Health Surveillance Assistants Research Articles

‘Vaccinate my village’ strategy in Malawi: an effort to boost COVID-19 vaccination

ABSTRACTObjectivesTo boost COVID-19 vaccine uptake, an innovative ‘vaccinate my village’ (VMV) strategy using door-to-door vaccination by Health Surveillance Assistants (HSA) was adopted. In this study, we assessed the impact of the ‘vaccinate my village’ strategy on COVID-19 vaccine uptake.MethodsThis was a cross-sectional review of the data on COVID-19 vaccination obtained from the Ministry of Health, Malawi, from 11 March 2021 to September 2022.ResultsFrom March 2021–4 September 2022,091,551 COVID-19 vaccine doses were administered, out of which 2,253,546 were administered over just six months as a part of VMV as compared to 1,838,005 doses were administered over 13 months as a part of other strategies. The proportion of Malawi’s population receiving at least one dose of the COVID-19 vaccine increased substantially from 4.66 to 15.4 with the implementation of the VMV strategy (p = 0.0001). District-wise coverage of the COVID-19 vaccine also increased significantly after its implementation (p = 0.0001).ConclusionsDoor-to-door vaccination involving HSAs benefitted the COVID-19 vaccination program in Malawi by ensuring accessibility, availability, and acceptability.

Leveraging community health workers as vaccinators: a case study exploring the role of Malawi’s Health Surveillance Assistants in delivering routine immunization services

BackgroundGlobal chronic health worker shortages and stagnating routine immunization rates require new strategies to increase vaccination coverage and equity. As trained, trusted members of their local communities, community health workers (CHWs) are in a prime position to expand the immunization workforce and increase vaccination coverage in under-reached communities. Malawi is one of only a few countries that relies on CHWs—called Health Surveillance Assistants (HSAs) in Malawi—to administer routine immunizations, and as such offers a unique example of how this can be done.Case presentationWe sought to describe the operational and programmatic characteristics of a functional CHW-led routine immunization program by conducting interviews with HSAs, HSA supervisors, ministry of health officials, and community members in Malawi. This case study describes how and where HSAs provide vaccinations, their vaccination-related responsibilities, training and supervision processes, vaccine safety considerations, and the community-level vaccine supply chain. Interview participants consistently described HSAs as a high-functioning vaccination cadre, skilled and dedicated to increasing vaccine access for children. They also noted a need to strengthen some aspects of professional support for HSAs, particularly related to training, supervision, and supply chain processes. Interviewees agreed that other countries should consider following Malawi’s example and use CHWs to administer vaccines, provided they can be sufficiently trained and supported.ConclusionsThis account from Malawi provides an example of how a CHW-led vaccination program operates. Leveraging CHWs as vaccinators is a promising yet under-explored task-shifting approach that shows potential to help countries maximize their health workforce, increase vaccination coverage and reach more zero-dose children. However, more research is needed to produce evidence on the impact of leveraging CHWs as vaccinators on patient safety, immunization coverage/vaccine equity, and cost-effectiveness as compared to use of other cadres for routine immunization.

Evaluation of implementation outcomes of an integrated group postpartum and well-child care model at clinics in Malawi

BackgroundPersistently elevated rates of maternal and infant mortality and morbidities in Malawi indicate the need for increased quality of maternal and well-child care services. The first-year postpartum sets the stage for long-term health for the childbearing parent and infant. Integrated group postpartum and well-child care may improve maternal and infant health outcomes. The purpose of this study was to examine implementation outcomes for this model of care.MethodsWe used mixed methods to examine implementation outcomes of integrated group postpartum and well-child care. We piloted sessions at three clinics in Blantyre District, Malawi. During each session we evaluated fidelity using a structured observation checklist. At the end of each session, we administered three surveys to health care workers and women participants, the Acceptability of Intervention Measure, the Intervention Appropriateness Measure, and the Feasibility of Intervention Measure. Focus groups were conducted to gain greater understanding of people’s experience with and evaluation of the model.ResultsForty-one women with their infants participated in group sessions. Nineteen health care workers across the three clinics co-facilitated group sessions, 9 midwives and 10 health surveillance assistants. Each of the 6 sessions was tested once at each clinic for a total of 18 pilot sessions. Both women and health care workers reported group postpartum and well-child care was highly acceptable, appropriate, and feasible across clinics. Fidelity to the group care model was high. During each session as part of structured observation the research team noted common health issues, the most common one among women was high blood pressure and among infants was flu-like symptoms. The most common services received within the group space was family planning and infant vaccinations. Women reported gaining knowledge from health promotion group discussions and activities. There were some challenges implementing group sessions.ConclusionWe found that clinics in Blantyre District, Malawi were able to implement group postpartum and well-child care with fidelity and that it was highly acceptable, appropriate, and feasible to women and health care workers. Due to these promising results, we recommend future research examine the effectiveness of the model on maternal and child health outcomes.

