, such as Engraulicypris sardella, from Lake Malawi an important ecological and food system. However, human-induced activities can potentially pollute Lake Malawi exposing E. sardella to heavy metals contamination. This could pose a food system health risk to the population of Malawians and neighboring countries, which heavily rely on fish as a source of animal protein. Therefore, this study investigated the concentration levels of Lead (Pb), Cadmium (Cd), Zinc (Zn), Copper (Cu), Manganese (Mn), and Iron (Fe) in sun-dried E. sardella and conducted a health risk assessment associated with its consumption. E. sardella samples were collected from Karonga, Nkhata Bay, Nkhotakota, Salima, and Mangochi districts in Malawi between December 2023 and February 2024. The results revealed significant variations in Cd, Zn, Cu, Mn, and Fe concentrations among the sampled sites while Pb contamination was not detected. The concentrations of Zn, Cu, Mn, and Fe in E. sardella were within acceptable consumption limits set by the Food and Agriculture Organization (FAO) and the World Health Organization (WHO) in 2012. However, the fish's average Cd levels (0.17 mg kg−1 ww) were slightly above the recommended threshold of 0.1 mg kg−1 ww by FAO/WHO (2012) but remained below the limit of 0.5 mg kg−1 ww set by FAO in 1983. Furthermore, none of the analyzed heavy metals posed a health risk effect to people. Therefore, there is a need for regular monitoring of heavy metal concentrations in E. sardella and other mostly consumed fish species from Lake Malawi, both fresh and processed, for a sustained guarantee of the safety of the fish consumers.

Potential contribution of agronomic practices and conservation agriculture towards narrowing smallholders’ yield gaps in Southern Africa: lessons from the field

Summary Smallholders in Southern Africa continue to grapple with low maize productivity despite this being the staple food crop. This study sought to analyze and isolate the relative contribution of agronomic practices to maize yields obtained by smallholders in Malawi and Mozambique using data generated from on-farm trials testing the performance of conservation agriculture cropping systems. The trials were implemented in two communities, namely Kasungu district in Malawi and Sussundenga district in Mozambique, and ran for seven consecutive growing seasons starting in 2010–2011. Maize yield was measured annually in the on-farm trials, which included a ‘control treatment’ representing an improved farm practice, and in neighboring fields managed by the same farmers on their own, hence representing a ‘true farm practice’. Results indicated that maize yield increased linearly with increasing plant population at harvest at both sites. On average, an increase in plant population at harvest by 1000 plants ha–1 resulted in an increase in maize yield of 90 and 63 kg ha–1 at Kasungu and Sussundenga, respectively. The greatest maize yields were obtained when plant population at harvest exceeded 40 000 plants ha–1. Yet, the plant population at harvest was below the generally recommended optimum for most of the cropping systems studied and in most growing seasons. Furthermore, the use of agronomic practices alone without conservation agriculture (i.e., improved varieties, fertilizer management, and timely weed control) resulted in maize yield gains of as much as 54% and 43% relative to the ‘true farm practice’ at Kasungu and Sussundenga, respectively. Overall, the proportion of these yield increases relative to the ‘true farm practice’ accounted for by agronomic practices amounted to 53–70% and 57–85% at Kasungu and Sussundenga for the highest to the lowest-yielding cropping system. Although conservation agriculture significantly improved maize yield at both sites, such increases were smaller in magnitude compared to the yield gains derived from improved agronomic practices. The study suggests that considerable strides toward narrowing maize yield gaps in Southern Africa can be achieved through improvement of current crop management practices, let alone adhering to the conservation agriculture principles of minimum tillage, residue retention, and crop diversification.

Prevalence of Plastic and Hardware Foreign Bodies among Goats at Malawi Markets.

Smallholder goat production plays a major role in rural livelihoods and food security in Malawi, but suffers from drastic and unpredictable production losses. While goat production is closely linked to small-scale local markets for slaughter and butchering, the perspectives of butchers and their potential as a source of animal health information are largely untapped. Butchers can provide insights into goat health status at slaughter as well as issues that go unseen before slaughter, such as the presence of indigestible foreign bodies (IFBs). IFBs include solid materials such as plastics and hardware (metals, stones, and other hard objects) that cause foreign body syndrome and can lead to impaction, oedema, malnutrition, and death. To estimate the presence of IFBs, 150 market stand butchers were surveyed across five districts in Malawi, focusing on a distinction between hardware and single-use plastics, which are still widely present in Malawi despite bans on production. Most butchers found plastic IFBs (80.7%), with over half (56.7%) reporting plastic IFBs recently among the past five slaughters. Hardware IFBs were less common, reported by 45.3% of butchers. While some butchers commented on the impact of IFBs on meat quality metrics ex-post, the majority observed no differences. While butchers unanimously considered health to be an important characteristic when sourcing goats, 70.7% consider injury status to be less important or not important. Overall, this study highlights the issue of anthropogenic waste pollution on goat production in Malawi and demonstrates the potential for the surveillance of goat health at market.

