Malawi Government Research Articles

Patient satisfaction with health care at a tertiary hospital in Northern Malawi: results from a triangulated cross-sectional study

BackgroundIn 2016 the Malawi government embarked on several interrelated health sector reforms aimed at improving the quality of health services at all levels of care and attain Universal Health Coverage by 2030. Patient satisfaction with services is an important proxy measure of quality. We assessed patient satisfaction at a tertiary hospital in Northern Malawi to understand the current state.MethodsWe conducted exit interviews with patients aged ≥ 18 years using a 28 statement interviewer administered questionnaire. Patients were asked to express their level of agreement to each statement on a five-point Likert scale – strongly disagree to strongly agree, corresponding to scores of 1 to 5. Overall patient satisfaction was calculated by summing up the scores and dividing the sum by the number of statements. Mean score > 3 constituted satisfaction while mean score ≤ 3 constituted dissatisfaction. A χ2 test was used to assess the association between overall patient satisfaction and demographic variables, visit type and clinic consulted at alpha 0.05. Patient self-rated satisfaction was determined from a single statement that asked patients to rate their satisfaction with services on a five-point Likert scale. We also asked patients to mention aspects of hospital care that they did not like. Responses were summarized into major issues which are presented according to frequencies.ResultsOverall patient satisfaction was 8.4% (95% CI: 5.2 − 12.9%). Self-rated patient satisfaction was 8.9% (95% CI: 5.5 − 13.4%). There was no significant association between overall patient satisfaction and all predictor variables assessed. Patients raised six major issues that dampened their health care seeking experience, including health workers reporting late to work, doctors not listening to patients concerns and neither examining them properly nor explaining the diagnosis, shortage of medicines, diagnostics and medical equipment, unprofessional conduct of health workers, poor sanitation and cleanliness, and health worker behaviour of favouring relatives and friends over other patients.ConclusionsWe found very low levels of patient satisfaction, suggesting that quality of services in the public health sector is still poor. It is, therefore, critical to accelerate and innovate the Ministry of Health’s quality improvement initiatives to attain Malawi’s health goals.

The Elephant Marsh, Malawi – Part 3: the application of an eco-social model to assess options for managing ecological status

In 2016, an application was prepared by the Malawian government for the Elephant Marsh on the Shire River to be granted RAMSAR status. As part of the support for that application and to help guide the resulting management plan, the eco-social holistic environmental flow assessment model DRIFT was set up for the Marsh. The aim was to predict the response of the Marsh to scenarios of changing water and sediment inflows, and to different levels of harvesting of its natural resources, in order to identify threats to and viable options for sustaining its biodiversity. The results of the DRIFT assessment provided three main points of guidance for the RAMSAR application and the subsequent development of a management plan. First, it was shown the Marsh has been fairly resilient to short-term changes in the inflows of water and sediments, having endured significant fluctuations in both in its history, and was able to recover in terms of biodiversity from extreme dry periods. Second, it was revealed that conservation efforts to protect biodiversity should concentrate on the central, eastern and southern areas, as they were less vulnerable to decreases in water flows than the other areas of the Marsh. Third, restricting access to some parts of the Marsh, in particular the core eastern, central and southern areas, could markedly improve its overall condition, increase many of its resources and improve its resilience to Climate Change. Of the access restrictions assessed, the greatest benefit to the ecological integrity of the Marsh would be achieved if all access to the central area was stopped, and if access to the eastern and southern areas was reduced to 50% of the 2014 baseline levels.