Perspectives on DMPA-SC for self-injection among adolescents with unmet need for contraception in Malawi.

Malawi has made progress in expanding access to modern contraceptive methods over the last decade, including the introduction of depot-medroxyprogesterone acetate subcutaneous (DMPA-SC) in 2018. DMPA-SC offers women the option to self-inject at home and may benefit adolescents with unmet need for contraception due to its discretion. This qualitative study was conducted to assess perspectives and preferences of adolescents with unmet need for contraception regarding the self-injection option of DMPA-SC in Malawi. Six focus group discussions were conducted involving 36 adolescents with unmet need for contraception (aged between 15 and 19 years, married and never-married) in October 2021 in three districts in Malawi. Data were coded inductively and analyzed thematically, using Dedoose software. Two validation workshops were conducted with other adolescents with unmet need in February 2022 to elucidate the preliminary findings. DMPA-SC attributes such as discretion and reduced facility visits were ranked most appealing by both married and never-married adolescents, particularly for adolescents needing covert contraception use. Concerns about self-injection included fear of pain, injury, and doubt in ability to self-inject. Never-married adolescents had additional concerns around privacy at home if using covertly, and fears of affecting long-term fertility. Overall, health surveillance assistants (community-based healthcare workers) were voted to be the most private, convenient, and affordable sources for potential DMPA-SC self-injection training. Self-injection of DMPA-SC may offer an appealing option for adolescents in Malawi, aligning most closely to the needs of married adolescents who may wish to delay or space pregnancies conveniently and discreetly, and who also may face fewer access barriers to receiving self-injection training from health care providers. Access barriers including stigma and concerns about privacy at home for adolescents needing to use contraception covertly would need to be adequately addressed if never-married adolescents were to consider taking up this option.

Health systems' resilience during the COVID-19 pandemic public health emergency: The role of existing community health structures in rural Malawi.

The emergence of the COVID-19 pandemic has put health systems under enormous pressure, pushing for health systems' resilience. Malawi, mostly rural with hard-to-reach areas, had their first case in April 2020, amidst political turmoil. So far, much has been documented on how health systems contained the COVID-19 pandemic. This paper describes the role of community health system structures in ensuring health systems' resilience during the COVID-19 pandemic in rural Malawi. To highlight the role of community health structures in the Malawian health system, we developed and applied a framework on health systems' resilience through the community health system structures in a rural district in Malawi. Our data collection and analysis were informed by a desk review of government documents and other publications. We drew on authors' expertise and experience in Malawi community health, and joint reflections on the role played by community health structures in ensuring access to essential health services during the COVID-19 pandemic in Malawi. The desk review and experts' reflections have highlighted the strong Malawi community health strategy with a clear chain of command from national to community levels. The community health surveillance assistants and volunteers have shown to be the backbone of community health structures and positive service delivery, contributing to health systems resilience during the COVID-19 pandemic. Countries' existing health system structures are a key determinant of response to pandemics -regardless of the available resources. Even though Malawi's health system is under-resourced, the existing community-based health structures have shown to contribute to the health systems' resilience during the COVID-19 pandemic. The proposed framework in this paper is a great tool in allowing countries to reflect on having pre-existing health system structures to strengthen the health systems' resilience during such pandemics. Therefore, having independent disease prevention and control structures from national to community levels, as done in Malawi, can help countries to absorb the shocks of health system emergencies and maintain essential health services, the core business of the health system.