Understanding sustained adoption of conservation agriculture among smallholder farmers: insights from a sentinel site in Malawi

Abstract Smallholder farming systems need climate-proofing and sustainable intensification practices such as conservation agriculture (CA), are promising options. However, there is a general perception that the adoption of CA systems in southern Africa is low. Sentinel sites, where CA has been promoted for a long time, offer forward-looking new insights. This paper, thus, takes a deep dive at Nkhotakota district of Malawi to understand what could have led to the success of CA promotion and subsequent perceived high adoption. We use survey data from 620 farmers, with 298 farmers sampled from treatment areas – known to have had contact with host farmers and 320 from a control group. Overall, 31% of the farmers in both groups adopted full CA over at least a 2-year period. We also find that about 57% of farmers in the treatment area adopted full CA and only 7% of farmers in the control areas. This highlights that longer-term CA promotion with dedicated extension support can enhance the uptake of CA practices. In essence, this paper offers a different perspective to the current narrative that CA systems are too complex and knowledge intensive to be adopted despite its long-term promotion and significant investments. However, there are some nuances: sustained adoption even in sentinel sites is neither 100% nor persistent over the long term. We find an appreciable adoption decay, showing large declines from highs of 57 and 7% in adoption for at least 2 years for treatment and control, respectively, to 12% in the treatment group and practically zero in the control when we condition full CA adoption to at least 7 years. This means that fewer farmers adopted CA for a longer period and suggests some dis-adoption over time even in sentinel sites. The key adoption enablers in the sentinel sites include the availability of training, dedicated longer-term extension support coupled with farmer experiential learning through demonstration plots managed by host farmers. Based on our findings, there is need to consistently promote CA using farmer-centric approaches that include peer-to-peer learning over long periods. This allows farmers time to experiment with different CA options, enable behavioral and lasting change. At policy level, there is need to build and strengthen farmer groups to facilitate easier access to inputs like leguminous crop seeds for farmers practicing CA and to offer market-smart incentives to induce initial adoption in the short term to facilitate sustained adoption.

Inclusion of persons living with disabilities in a district-wide sanitation programme: A cross-sectional study in rural Malawi.

Community-led total sanitation (CLTS) is embraced as a key strategy to achieve universal sanitation coverage (Sustainable Development Goal 6.2). Although inclusion is identified as a predictor of CLTS success, people living with disabilities are often excluded from community sanitation programmes and there is limited research exploring CLTS participation amongst people living with disabilities. This study aims to explore the extent to which people living with disabilities participated in a CLTS intervention delivered in rural Malawi using standard approaches. This cross-sectional study was conducted in the Chiradzulu district of Malawi. A household questionnaire was administered to collect information about CLTS participation. Multivariable logistic regression was performed to compare participation in different CLTS activities between households with (n = 80) and without a member with a disability (n = 167), and between household members with (n = 55) and without a disability (n = 226). No difference in CLTS participation was observed at the household-level, but there were marked differences in CLTS participation between household members with and without a disability. Household members without a disability felt they could give more input in triggering activities (OR = 3.72, 95%CI 1.18-11.73), and reported higher participation in the transect walk (OR = 4.03, 95%CI 1.45-11.18), community action planning (OR = 2.89, 95%CI 1.36-6.13), and follow-up visits (OR = 3.37, 95%CI 1.78-6.40) compared to household members with disabilities. There was no difference in the likelihood of being invited to triggering (OR = 0.98, 95%CI 0.41-2.36), attending triggering (OR = 2.09, 95%CI 0.98-4.46), or participating in community mapping (OR = 2.38, 95%CI 0.71-7.98) between household members with and without a disability. This study revealed intra-household inequalities in CLTS participation. To improve participation in CLTS interventions, facilitators should be trained on action steps to make CLTS more inclusive. Further research could include an in-depth analysis of predictors of CLTS participation amongst people living with disabilities, including disability types, severity and age.