A legal-realist assessment of human rights, right to health and standards of healthcare in the Malawian prison system during COVID-19 state disaster measures

PurposeThe first case of COVID-19 in the Malawi prison system was reported in July 2020. Human rights organisations raised concerns about the possibility of significant COVID-19 outbreaks and deaths in the prison system, because of the poor infrastructure, lack of healthcare and adequate COVID-19 mitigation measures, existing co-morbidities (tuberculosis, HIV and hepatitis C), malnutrition and poor health of many prisoners.Design/methodology/approachThe authors conducted a legal-realist assessment of the Malawian prison system response to COVID-19 during state disaster measures, with a specific focus on the right to health and standards of healthcare as mandated in international, African and domestic law.FindingsThe Malawi prison system was relatively successful in preventing serious COVID-19 outbreaks in its prisons, despite the lack of resources and the ad hoc reactive approach adopted. Whilst the Malawi national COVID plan was aligned to international and regional protocols, the combination of infrastructural deficits (clinical staff and medical provisions) and poor conditions of detention (congestion, lack of ventilation, hygiene and sanitation) were conducive to poor health and the spread of communicable disease. The state of disaster declared by the Malawi Government and visitation restrictions at prisons worsened prison conditions for those working and living there.Originality/valueIn sub-Saharan Africa, there is limited capacity of prisons to adequately respond to COVID-19. This is the first legal-realist assessment of the Malawian prison system approach to tackling COVID-19, and it contributes to a growing evidence of human rights-based investigations into COVID-19 responses in African prisons (Ethiopia, South Africa and Zimbabwe).

Perceived implications of COVID-19 policy measures on food insecurity among urban residents in Blantyre Malawi

BackgroundMalawi is at the brink of experiencing food insecurity amidst the COVID-19 pandemic as the vast majority of its population lives in extreme poverty. While measures are being implemented to avert the spread of COVID-19, little is known about how COVID-19 policy measures have impacted food insecurity in urban Malawi. This study addresses this gap by exploring the implications of COVID-19 policy measures on food insecurity in low-income areas of Blantyre in Malawi.MethodsWe used Bronfenbrenner's ecological theory to explore the implications of COVID-19 policy measures on peoples’ access to food. In-depth interviews were conducted with fifteen participants comprising of private school teachers, street vendors, sex workers, and minibus drivers. Data were analyzed using thematic analysis in which emerging patterns and themes from the transcripts were identified.ResultsThe COVID-19 lockdown measures undermined participants’ ability to maintain livelihoods. These measures have increased the vulnerability of the residents to food insecurity, forcing them to face severe challenges to accessing adequate food to support their families as a result of low incomes, job loss, and business disruptions.ConclusionOur study underscores the need for the Malawi government to seriously consider the provision of basic necessities such as food to the urban poor. We also suggest that the Malawi government should continue and expand the social cash transfer or relief funding packages by targeting the most vulnerable groups in the city. There is also a need for the government to engage all stakeholders and work collaboratively with people at local level in policymaking decisions in times of crisis.

Theological education and the COVID-19 pandemic in Sub-Saharan Africa: A Malawian perspective

The coronavirus disease 2019 (COVID-19) pandemic has brought a unique disruptive moment of unprecedented proportions in world history affecting all spheres of life. Theological education in Malawi, Sub-Saharan Africa, has not been spared in experiencing the effects of the COVID-19 pandemic. This study argues that the effectiveness of theological education in Africa contributes towards the future of Christianity on the continent, because it serves as a foundation for a vibrant missional church. Nevertheless, the COVID-19 pandemic has provided opportunities for creativity and innovation which could ensure the survival and sustainability of theological education in Africa. It is therefore crucial to critically reflect on how the provision of theological education in Malawi in particular, and in Sub-Saharan Africa, in general, can be sustained during the uncertain and challenging times when the COVID-19 pandemic is devastating the African continent and the entire world. This article investigated the challenges and opportunities for theological education in Malawi in view of the ongoing COVID-19 pandemic. In view of this, the following five objectives emerged: (1) to evaluate the Malawi government’s response to the COVID-19 pandemic; (2) to discuss the history and importance of theological education in Africa; (3) to examine the challenges of theological education in Malawi in view of the ongoing COVID-19 pandemic; and (4) to assess the prospects of theological education in Malawi in view of the ongoing COVID-19 pandemic. A qualitative research methodology was used, namely a literature review and interviews with members of the faculty of theological institutions in Malawi. Six main findings were established: First, the COVID-19 pandemic has presented both challenges and opportunities for theological education in Africa. Second, the effectiveness of theological education in Africa has contributed towards the future of Christianity on the continent. Third, the COVID-19 pandemic has challenged the dominant models of theological education in Africa. This entails a shift from face-to-face teaching to online teaching and learning. Fourth, the COVID-19 pandemic has provided opportunities for the sustainability of theological education in Africa. Fifth, theological education has encountered misleading theologies regarding the COVID-19 pandemic. Sixth, theological education has the opportunity of constructing life-giving theologies in Africa. This study has two implications: (1) navigating the changing terrain of theological education in Malawi; and (2) theological education’s employment of digital technologies during and post the COVID-19 pandemic.Contribution: This study has contributed to the discourse of theological education in Africa by providing solutions to the challenges posed by the COVID-19 pandemic.