Community-based house improvement for malaria control in southern Malawi: Stakeholder perceptions, experiences, and acceptability.

House improvement (HI) refers to the full screening or closing of openings such as windows, doors, and eaves, as well as the installation of ceilings, to reduce mosquito-human contact indoors. HI is a viable supplementary intervention that reduces malaria transmission further than the existing strategies alone. In Malawi, HI has not been widely implemented and evaluated for malaria control. Concerns about lack of local evidence, durability in different epidemiological and cultural settings, and the cost of large-scale implementation are among the reasons the strategy is not utilised in many low-income countries. This study assessed community perceptions, experiences, and acceptability of community-led HI in Chikwawa district, southern Malawi. This was a qualitative study where separate focus group discussions were conducted with members from the general community (n = 3); health animators (n = 3); and HI committee members (n = 3). In-depth interviews were conducted with community members (n = 20), and key-informant interviews were conducted with health surveillance assistants and chiefs (n = 23). All interviews were transcribed and coded before performing a thematic content analysis to identify the main themes. Coded data were analysed using Nvivo 12 Plus software. Study participants had a thorough understanding of HI. Participants expressed satisfaction with HI, and they reported enabling factors to HI acceptability, such as the reduction in malaria cases in their villages and the safety and effectiveness of HI use. Participants also reported barriers to effective HI implementation, such as the unavailability and inaccessibility of some HI materials, as well as excessive heat and darkness in HI houses compared to non-HI houses. Participants indicated that they were willing to sustain the intervention but expressed the need for strategies to address barriers to ensure the effectiveness of HI. Our results showed the high knowledge and acceptability of HI by participants in the study area. Intensive and continued health education and community engagement on the significance of HI could help overcome the barriers and improve the acceptability and sustainability of the intervention.

Exploring the cultural appropriateness of a psychosocial intervention, the Thinking Healthy Programme-Peer delivered (THPP), for perinatal depression in Lilongwe, Malawi.

Perinatal depression is a common and disabling mental health problem in Malawi and other Low- and middle-income countries. There is evidence for effective psychosocial interventions for perinatal depression, but no such intervention has been developed for use in Malawi. The broad aim of this study was to explore the cultural appropriateness of a psychosocial intervention for perinatal depression called the Thinking Healthy Programme-Peer delivered for adaptation and use in Lilongwe, Malawi. A qualitative exploratory design was used. Data were collected through conducting five Focus Group Discussions, involving thirty-eight purposefully selected participants including pregnant women, community volunteers and their supervisors, the Health Surveillance Assistants and maternal health care workers at implementation and policy level following observations of video recorded role plays of the Thinking Healthy Programme-Peer delivered sessions in theatre testing. A content analysis approach was used to analyse data. Six main themes were generated regarding the appropriateness of the content and delivery of the Thinking Healthy Programme-Peer delivered intervention, including: 1) Focus of the intervention; 2) Cultural appropriateness of the content; 3) Language used; 4) Context; 5) Provider of the intervention; and 6) Flexibility in the delivery of the intervention. The Thinking Healthy Programme-Peer delivered intervention was deemed appropriate for the target population, though with recommendations to: review illustrations to enhance clarity, use culturally appropriate stories and idioms, use daily spoken language, and adapt the number and duration of sessions to meet the needs of individual clients. These findings highlight important areas to inform adaptation of the Thinking Healthy Programme-Peer delivered and add to the growing evidence of cultural adaptation of psychosocial interventions for perinatal depression.