Non-communicable diseases and HIV/AIDS burden by socio-demographic characteristics in Malawi

Background The co-existence of non-communicable diseases (NCDs) and HIV/AIDS is a health concern that needs to be promptly addressed in Sub-Saharan Africa. However, with limited data, responding to this problem may be difficult. This paper aims to describe the burden of NCDs and HIV/AIDS within patients’ socio-demographic and health facility characteristics across the cities and districts in Malawi. Methods We analysed health facility-based data extracted from NCD patient mastercards from 2019 to 2022 from 70 health facilities in 11 cities and districts in Malawi. Data analysis was done in R using mean, proportions, frequency distributions and charts. Hybrid k-means clustering was used to determine health facilities with similar cases. Results A total of 29,196 patients had at least one non-communicable disease, with 7.9% having NCDs comorbid with HIV/AIDS. The southern part of Malawi (54.2%), inland locations (69.9%) and health centres (55.3%) recorded large numbers of cases in their respective categories. The health facilities’ case clustering indicated that Neno and Salima district hospitals had similar cases. About 16.1% of the young adults (19 - 39 years) had either a non-communicable disease or NCD-HIV/AIDS comorbidity. The most prominent NCD was hypertension (63.2%), followed by asthma (9.2%). The most commonly employed intervention was medication for NCD (51.6%) and NCD-HIV/AIDS comorbidity (43.4%). Only 13% of all the health facilities in the selected cities/districts used NCD mastercards from which data for this study was extracted. Conclusions NCDs and NCD-HIV/AIDS comorbidity among young adults pose a major concern since the ailment would lead to days off during the peak of their productivity. The NCD and NCD-HIV/AIDS comorbidity is a major public health problem that needs more attention than realised since the cases reported in this study could be under-reported.

Knowledge, practices and adherence to COVID-19 preventive measures by community members in the Phalombe District Malawi: a cross-sectional qualitative study.

The COVID-19 pandemic has strained already struggling health systems in low- and middle-income countries such as Malawi. To slow the spread of the virus, the World Health Organization recommended non-pharmaceutical measures including frequent hand washing, wearing of face masks when in groups or social gatherings and maintaining physical distance. To ensure adequate uptake of these preventive measures, many communities intensified engagement, advocacy meetings and health promotion interventions. In this study, we investigated knowledge, practice and adherence towards COVID-19 preventive measures of people living in the rural community of Phalombe District of Malawi. In this cross-sectional, qualitative study, data were collected in focus group discussions and in-depth interviews. Participants were selected from six randomly selected villages under traditional authorities, namely Nazombe, Jenala and Nkhumba from Phalombe District. Data were thematically analysed to identify emerging themes. Most participants knew about and were aware of, but reported poor adherence to COVID-19 preventive measures. Two major themes emerged, namely, perceived low-risk of COVID-19 and non-adherence to preventive measures. Various sub-themes emerged regarding the use of preventive measures when participating in social gatherings. These sub-themes included knowledge of preventive measures, use of face masks, observing physical distance and hand washing practices. People living in the rural district of Phalombe District of Malawi were able to identify COVID-19 preventive methods. Participants reported low adherence to preventive methods, which was associated with low perceived risk. Community perceptions and willingness need to be considered when mandating preventive measures for future pandemics.

Factors associated with stunting among children aged below 60 months from rural Malawi: a matched case-control study