Developing Malawi's Universal Health Coverage Index.

The inclusion of Universal Health Coverage (UHC) in the Sustainable Development Goals (target 3.8) cemented its position as a key global health priority and highlighted the need to measure it, and to track progress over time. In this study, we aimed to develop a summary measure of UHC for Malawi which will act as a baseline for tracking UHC index between 2020 and 2030. We developed a summary index for UHC by computing the geometric mean of indicators for the two dimensions of UHC; service coverage (SC) and financial risk protection (FRP). The indicators included for both the SC and FRP were based on the Government of Malawi's essential health package (EHP) and data availability. The SC indicator was computed as the geometric mean of preventive and treatment indicators, whereas the FRP indicator was computed as a geometric mean of the incidence of catastrophic healthcare expenditure, and the impoverishing effect of healthcare payments indicators. Data were obtained from various sources including the 2015/2016 Malawi Demographic and Health Survey (MDHS); the 2016/2017 fourth integrated household survey (IHS4); 2018/2019 Malawi Harmonized Health Facility Assessment (HHFA); the MoH HIV and TB data, and the WHO. We also conducted various combinations of input indicators and weights as part of sensitivity analysis to validate the results. The overall summary measure of UHC index was 69.68% after adjusting for inequality and unadjusted measure was 75.03%. As regards the two UHC components, the inequality adjusted summary indicator for SC was estimated to be 51.59% and unadjusted measure was 57.77%, whereas the inequality adjusted summary indicator for FRP was 94.10% and unweighted 97.45%. Overall, with the UHC index of 69.68%, Malawi is doing relatively well in comparison to other low income countries, however, significant gaps and inequalities still exist in Malawi's quest to achieve UHC especially in the SC indicators. It is imperative that targeted health financing and other health sector reforms are made to achieve this goal. Such reforms should be focused on both SC and FRP rather than on only either, of the dimensions of UHC.

Impact of Safety Nets on Household Coping Mechanisms for COVID-19 Pandemic in Malawi.

BackgroundCovid-19 pandemic induced various shocks to households in Malawi, many of which were failing to cope. Household coping mechanisms to shocks have an implication on household poverty status and that of a nation as a whole. In order to assist households to respond to the pandemic-induced shocks positively, the government of Malawi, with support from non-governmental organizations introduced Covid-19 Urban Cash Intervention (CUCI) and other safety nets to complement the existing social protection programs in cushioning the impact of the shocks during the pandemic. With these programmes in place, there is a need for evidence regarding how the safety nets are affecting coping. Therefore, this paper investigated the impact that safety nets during Covid-19 pandemic had on the following household coping mechanisms: engaging in additional income-generating activities, receiving assistance from friends and family; reducing food consumption; relying on savings; and failure to cope.MethodsThe study used a nationally representative panel data from the Malawi High Frequency Phone Survey on Covid-19 (HFPS Covid-19) and complemented it with the fifth Integrated Household Panel Survey (IHPS), also known as living standards measurement survey. Five Random Effects Probit Models were estimated, one for each coping mechanism.ResultsFindings from this study indicated that beneficiaries of safety net programs were more likely to rely on remittances from friends and family than the people who had no safety nets. Furthermore, the safety net recipients were less likely to reduce food consumption or rely on savings than the non-recipients. Despite the interesting findings, we also noticed that safety nets had no significant impact on household engagement in other income-generating activities in response to shocks.ConclusionThe results imply that safety nets in Malawi during the Covid-19 pandemic had a positive impact on consumption and prevented the dissolving of savings. Therefore, these programs have to be scaled up, and the volumes be revised upwards.