Examining study participants\u2019 decision-making and ethics-related experiences in a dietary community randomized controlled trial in Malawi

BackgroundThe participant recruitment process is a key ethical pivot point when conducting robust research. There is a need to continuously review and improve recruitment processes in research trials and to build fair and effective partnerships between researchers and participants as an important core element in ensuring the ethical delivery of high-quality research. When participants make a fair, informed, and voluntary decision to enroll in a study, they agree to fulfill their roles. However, supporting study participants to fulfill study requirements is an important ethical obligation for researchers, yet evidenced as challenging to achieve. This paper reports on participants’ motivations to volunteer and remain part of a dietary study conducted in Kasungu District, Malawi.MethodsWe conducted twenty in-depth interviews (with chiefs, religious leaders, trial participants, and health surveillance assistants), five systematic ethnographic observations, and fourteen focus group discussions with trial participants and their partners. Interviews were audio-recorded and transcribed verbatim. We used a grounded theory methodology to analyse data that included coding, detailed memo writing, and data interpretation.FindingsThe findings reveal that many participants had concerns during the trial. Thematically, experiences included anxieties, mistrust of researchers, rumours, fears of exploitation, and misconceptions. Anonymous concerns collected from the participants were reported to the trial team which enabled the researchers to appropriately support participants. Despite initial concerns, participants described being supported and expressed motivation to take up their role.ConclusionThese findings highlight a diverse map of multiple notions of what is ethically relevant and what can impact participation and retention within a study. The study has revealed how embedding a responsive approach to address participants’ concerns and ethical issues can support trust relationships. We argue for the need to employ embedded ethics strategies that enhance informed consent, focus on participants’ needs and positive experiences, and support researchers to fulfill their roles. This work highlights the need for research ethics committees to focus on the risks of undue influence and prevent exploitation especially in settings with a high asymmetry in resources and power between researcher and participant groups.Trial Registration: The Addressing Hidden Hunger with Agronomy (Malawi) trial was registered on 5th March 2019 (ISCRTN85899451).

Effectiveness of Smartphone-Based Community Case Management on the Urgent Referral, Reconsultation, and Hospitalization of Children Aged Under 5 Years in Malawi: Cluster-Randomized, Stepped-Wedge Trial.

BackgroundIntegrated community case management (CCM) has led to reductions in child mortality in Malawi resulting from illnesses such as malaria, pneumonia, and diarrhea. However, adherence to CCM guidelines is often poor, potentially leading to inappropriate clinical decisions and poor outcomes. We determined the impact of an e-CCM app on the referral, reconsultation, and hospitalization rates of children presenting to village clinics in Malawi.ObjectiveWe determined the impact of an electronic version of a smartphone-based CCM (e-CCM) app on the referral, reconsultation, and hospitalization rates of children presenting to village clinics in Malawi.MethodsWe used a stepped-wedge, cluster-randomized trial to compare paper-based CCM (control) with and without the use of an e-CCM app on smartphones from November 2016 to February 2017. A total of 102 village clinics from 2 districts in northern Malawi were assigned to 1 of 6 clusters, which were randomized on the sequencing of the crossover from the control phase to the intervention phase as well as the duration of exposure in each phase. Children aged ≥2 months to <5 years who presented with acute illness were enrolled consecutively by health surveillance assistants. The primary outcome of urgent referrals to higher-level facilities was evaluated by using multilevel mixed effects models. A logistic regression model with the random effects of the cluster and the fixed effects for each step was fitted. The adjustment for potential confounders included baseline factors, such as patient age, sex, and the geographical location of the village clinics. Calendar time was adjusted for in the analysis.ResultsA total of 6965 children were recruited—49.11% (3421/6965) in the control phase and 50.88% (3544/6965) in the intervention phase. After adjusting for calendar time, children in the intervention phase were more likely to be urgently referred to a higher-level health facility than children in the control phase (odds ratio [OR] 2.02, 95% CI 1.27-3.23; P=.003). Overall, children in the intervention arm had lower odds of attending a repeat health surveillance assistant consultation (OR 0.45, 95% CI 0.34-0.59; P<.001) or being admitted to a hospital (OR 0.75, 95% CI 0.62-0.90; P=.002), but after adjusting for time, these differences were not significant (P=.07 for consultation; P=.30 for hospital admission).ConclusionsThe addition of e-CCM decision support by using smartphones led to a greater proportion of children being referred to higher-level facilities, with no apparent increase in hospital admissions or repeat consultations in village clinics. Our findings provide support for the implementation of e-CCM tools in Malawi and other low- and middle-income countries with a need for ongoing assessments of effectiveness and integration with national digital health strategies.Trial RegistrationClinicalTrials.gov NCT02763345; https://clinicaltrials.gov/ct2/show/NCT02763345