Stunting currently affects 37% (1.1 million) of Malawian children and causing unfavorable impact for both children and their households. Identifying risk factors to stunting would go a long way in developing appropriate interventions. The objective of this study was to identify the risk factors of stunting among children aged below 60 months from Balaka, Dedza and Mzimba districts in Malawi. A matched cross-sectional case-control study was conducted among 913 (446 controls; 467 cases) children aged below 60 months from three regions of Malawi. Household demographic, anthropometric measurements, dietary intake, food security, and morbidity information were collected. Case-Control Stepwise multiple logistic regression models are used to determine risk factors of stunting. The following were identified as risk factors for stunting including; age of child (AOR= 6.3; 95% CI: 2.9, 8.9), polygamy (AOR= 8.9; 95%, CI: 3.3, 13.03), maternal education (AOR= 9.9; 95%, CI: 2.8, 20.1), access to markets (AOR= 1.3; 95%, CI: 0.2, 2.4), childhood infections (AOR= 2.11; 95%, CI: 1.4, 4.2) and presence of oedema (AOR= 2.5; 95%, CI: 1.3, 4.1). Also, lack of food any month (AOR= 1.31; 95%, CI: 1.01, 4.9), purchasing food on credit (AOR= 1.48; 95%, CI: 1.4, 1.7), begging for food (AOR= 1.55; 95%, CI: 1.2, 2.1), mothers or caregivers consuming less than 5 food groups (MDD-W) (AOR = 4.83; 95% CI: 1.9, 16.4), exclusive breastfeeding (AOR= 5.45; 95%, CI: 4.33, 7.61) children weaned on plain water (AOR= 1.6; 95%, CI: 1.6, 2.41), powdered milk (AOR= 0.63; 95%, CI: 0.4, 1.32), juices (AOR= 0.44; 95%, CI: 0.12, 0.96) and children fed on sugary food (AOR= 0.66; 95%, CI: 0.4, 0.99) were significantly related to stunting. Stunting is associated with increasing age of children, boys, polygamous households, lack of education by mothers or caregivers, inaccessible markets, childhood infections and presence of oedema, food insecurity, breastfeeding and complementary feeding among children and dietary diversity of mothers or caregivers. These results suggest that interventions against childhood stunting should be designed according to the factors that significantly affect stunting. Key words: child growth, Malawi, stunting and complementary feeding, Regression, Food Security and Health

Direct and spillover effects of biofortified sweetpotato interventions on sustained adoption in Malawi

Agriculture-nutrition interventions (ANI) have recently received attention as a promising delivery mechanism for achieving desirable nutritional outcomes. However, more evidence is needed on the effectiveness of such interventions. In this study, we analyze direct and spillover effects of ANIs for biofortified orange-fleshed sweetpotato (OFSP) in Malawi on sustained household outcomes: OFSP adoption, area planted, harvest, and sales. In Malawi, we selected three large-scale OFSP interventions and use a rich dataset of 2,492 smallholder farmers selected from every district of Malawi. Methodologically, we employ bivariate probit, instrumental variables, and propensity score matching techniques. We find positive and sustained participation effects for all outcomes. Second, we find that OFSP interventions spilled over and benefited non-participants who lived in treatment villages. Vine multipliers and vine conservation techniques were key diffusion mechanisms for initial and sustained adoption of OFSP varieties. Interventions promoted higher OFSP root sales which suggests that generating income is an important motivator of adoption, in addition to own-consumption. Also, root sales is an often overlooked diffusion mechanism to reach additional farmers beyond the direct participants. Relevant for policy-makers is that OFSP interventions have sustained positive adoption and diffusion effects, and thus feature well as a relatively cost-effective food-based approach among other strategies to eradicate hidden hunger. Designing ANIs with strong supply-push (e.g., (de)centralized vine multipliers, vine conservation techniques) and demand-pull components (e.g., participatory varietal selection and agronomic training) are key and will need to be accompanied by strategies that create a stronger economic case for OFSP, for instance, by investments to strengthen a processing industry for OFSP roots.

The politics of agricultural policy and nutrition: A case study of Malawi's Farm Input Subsidy Programme (FISP).

The concept of food and nutrition policy has broadened from simply being an aspect of health policy, to policy interventions from across a wide range of sectors, but still with potentially important impact on nutritional outcomes. This wider and more complex conceptualisation involves policy with multiple objectives and stakeholder influences. Thus, it becomes particularly important to understand the dynamics of these policy processes, including policy design and implementation. To add to this literature, we apply the Kaleidoscope Model for understanding policy change in developing country contexts to the case-study of an agricultural input subsidy (AIS) programme in Malawi, the Farm Input Subsidy Programme (FISP), exploring the dynamics of the FISP policy process including nutritional impact. Over a three-month period between 2017 and 2019 we conducted in-depth interviews with key stakeholders at national and district levels, and focus groups with people from rural districts in Malawi. We also undertook a review of literature relating to the political economy of the FISP. We analysed the data thematically, as per the domains of the Kaleidoscope Model. The analysis across the FISP policy process including policy design and implementation highlights how stakeholders' ideas, interests and influence have shaped the evolution of FISP policy including constraints to policy improvement-and the nutritional impacts of this. This approach extends the literature on the tensions, contradictions and challenges in food and nutrition policy by examining the reasons that these occur in Malawi with the FISP. We also add to the political science and policy analysis literature on policy implementation, extending the concept of veto players to include those targeted by the policy. The findings are important for consideration by policymakers and other stakeholders seeking to address malnutrition in rural, food-insecure populations in Malawi and other low-income settings.