Community Policing in Malawi: Citizen Involvement, Satisfaction and Challenges

Abstract The concept of community policing was adopted by the Malawi government as a vehicle to facilitate police and the public engagement in fighting crimes. Considering that community policing has existed for over a decade in Malawi, this study was carried out to holistically uncover challenges associated with public involvement in community policing activities with the purpose to provide empirically backed strategies for the efficient implementation of the concept. The study employed a case study approach. Purposive sampling was used on one hand to select the research site – Central Regions of Malawi and to select the police officers working as Community Policing Coordinators and members of the communities working in Community Police Forums. Quota sampling was used to select police officers and members of the community from each district. Finally, convenient sampling was used to select police officers and members within the quotas of each district. Focus group discussions were conducted with 16 Community Police Forums; interviews were conducted with 16 Community Policing Coordinators; a questionnaire was used to collect data from 144 community members and 200 police officers. Results show that the community members are not satisfied with police officers in the way they implement the community policing because the police do not offer the public enough protection from criminals and that the police mostly treat the community badly. The community members were involved in the implementation of the community policing mainly because of worsening crimes in the community, personal fear of the crimes, need to be recognised by the police and the desire to benefit from the rewards from Non-Governmental Organisations in form of food. The factors that challenged the implementation of community policing include lack of knowledge on community policing on the part of police officers; lack of recognition of community policing; corrupt practices; lack of confidentiality; poor working relationship; and lack of resources. The concept of community policing continues to receive unprecedented attention in police reforms. Much as there is evidence of growing literature on this concept, little is known in Malawi where this study was conducted. In light of this, the study provides valuable literature which might be necessary for global academics and particularly in community policing in Malawi with practical implications on re-designing and continued implementation of community policing in Malawi and perhaps other developing countries.

Would female student teachers at primary teacher education colleges study mathematics were it optional?

In this this article we discuss findings from an investigation of whether female student teachers would choose to study mathematics if it were optional for primary teacher education in Malawi. A mixed methods research methodology was used to collect data through survey and focus group discussions (FGDs). Five hundred and twenty three female students from 6 public teacher education colleges completed a questionnaire, and 160 of them participated in FGDs. A descriptive statistical analysis was conducted on the quantitative data while a thematic analysis was conducted on the qualitative data. The findings show that 68% of female students would choose to study mathematics while 32% would not. This correlated with the students’ mathematics scores at the end of their secondary school national examination. Those students with high score passes opted for mathematics and those with low score passes did not, suggesting that performance at secondary school influenced their confidence in studying mathematics. Female student teachers’ reasons for choosing or not choosing mathematics were it optional are classified into 5 categories: the perceived usefulness of mathematics, inner motivation to study mathematics, the nature of the college mathematics content, how mathematics courses are taught at colleges, and gender stereotype in mathematics lessons. We discuss these in relation to the Malawian government’s agenda of increasing participation of females in mathematics, science, technology, and engineering.

Leveraging the Scaling Up Nutrition Movement to Operationalize Stunting Prevention Activities: Implementation Lessons From Rural Malawi.