Community-level integration of health services and community health workers’ agency in Malawi

Despite a large literature on integration of health services, there is a dearth of scholarship assessing service integration in its totality at the community level. Similarly, across the wide evidence base on community health workers (CHWs), there is little that analyses the ways in which they interact with both formal and informal structures and how these interactions shape their agency and ultimately the delivery of integrated services. A better understanding of agency in the work of CHWs would help health systems, policy makers and practitioners to better design and support the delivery of community-level integrated health packages to improve health outcomes.In this study, we explored the agency of CHWs in Malawi known as Health Surveillance Assistants (HSAs). We used qualitative methods: participant observation, in-depth interviews, and focus group discussions between July and October 2018. Overall, the ethnographic study utilised actors-centred frameworks (structuration theory and street-level bureaucracy). The study findings unravel the complexities involving HSAs’ agency shaped by health system structures (staffing, infrastructure, drugs, and supplies) and informal structures (community relations, local power structures, gendered-household relations) which narrowed or widened their discretionary decision-making space. The flexibility of HSAs was a distinctive feature in their work, but they developed other coping mechanisms: task shifting, teamwork, creative community engagement, and referrals to deliver integrated maternal and child health services.HSAs' unique position as community-based providers meant they needed to consider diverse factors that constrained or facilitated their work. Overall, we argue that HSAs need to be fully involved in the design of community-level integrated health programmes. There should be a consideration to address both informal and formal structures that together shape agency. Additionally, CHWs’ flexibility and agency to make locally informed decisions must be protected and maintained because it enhances their ability to deliver essential health services.

Effectiveness of Smartphone-Based Community Case Management on Urgent Referral, Re-Consultation and Hospitalization of Children Under-5 in Malawi: Results of a Cluster-Randomized, Stepped-Wedge Trial

Background: Integrated community case management (CCM) has led to reductions in child mortality in Malawi from illnesses such as malaria, pneumonia and diarrhoea. However, adherence to CCM guidelines is often poor, potentially leading to inappropriate clinical decisions and outcomes. We determined the impact of an electronic version of CCM (eCCM) application on referral, re-consultation and hospitalization rates of children presenting to village clinics in Malawi. Methods: A stepped-wedge cluster-randomized trial compared paper-based CCM (control) with and without use of an eCCM app on smartphones from November 2016 to April 2017.A total of 102 village clinics from two districts in Northern Malawi were assigned to one of six clusters which were randomized to the sequencing of crossover from the control to the intervention phases, as well as the duration of exposure in each phase. Children ≥2 months to <5 years presenting with acute illness were enrolled consecutively by Health Surveillance Assistants (HSAs). The primary outcome of urgent referrals to higher-level facilities was evaluated using multi-level mixed effects models. A logistic regression model with random effect of cluster and fixed effect for each step was fitted. Adjustment for potential confounders included baseline factors, such as patient’s age, sex, and geographical location of village clinics. Calendar time was adjusted for in the analysis. Results: A total of 6965 children were recruited, 3421 in the control and 3544 in the intervention phase. After adjusting for calendar time, children in the intervention phase were more likely to be urgently referred to a higher-level health facility compared with children in the control phase (OR 2.02, 95% CI 1.27-3.23; p 0.05). Conclusions: Addition of eCCM decision support led to a greater proportion of children being referred to higher-level facilities, with no apparent increase in hospital admissions or repeat consultations in village clinics. Our findings provide support for the implementation of eCCM tools in Malawi and other Low and Middle Income Countries (LMIC), with a need for ongoing assessment of effectiveness and integration with national digital health strategies. Trial Registration: ClinicalTrials.gov; NCT02763345. Registered 3 May 2016 Funding Statement: This work was supported by the European Union’s Seventh Framework Programme for research, technological development and demonstration (grant agreement no 305292). Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: Ethics approval and consent to participate: The study received ethical approval from the University of Washington Human Subjects Division in Seattle USA (#51750), Imperial College of London Research Ethics Committee (16IC3396) in London UK and the College of Medicine Research and Ethics Committee (COMREC) in Blantyre Malawi (P.07/16/1984). National and community-level permissions were also obtained prior to the conduct of this study. Consent for