Fluoride Levels in Borehole Water: The Case of Chiradzulu District in Malawi

Aims: The objective of this study was to determine the levels of fluoride in borehole water samples.
 Study Design: The total of eight samples were collected from five villages in Chiradzulu and transported in cooler ice-bath to the laboratory for the analysis.
 Place and Duration of Study: The study was conducted in the Department of Chemistry and Chemical Engineering Laboratories, at University of Malawi in the month of June.
 Methodology: The ion selective electrode technique was used to assess fluoride levels. Physicochemical water parameters were measured with multi-meters. 
 Results: The results obtained ranged from 2.26 to 3.08 mg/L, 136 to 561 mg/L, 261-1212 μs/cm and 6.27 to 6.97, for Fluorides, TDS, conductivity and pH, respectively. Levels of fluorides exceeded permissible limits for borehole water established by WHO and were below the standards for MBS
 Conclusion: The results attained in the scope of the study support coloration of teeth observed amongst individuals in study communities, helping to understand that groundwater is not suitable for consumption. Therefore, the study provides recommendation for urgent implementation of defluoridation measures to provide clean and safe water for the existing community members.

Effect of participation in goat keeping on household food security:A case study of Dowa district, Malawi

Goat keeping is a common practice among rural farmers due to the adaptability of goats to harsh environments, their efficient forage conversion and rapid growth, and their multiple benefits, including the production of manure and high-quality milk. However, limited research has been done on the direct effect of participation in goat keeping on food security in Malawi. Therefore, this study investigated the effect of participation in goat keeping on household food security in Dowa district in Malawi using the propensity score-matching technique. The results reveal a positive correlation between goat farming and household food security. This was evident from the significant average treatment effect on the treated (ATT), which indicated a lower value of the Household Food Insecurity Access Scale (HFIAS) for goat keepers compared to non-keepers. These findings highlight the potential of goat farming to enhance food security among rural households, emphasising the importance of promoting this type of farming at the household level.

Provider-led community antiretroviral therapy distribution in Malawi: Retrospective cohort study of retention, viral load suppression and costs.

Outcomes of community antiretroviral therapy (ART) distribution (CAD), in which provider-led ART teams deliver integrated HIV services at health posts in communities, have been mixed in sub-Saharan African countries. CAD outcomes and costs relative to facility-based care have not been reported from Malawi. We performed a retrospective cohort study in two Malawian districts (Lilongwe and Chikwawa districts), comparing CAD with facility-based ART care. We selected an equal number of clients in CAD and facility-based care who were aged >13 years, had an undetectable viral load (VL) result in the last year and were stable on first-line ART for ≥1 year. We compared retention in care (alive and no period of ≥60 days without ART) using Kaplan-Meier survival analysis and Cox regression and maintenance of VL suppression (<1,000 copies/mL) during follow-up using logistic regression. We also compared costs (in US$) from the health system and client perspectives for the two models of care. Data were collected in October and November 2020. 700 ART clients (350 CAD, 350 facility-based) were included. The median age was 43 years (IQR 36-51), median duration on ART was 7 years (IQR 4-9), and 75% were female. Retention in care did not differ significantly between clients in CAD (89.4% retained) and facility-based care (89.3%), p = 0.95. No significant difference in maintenance of VL suppression were observed between CAD and facility-based care (aOR: 1.24, 95% CI: 0.47-3.20, p = 0.70). CAD resulted in slightly higher health system costs than facility-based care: $118/year vs. $108/year per person accessing care; and $133/year vs. $122/year per person retained in care. CAD decreased individual client costs compared to facility-based care: $3.20/year vs. $11.40/year per person accessing care; and $3.60/year vs. $12.90/year per person retained in care. Clients in provider-led CAD care in Malawi had very good retention in care and VL suppression outcomes, similar to clients receiving facility-based care. While health system costs were somewhat higher with CAD, costs for clients were reduced substantially. More research is needed to understand the impact of other differentiated service delivery models on costs for the health system and clients.