The rural district of Ntchisi is in the central region of Malawi. Among children aged 6 to 23 months, the stunting prevalence is 40% to 50%. To address this high prevalence, the World Food Programme, with cooperating partners, supported the Government of Malawi to implement an integrated stunting prevention program entitled The Right Foods at the Right Time from 2013 to 2018. To provide implementation lessons learned from systematic documentation of how the Scaling Up Nutrition (SUN) movement, combined with other international and national initiatives and policies, was translated into tailored programming. During program conception, early design, and implementation, this descriptive study systematically documented the process of translating SUN principles and government policies into an operational stunting prevention program in rural Malawi. We identified 8 factors that contributed to successful translation of policy into program activities: (1) well-structured National SUN framework, (2) reliable coordination platforms and district ownership, (3) systematic and evidence-informed program design, (4) multiple forms of data used to inform program planning, (5) multisectoral implementation approaches to stunting prevention, (6) innovation in technology to improve overall program efficiency, (7) systematic collaboration among diverse stakeholders, and (8) strong public health nutrition capacity of program team members. Lessons from this nutrition program in Ntchisi, Malawi, provide one case illustrating how the SUN movement, government policies, and global evidence base can be operationalized into tailored programming for improving nutrition.

Factors Influencing the Awareness and Adoption of Borehole-Garden Permaculture in Malawi: Lessons for the Promotion of Sustainable Practices

Using wastewater accumulating around rural waterpoints to irrigate community gardens, borehole-garden permaculture (BGP) presents a method of sustainable water management. BGP also presents public health benefits through the removal of stagnant water around boreholes, key Malaria breeding grounds, and through providing year-round food to supplement diets. By analysing a dataset of over 100,000 cases, this research examines the awareness and adoption of BGP across Malawi. Generalised linear models identified significant variables influencing BGP awareness and uptake revealing that socioeconomic, biophysical and waterpoint-specific variables influenced both the awareness and adoption of BGP. BGP had low uptake in Malawi with only 2.4% of communities surveyed practising BGP while 43.0% of communities were aware of BGP. Communities in areas with unreliable rainfall and high malaria susceptibility had low BGP awareness despite BGP being particularly beneficial to these communities. This work suggests that future work in the promotion of BGP should focus their efforts within these areas. Furthermore, this work highlights the value of community networks in knowledge sharing and suggests that such social capital could be further used by NGOs and the Government of Malawi in the promotion of BGP and other sustainable practices.

Working lives of maternity healthcare workers in Malawi: an ethnography to identify ways to improve care

BACKGROUNDMaternal mortality in East Africa is high with a maternal mortality rate of 428 per 100,000 live births. Malawi, whilst comparing favourably to East Africa as a whole, continues to have a high maternal mortality rate (349 per 100,000 live births) despite it being reduced by 53% since 2000. To make further improvements in maternal healthcare, initiatives must be carefully targeted and evaluated to achieve maximum influence. The Malawian Government is committed to improving maternal health; however, to achieve this goal, the quality of care must be high. Furthermore, such a goal requires enough staff with appropriate training. There are not enough midwives in Malawi; therefore, focusing on staff working lives has the potential to improve care and retain staff within the system.OBJECTIVEThis study aimed to identify ways in which working lives of maternity healthcare workers could be enhanced to improve clinical care.STUDY DESIGNWe conducted a 1-year ethnographic study of 3 district-level hospitals in Malawi. Data were collected through observations and discussions with staff and analyzed iteratively. The ethnography focused on the interrelationships among staff as these relationships seemed most important to working lives. The field jottings were transcribed into electronic documents and analyzed using NVivo. The findings were discussed and developed with the research team, participants, and other researchers and healthcare workers in Malawi. To understand the data, we developed a conceptual model, “the social order of the hospital,” using Bourdieu's work on political sociology. The social order was composed of the social structure of the hospital (hierarchy), rules of the hospital (how staff in different staff groups behaved), and precedent (following the example of those before them).RESULTSWe used the social order to consider the different core areas that emerged from the data: processes, clinical care, relationships, and context. The Malawian system is underresourced with staff unable to provide high-quality care because of the lack of infrastructure and equipment. However, some processes hinder them on national and local level, for example staff rotations and poorly managed processes for labeling drugs. The staff are aware of the clinical care they should provide; however, they sometimes do not provide such care because they are working with the predefined system and they do not want to disrupt it. Within all of this, there are hierarchical relationships and a desire to move to the next level of the system to ensure a better life with more benefits and less direct clinical work. These elements interact to keep care at its most basic as disruption to the “usual” way of doing things is challenging and creates more work.CONCLUSIONTo improve the working lives of the Malawian maternity staff, it is necessary to focus on improving the working culture, relationships, and environment. This may help the next generation of Malawian maternity staff to be happier at work and to better provide respectful, comprehensive, high-quality care to women.