End-user perspectives of two mHealth decision support tools: Electronic Community Case Management in Northern Malawi

BackgroundThe introduction of a paper-based Community Case Management (CCM) in Malawi has contributed to a reduction of child morbidity and mortality rates. In addition, the introduction of electronic Community Case Management (eCCM) (smartphones with built in CCM apps) may help to reduce the under-five mortality rates even further. PurposeIt is not uncommon for Apps with a similar area of interest to develop different features to assist the end users. Such differences between Apps may have a significant role to play in its overall adoption and integration. The purpose of this research was to explore end users perspectives of two eCCM decision support tools developed and implemented by the Supporting LIFE project (SL eCCM App) and D-Tree International’s (Mangologic eCCM App)in Northern Malawi. MethodsA mixed methods approach was applied, involving a survey of 109 users (106 Health Surveillance Assistants (HSAs), and 3 Integrated Management of Childhood Il6lnesses (IMCI) coordinators). This was followed up with semi-structured interviews with 34 respondents (31 HSAs, and 3 IMCI coordinators). Quantitative data was analyzed using SPSS version 20 where descriptive statistics and Chi-Squared tests were generated. Qualitative data were analyzed based on thematic analysis. ResultsParticipants reported that both Apps could assist the HSAs in the management of childhood illnesses. However, usability differed between the two apps where the Supporting LIFE eCCM App was found to be easier to use (61%) compared to the Mangologic eCCM App (4%). Both Apps were perceived to provide credible and accurate information. ConclusionIt is essential that the quality of the data within Mobile Health (mHealth) Apps is high, however even Apps with excellent levels of data quality may not succeed if the overall usability of the App is low. Therefore it is essential that the Apps has high levels of data quality, usability and credibility. The results of this study will help inform mobile Health (mHealth) App designers in developing future eCCM Apps as well as researchers and policy makers when considering the adoption of mHealth solutions in the future in Malawi and other LMICs.

Relationship between role stressors, job tasks and job satisfaction among health surveillance assistants in Malawi: a cross-sectional study

ObjectivesThe objective of this study was to investigate the role stressors, sociodemographic characteristics and job tasks of health surveillance assistants (HSAs) and to explore major predictors of role stressors and...

Aflatoxin contamination: Knowledge disparities among agriculture extension officers, frontline health workers and small holder farming households in Malawi

The aims of this study were to assess the state of knowledge and perceptions regarding aflatoxin contamination among frontline workers in direct contact with small holder farming households in Malawi as well as among the households themselves. The study first investigated and documented demographic profiles of agriculture extension workers (n = 22) and frontline health workers (n = 161) both from Ntchisi district and small holder farming households (n = 915) from Dedza, Balaka and Mzimba districts. Structured questionnaires were administered to document knowledge and perceptions. Majority of the respondents in Ntchisi were frontline nutrition and health workers as follows: care group promoters (31.7%), cluster leaders (51.9%) and health surveillance assistants (4.4%). Only 12% of the respondents were agriculture extension officers. Among frontline workers, using factor analyses, factors highly associated with the knowledge on domestic management of aflatoxin contamination and the impact of aflatoxin contamination on child linear growth and health in general were most prominent. Whereas, their knowledge of pre & post-harvest practices that pre-dispose crops to aflatoxin contamination and impact of aflatoxin contamination on trade and income losses was relatively low. On the other hand, among small holder farming households, lowest knowledge was related to occurrence of aflatoxin contamination pre and post-harvest. Highest knowledge was observed on issues around loss of income due to aflatoxin contamination. Across all districts over 50% of surveyed respondents reported that they perceived aflatoxin contamination severity as low. Majority of the households (>50%) did not perceive aflatoxin contamination as a problem that could be controlled.This is the first study to investigate knowledge, attitudes, practices and perceptions on aflatoxin contamination among a combination of agriculture extension officers and frontline health workers in parallel with the households they usually are in contact with. The current investigation is crucial because it elucidates knowledge gaps in aflatoxin critical control across agriculture extension, health workers and the small holder farming households. This is especially crucial among agriculture extension workers and frontline health workers as they have direct contact with households and therefore serve as an important source of information that could influence behavior change.