Does climate information source matter in smallholder farmers' climate resilience? Comparative insights from Malawi and Ghana

Due to increasing climate variability and change, the need for more accessible, timely, and reliable climate information has risen, particularly in African rain-fed smallholder farming communities. Yet, studies on the role of information sources in climate resilience are limited. Given the plurality of climate information sources, it is uncertain which medium offers better chances to build resilience against the changing climate. To fill this gap, we employed quantitative survey data from smallholder agricultural households in the Mzimba District in Malawi (n = 1090) and the Upper West Region of Ghana (n = 1100). Our findings reveal that in Malawi, households whose primary source of climate information was the mass media (OR = 2.37; p ≤ 0.001) and external organizations (government, private sector, and nonprofit sector) (OR = 2.11; p ≤ 0.001) were over two times more likely to rate their resilience as good compared to those who relied primarily on self-experience. While in Ghana, interpersonal sources (other farmers, friends/relatives, special activities by the community) significantly increased a household's odds (OR = 3.46; p ≤ 0.001) of reporting good resilience, while external sources reduced farmers' likelihood of reporting climate resilience (OR = 0.06; p ≤ 0.001) compared to those who relied primarily on self-experience. Farmers in Malawi who practiced intercropping were also more likely to rate their resilience as good than those engaged in monocropping. The findings suggest that the relevance of information sources on climate change resilience is place-specific and that some sources may impede resilience-building if contextual factors are sidelined. This finding reaffirms the need for context-specific policies due to the heterogeneity of agrarian communities across Africa.

Turned away and sleeping apart: A qualitative study on women's perspectives and experiences with family planning denial in Malawi

IntroductionBarriers to family planning for potential clients have been explored in the literature, but rarely from the perspective of the women themselves in a low-income setting. This research aimed to understand clients’ perspectives on being turned away from receiving a method of family planning at a facility on the day it was sought. MethodsThree focus group discussions were held in two districts of Malawi in 2019 with clients who had been turned away approximately three to six months prior. ResultsThe reasons for turnaway participants mentioned fell into eight categories: no proof of not being pregnant, method and/or supply stock-outs, arriving late, provider unavailable, provider refusal, needing to wait longer after delivery of a child, financial constraints, and medical reasons. Participants were often turned away more than once before finally being able to initiate a method, in some cases returning to the same facility and in others finding it through community health workers, traditional healers, or private facilities. Clients often resorted to sleeping apart from their husbands until they could initiate a method and reported stress and worry resulting from being turned away. ConclusionsClients are turned away without a method of FP on the day they seek one for multiple reasons, nearly all of which are preventable. Many examples given by the participants showed a lack of knowledge and respect for clients on the part of the providers. Changing attitudes and behaviour, however, may be difficult and will require additional steps. Increasing the availability and use of pregnancy tests, having a more reliable supply of methods and materials, increasing the number of providers—including those trained well in all methods—and providing daily FP services would all help reduce turnaway. Improved access to family planning will help counties achieve their Sustainable Development Goals.

Evaluating the role that Care Groups play in providing breastfeeding and infant feeding support at community level: a qualitative study in Dedza district in Malawi

Background: Promoting exclusive breastfeeding is a key nutrition policy objective in Malawi. This study assesses the role that care group volunteers (CGVs) play in providing breastfeeding and infant feeding support at community level. Care groups are a peer-to-peer learning approach, which has been part of Malawi’s nutrition policy since 2012, yet its efficacy and its role within community-level nutrition support remains under-researched. Methods: In July 2021, we conducted 60 qualitative semi structured interviews in Dedza District with village leaders, Health Surveillance Assistants (HSAs), CGVs and district health officials, mothers with at least one child under two (n=36) who were randomly selected, and (purposively selected) mothers who had a child who was born prematurely or with low birthweight. The research was conducted in one of two care group programme implementation areas, or in several villages where care group interventions had not taken off. All interviews were recorded, transcribed and translated into English and then analysed using qualitative data analysis software. Thematic analysis was used to elicit key themes. Results: Only eight out of 26 women in locations where care groups were active reported receiving breastfeeding support from care groups. All mothers reported receiving breastfeeding support at the health facility where they delivered their baby(ies) (n=36) and some (n=24) also at ante-natal care clinics. Where care groups were active, 18 out of 26 interviewees reported interacting with them, mostly during cooking demonstrations or receiving home visits. Little interaction was observed by interviewees between HSAs and CGVs (n=1) and no evidence suggested coordination between HSAs and CGVs around (vulnerable) newborn baby visits, as described by one HSA. Conclusions: This research shows that care groups, despite being well-known, remain an under-appreciated and un-integrated volunteer cadre. Policy reform in relation to care groups in Malawi could improve care group efficacy.