National scale of neonatal CPAP to district hospitals in Malawi improves survival for neonates weighing between 1.0 and 1.3 kg

ObjectiveTo determine whether a national quality improvement programme implementing continuous positive airway pressure (CPAP) at government hospitals in Malawi improved outcomes for neonates prioritised by an algorithm recommending early CPAP...

Reconciling access to information and political party funding in Malawi: a comparative analysis of legislation

PurposeThe purpose of this paper was to assess the similarities and differences between the Political Parties and the Access to Information Acts in Malawi. While political parties are largely funded by donations that are frequently kept as a secret, the Access to Information Act does not include political party funding among the categories of non-disclosed information.Design/methodology/approachThis paper is based on the qualitative content analysis of the legislation in Malawi. Content analysis of the two pieces of legislation was adopted. This paper is a review of the literature and an examination of Malawi's Political Parties and Access to Information Acts. The document study was supplemented by a review of related literature on the two legislations.FindingsThe Political Parties Act prohibits the government, ministries and departments from directly or indirectly funding political parties. The Access to Information Act to ensure information generated by Malawi government ministries, departments and agencies is readily made available by the citizens when needed or requested. The Access to Information Act does not exempt political parties from disclosing their funding sources. The two acts work in tandem to promote accountability and transparency in political party funding and sources.Research limitations/implicationsThis study is limited to Malawi's Political Parties and Access to Information Acts. Only the South African related acts have informed the paper. However, several acts within developing countries would have greatly aided the paper.Practical implicationsThe implementation of the two pieces of legislation has implications for the balance between disclosure and non-disclosure of political party funding. Oversight functions and credible human resource capacity are needed in both political parties and government enforcement institutions.Social implicationsOversight functions by the Administrator-General through the Registrar of Political Parties and the Malawi Human Rights Commission are key to the implementation of Malawi's Political Parties and Access to Information Acts, respectively. Proper enforcement of the oversight functions is expected to result in an open, transparent and accountable Malawian society.Originality/valueVarious players are needed in the accountability chain to protect disclosure and non-disclosure of information. Very little information is known on the powers, functions and duties of office bearers capable of enforcing legislation to keep political parties' funding clean. Little is known on how the citizens can access information regarding political parties funding.

Analyzing the Changes of the Meaning of Customary Land in the Context of Land Grabbing in Malawi

Ordinary Malawians who live in customary land have been suffering from land grabbing due to their weak and ill-defined land rights. Although Malawi has experienced a number of land reforms that should have contributed to strengthening customary land rights, many people in customary land still suffer from land grabbing. Accordingly, it is important to understand the factors that lead to land grabbing in customary land in Malawi. Thus, by looking at the overview of land laws and policies throughout history, this study has two aims: (1) to analyze the historical changes in the meaning and position of customary land in Malawi and (2) to analyze the land grabbers in Malawi before, during, and after the colonial era. In order to achieve the main goals, this research mainly analyzes land laws and policies connected to customary land in Malawi. The main findings of this research are that (1) the meaning of customary land changed before and after the colonial period, but little has changed between the colonial period and the present. Since the creation of land laws during the colonial period, the land rights of the people who live in customary land have not been secured, and (2) the land grabbers changed from the British colonial rulers and European settlers to the Government of Malawi. Further, with the recent land laws, such as Land Act 2016 and Customary Land Act 2016, wealthy Malawians may become new land grabbers who can afford to obtain the customary estate grants. By examining the main results, it was found that from the colonial period until the present, customary land has been vulnerable to land grabbing as its weak position still resembles that of the colonial era. Thus, Malawi appears to face significant challenges in amending its customary land laws for the benefit of the poor.