Determinants of exclusive breastfeeding in infants of six months and below in Malawi: a cross sectional study

BackgroundUNICEF and WHO recommend that all children should be exclusively breastfed for the first 6 months of life as breastmilk contains all the nutrients an infant needs during this period. In Malawi, exclusive breastfeeding has been declining from 72% (2009), 70.2% (2014) and 61% in the most recent survey (2015–16). We aimed to determine factors associated with exclusive breastfeeding in Malawi.MethodsWe used data from the Malawi Demographic and Health Survey (MDHS) 2015–2016. Survey records for 2059 mothers of children aged 6 months and below were identified and potential factors influencing infant feeding were examined. Logistic regression analysis was carried out to model determinants of exclusive breastfeeding (EBF).ResultsEBF declined in proportion to the age of the infant. Significant associations with continuing EBF were age of the mother, ethnicity of the mother, sex of infant and number of siblings. Members of the Tumbuka (OR = 1.71, CI. 1.13–2.59) and Ngoni (OR = 2.05, CI. 1.38–3.05) communities were more likely to practice EBF. In addition, mothers with female babies (OR = 1.35, CI. 1.08–1.70) and those with 3–4 children (OR = 1.47, CI. 1.04–2.08) were more likely to engage in EBF.ConclusionWe identify important variations in EBF practices among population sub-groups in Malawi that need to be considered when framing health education messaging. Work is needed to assess the impact of more targeted messaging, whether delivered via ‘ten steps’ to successful breastfeeding under Baby Friendly Hospital Initiative (BFHI) programming or other health education and awareness campaigns to sensitize communities on implications of some cultural practices on the lives of babies. The potential role for mass media, targeted Health Surveillance Assistants’ (HSA) home visits and male involvement also require exploration.

Health Surveillance Assistants’ Practices of Postnatal Care in Lilongwe District, Malawi

Health surveillance assistants (HSAs) participate in the provision of postnatal care in Malawi, although their knowledge and skills in maternal and reproductive health are limited. This article presents the findings of a mixed-methods study that was conducted in three selected health centres to document the practices of HSAs in the provision of postnatal care to mothers and babies in Lilongwe district in Malawi. A random sample of 97 HSAs participated in the quantitative part of this study and 30 of these participated in the qualitative aspect of the study. Quantitative data were analysed using descriptive statistics while qualitative data were analysed using thematic analysis. This study found that many respondents (&gt;60%) had limited capacity to provide adequate postnatal care and 85.3% of them never checked the vital signs of mothers and babies. They also lacked knowledge and skills in some aspects of postnatal care including danger signs. Almost all the respondents (96.8%) had never received any training in Basic Emergency Obstetric and Neonatal Care (BEmONC), or Emergency Obstetric and Neonatal Care (EmONC). Considering that HSAs have limited capacity to provide postnatal care to mothers and their babies, shifting tasks of nurses or midwives to HSAs should not be considered as an “outright solution” for increasing access to postnatal care in low-resource settings because it may compromise the quality of care.

Integrated Family Planning and Immunization Service Delivery at Health Facility and Community Sites in Dowa and Ntchisi Districts of Malawi: A Mixed Methods Process Evaluation.

The Government of Malawi’s Health Sector Strategic Plan II highlights the importance of service integration; however, in practice, this has not been fully realized. We conducted a mixed methods evaluation of efforts to systematically implement integrated family planning and immunization services in all health facilities and associated community sites in Ntchisi and Dowa districts during June 2016–September 2017. Methods included secondary analysis of service statistics (pre- and postintervention), focus group discussions with mothers and fathers of children under age one, and in-depth interviews with service providers, supervisors, and managers. Results indicate statistically significant increases in family planning users and shifts in use of family planning services from health facilities to community sites. The intervention had no effect on immunization doses administered or dropout rates. According to mothers and fathers, benefits of service integration included time savings, convenience, and improved understanding of services. Provision and use of integrated services were affected by availability of human resources and commodities, community linkages, data collection procedures and availability, sociocultural barriers, organization of services, and supervision and commitment of health surveillance assistants. The integration approach was perceived to be feasible and beneficial by clients and providers.