Tariff setting for the sustainability of communal water points in Mangochi District, Malawi

Abstract The Malawian Government adopted a community-based management model for rural water supply systems, which assumes that users would cover costs related to the operation and maintenance (O&amp;M) of their communal water points through regular cash contributions. These communal water points are mostly boreholes fitted with Afridev hand pumps. However, studies have shown that Afridev hand pumps continue to fail within 3–5 years after installation, despite having a design lifespan of 10–15 years, mostly due to insufficient O&amp;M. Therefore, this study assessed the adequacy of tariffs being used at different water points in Mangochi District in Malawi through a household (HH) survey with a sample size of 288 HHs and a market prices survey. The results showed that 90% of the HHs were making contributions that could not sustainably support the lifecycle O&amp;M costs or the afterlife replacement of the Afridev hand pump. This study suggests a consistent minimum annual water point fund collection of MWK142,050 (US$172.29)1. It is recommended that the study be replicated in other areas. It is also recommended that further studies should focus on HH affordability with respect to the recommended tariff.

Modeling Pathways to Describe How Maternal Health Care Providers' Mental Health Influences the Provision of Respectful Maternity Care in Malawi.

Maternal health (MH) providers may experience traumatic events, such as maternal or fetal death, that can contribute to stress and burnout. Past trauma, poor working relationships, and under-resourced environments not only affect providers' own emotional well-being but also reduce their ability to provide respectful maternity care (RMC). Data were collected in mid-2021 as a cross-sectional survey with 302 MH providers working in 25 maternities in 3 districts in Malawi to measure burnout, depression, and post-traumatic stress disorder (PTSD). We present a pathway model describing how these factors interact and influence RMC. We used the provider-reported person-centered maternity care scale to measure RMC; the Maslach Burnout Inventory, which examines emotional exhaustion, depersonalization, and professional accomplishment; and standard validated screening tools to measure the prevalence of depression and PTSD. Although levels of burnout varied, 30% of MH providers reported high levels of exhaustion, feelings of cynicism manifesting as depersonalization toward their clients (17%), and low levels of professional accomplishment (42%). Moderate to severe depression (9%) and suicidal ideation within the past 2 weeks (10%) were also recorded. Many (70%) reported experiencing an event that could trigger PTSD, and 12% reported at least 4 of 5 symptoms in the PTSD scale. Path analysis suggests that depression and emotional exhaustion negatively influence RMC, and depersonalization is mediated through depression. PTSD has no direct effect on RMC, but increased PTSD scores were associated with increased burnout and depression scores. Positive relationships with facility managers were significantly associated with increased RMC and decreased emotional exhaustion and depersonalization. Burnout will continue to be a challenge among MH providers. However, pragmatic approaches for improving teamwork, psychosocial, and managerial support for MH providers working in challenging environments may help mitigate burnout, improve MH provider well-being, and, in turn, RMC for women seeking MH services.

Legitimization of data quality management practices in health management information systems: A soft systems methodology perspective

AbstractRecognizing the significance of data for policy change to improve population health, many developing countries and Health Partners have invested for decades in Health Management Information System (HMIS). Despite huge investments in technologies and capacity building to support the management of routine health data, there is still a problem in trying to make substantial improvements on gains made so far. A number of researchers have reported on lack of motivation, ownership, data use and work overload as some of the reasons explaining the persistent problem with routine health data quality. However not much has been reported on how legitimacy seekers and providers negotiate for the legitimacy of data quality management practices. We drew on this gap to explore how gaps are negotiated between the legitimacy seekers and the legitimacy providers when seeking legitimacy of data quality management practices in HMIS at micro level. Using institutional theory pillars: institutionalization and legitimation, we framed our qualitative study in soft systems methodology (SSM). We collected data using observations, semi‐structured interviews, and study of artifacts to answer our question based on the Malawi's District Health Information System (DHIS2) use case. Our findings revealed three factors shaping the gap negotiation: coercive approach, technical support and social relationship and moral judgment. The paper's contribution is two‐fold, (a) from a practical perspective we identify the pertinent context issues that come into play when negotiating a gap between the data cadres and the managers (from the Ministry of Health and partners) in the course of seeking legitimacy of data quality management practices; (b) theoretically we promote the application of SSM models with an institutional perspective in making sense of complex situations relating to legitimation.