Building a Community Library

This paper chronicles interventions to renovate and repurpose a community library in one of the poorest countries in the world; Malawi, where over 80% of the population lives below the poverty line (less than US$1.25/day). This initial report is based on activities undertaken by a team of individuals with diverse expertise and cultural backgrounds, and a common vision for repurposing the Kwakupokela Community Library. To date, key achievements include: the Kwakupokela Educational Trust has been created and registered with the Malawi government as a non-governmental organization which now operates the library; a Memorandum of Understanding (MoU) has been signed with Mzuzu University; new books have been donated; and both new and old library books have been processed; the dilapidated and relentlessly leaking roof has been replaced with new iron sheets; the ceiling has been fixed; and the inner walls painted. More importantly, the library has opened its doors to the community. Challenges remain for this ongoing initiative, and include outdated and limited information resources, sustainability of library operations, space shortages and hygiene issues, including lack of restrooms. Strategies have been developed to deal with the mentioned challenges, though their implementation will depend on availability of resources. This paper describes the role librarians can play in uplifting the living conditions of people in rural areas by taking relevant information resources to these segregated, neglected and dejected communities.

Perceptions of minimum age at marriage laws and their enforcement: qualitative evidence from Malawi

BackgroundChild marriage in Malawi is a significant problem with 42.1% of women 20–24 married by age 18. In 2017 the Malawi government formalized legislation to make marriage under age 18 illegal; violators are subject to fines. While leveraging laws to reduce child marriage is common, the enactment of laws and their enforcement has led to some novel practices. One such practice observed in Malawi is marriage withdrawal, where the community intervenes when a child marriage has taken place to force the girl to return to her natal home.MethodsThis paper is a qualitative analysis of perceptions regarding marriage withdrawal. We conducted focus group discussions and in-depth interviews with married and unmarried adolescents, parents of adolescents, and key community members in Mangochi and Nkhata Bay. Data were collected as part of an evaluation of the More Than Brides Alliance program aimed at delaying marriage and improving access to sexual and reproductive health services in Malawi.ResultsThe knowledge that violation of marriage laws entails substantial fines is widespread and marriage withdrawals are seen by some respondents as a way of enforcing the spirit of child marriage laws while avoiding fines. Some respondents suggest that enforcement of marriage laws has an unintended effect of driving marriages underground. One important disconnect between the laws and the realities of child marriage practices in these communities is that the law holds parents responsible for the marriage and for preventing it, while parents do not necessarily exercise control, particularly when the marriage is precipitated by pregnancy. While parents and other adults view withdrawals as an acceptable resolution of a problematic child marriage, girls noted many drawbacks for withdrawn girls such as stigma and limited education and livelihood opportunities once withdrawn.ConclusionsOur exploration of perceptions about marriage laws suggest that the imposition of fines may have some unintended consequences, both driving the practice underground and encouraging practices to evade fines, and may be associated with unintended consequences for adolescent girls. Programs to address child marriage should include other approaches that address more distal drivers including poverty and lack of alternatives to child marriage.Trial registrationThis work is part of an RCT registered August 4, 2016 in the AEA RCT registry identified as: AEARCTR-0001463. See: https://www.socialscienceregistry.org/trials/1463

Preparing for a community-based agriculture-to-nutrition trial in rural Malawi: formative research to assess feasibility and inform design and implementation decisions