Enabling and hindering factors of health surveillance assistants\u2019 roles in the provision of contraceptive services in Mangochi, Malawi

BackgroundContraceptive services are essential for promoting people’s health, and economic and social well-being. Despite increased contraceptive use over the past decades, unmet need is still high in Malawi. As a result of task shifting, health surveillance assistants (HSAs), Malawi’s paid community health worker cadre, provide an expanded range of contraceptive services, aimed at increasing access at community level. We conducted a qualitative study to explore enabling and hindering factors of HSAs’ roles in the provision of modern contraceptive services in Mangochi district, Malawi.MethodsThe study involved HSAs and their supervisors, a variety of community members, health workers and policy makers using 34 interviews and 12 focus group discussions. Data were recorded, transcribed, translated, coded and thematically analysed according to a framework that included community-, HSA- and health system-related factors.ResultsHSAs were found to be trusted providers of contraceptive services. At community level, gender norms, decision-making and beliefs about contraceptives were intertwined. They resulted in women using contraceptive services, including those offered by HSAs, in secret. There were misconceptions about contraceptives among both men and women, which were insufficiently addressed by HSAs. Residence and age of HSAs influenced their role in the provision of contraceptive services to (young) community members, whereas sex was not regarded as an enabling or hindering factor. While most community members reported to be satisfied with the quality of HSAs’ services, quality was compromised by a lack of contraceptive supplies and other resources, and limited supportive supervision and training.ConclusionsHSAs in Mangochi are important contraceptive service providers. Their ability to ensure male involvement, increase access to services for youth and address misconceptions about contraceptives needs improvement. This requires a thorough understanding of socio-cultural norms and improved behavioural change communication competencies, which need to be incorporated in future training under Malawi’s Community Health Strategy.

Feasibility of implementing the World Health Organization case management guideline for possible serious bacterial infection among young infants in Ntcheu district, Malawi.

Neonatal sepsis is a leading cause of mortality, yet the recommended inpatient treatment options are inaccessible to most families in low-income settings. In 2015, the World Health Organization released a guideline for outpatient treatment of young infants (0-59 days of age) with possible serious bacterial infection (PSBI) with simplified antibiotic regimens when referral was not feasible. If implemented widely, this guideline could prevent many deaths. Our implementation research evaluated the feasibility and acceptability of implementing the WHO guideline through the existing health system in Malawi. A prospective cohort study was conducted in 12 first-level health facilities in Ntcheu district. Trained health workers identified and treated young infants with PSBI signs with injection gentamicin for 2 days and oral amoxicillin for 7 days, whereas those with only fast breathing were treated with oral amoxicillin for 7 days. Health Surveillance Assistants (HSAs) were trained to promote care-seeking and to conduct home visits on day 3 and 6 to assess infants under treatment, encourage treatment adherence and remind the caregiver to return for facility follow up. Infants receiving outpatient treatment were followed up at health facility on day 4 and 8. The primary outcome was proportion of outpatient cases completing treatment per protocol. A total of 358 infants received outpatient treatment (202 clinical severe infection, 156 only fast breathing) from February to September 2017. Of these, 92.7% (332/358) met criteria for treatment completion and 88.8% (318/358) completed the day 4 follow-up. Twelve (3.4%) young infants clinically failed treatment with no reported deaths in those treated at outpatient level. This treatment failure rate was lower than those reported for the simplified regimens tested in the SATT (8-10%) and AFRINEST (5-8%) equivalency trials. More than half of infants (58.1%; 208/358) received HSA follow-up visits on days 3 and 6. Study results demonstrate the feasibility of outpatient treatment for sick young infants when referral is not feasible in Malawi, which will inform scale-up in other parts of Malawi and countries with similar health system constraints.

'Do you trust those data?'-a mixed-methods study assessing the quality of data reported by community health workers in Kenya and Malawi.

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