BackgroundThis study reports findings from formative research conducted to assess the feasibility and inform the design and implementation of the Addressing Hidden Hunger with Agronomy (AHHA) trial. The AHHA trial was a randomised, controlled trial conducted in rural Malawi, in which participants were given maize flour biofortified with selenium or control flour not biofortified with selenium for a period of 10 weeks, after which blood samples were taken to measure selenium status.MethodsFormative research was conducted in villages near to the AHHA trial study site 1 year before the planned intervention. A short questionnaire with adult women (n = 50), focus group discussions with male (n groups = 3) and female (n groups = 3) community members, and in-depth key informant interviews (n = 7) were conducted to understand community practices and perceptions.FindingsMeals were typically cooked and eaten at home in this community, while participants reported that maize flour would be less readily sold than maize grain – important considerations for the design of the trial. Regarding intervention delivery, we identified potential concerns around effects on fertility, links between blood sampling and witchcraft, and the potential for social stigma if community members considered participants lazy for receiving free flour. Participants reported that involvement of the Malawi government partners including health extension workers would increase trust.InterpretationFollowing the formative research, the AHHA trial appeared feasible. However, community sensitisation would be essential to address potential fears and concerns; effective sensitisation would support recruitment and treatment adherence, and would protect the safety and wellbeing of participants and researchers. People in positions of authority and trust including village headmen, religious leaders, health and agriculture extension workers, and community care groups should be involved in community sensitisation.

Crop Area Mapping in Southern and Central Malawi With Google Earth Engine

Agriculture in sub-Saharan Africa consists primarily of smallholder farms of rainfed crops. Historically, satellite data were too coarse to account for the heterogeneity in these landscapes. Sentinel-2 data have improved spectral resolution and much higher spatial resolution (10 m) than previously available satellites with global coverage, such as Landsat or MODIS, making mapping smallholder farms possible. Spectral mixture analysis was used to convert the Sentinel-2 signal into fractions of green vegetation, non-photosynthetic vegetation, soil, and shade endmembers. Very high spatial resolution imagery in Google Earth Pro was used to identify locations of crop and natural vegetation classes, with over 20,000 reference points interpreted. The high temporal resolution of Sentinel-2 (5 days repeat) allows for classification of landcover based on the phenological signal, with natural areas having smoothly varying amounts of photosynthetic vegetation annually, while cropped areas show more abrupt changes, and also the presence of bare soil due to agricultural activity at some point during the year. We summarized the endmember values using monthly medians, extracted values for the reference data points, randomly split them into training and test data sets, and input the training data into the random forests algorithm in Google Earth Engine to map crop area. We divided southern and central Malawi into tiles, and found crop/no crop classification accuracies on the test data for each tile to be between 87 and 93%. The 10 m map of crop area was aggregated to the district level and showed an R2 of 0.74 with ground-based statistics from the Malawi government and 0.79 with a remotely sensed product developed by the USGS.

Programmatic Challenges in Managing Multidrug-Resistant Tuberculosis in Malawi

Background:Multidrug-resistant tuberculosis (MDR-TB) is one of the most urgent challenges that Malawi tends to take a firm public health action. A recent increase in multidrug MDR-TB cases, a decrease in treatment success rate, and a double increase of lost-to-follow-up call into question the country’s programmatic management of MDR-TB (PMDT). As such, the study aimed at exploring programmatic challenges in managing MDR-TB in Malawi.Methods:A comprehensive and nonsystematic search was made in PubMed and Google Scholar using mainly the keywords “MDR-TB” “extensively drug-resistant TB,” Malawi. The study reviewed existing guidelines and gray literature and reviewed data obtained from the national TB program (NTP) as well.Results:The study found the following challenges affecting PMDT: decrease in funding, partial access to GeneXpert, delay in diagnosis, long treatment duration, lack of adequate personal protective equipment, the long turnaround time of culture results, failure to initiate all diagnosed patients on treatment, absence of alternative second-line medicines, and lack of transport from health facilities to patient homes.Conclusion:If the Malawi NTP is to achieve a vision of a “TB-free Malawi,” rigorous efforts at all levels must be made, including mobilizing domestic resources for improved MDR-TB program performance. Developing partners should continue providing the much-needed funding to the Malawi government to stand in the wake of the MDR-TB crisis.