Lilongwe District Research Articles

Understanding Crop Diversification Among Smallholder Farmers: Socioeconomic Insights from Central Malawi

In Eastern and Southern Africa (ESA), smallholder rain-fed systems are vital, yet they are challenged by land degradation, soil fertility decline, and climate risks. To address these challenges, crop diversification has been promoted as a potential pathway to enhance productivity, improve nutritional security, and offer a viable pathway out of poverty and hunger. This study explores crop diversification among 150 smallholder households in the Kasungu, Mchinji, and Lilongwe districts of Malawi, where the project Sustainable Intensification of Maize Legume Systems in East and Southern Africa (SIMLESA) has engaged the smallholder farmers in conservation agriculture (CA)-based sustainable intensification participatory research and development for seven years since 2010. This study used Simpson’s diversity index (SDI) to estimate crop diversification, and a multiple linear regression model (MLRM) to analyze how smallholder farmers’ socio-economic characteristics influence adoption. The findings show a prevalence of small farms of less than 1.5 hectares, with most farmers perceiving crop diversification as beneficial for soil fertility. Key adoption constraints include labor shortages and a lack of legume seeds. SIMLESA participants lead in crop rotations, with a 63% higher adoption rate, and show the highest crop diversity, with a 99% increase in farmers growing three crops and a 74% increase in those growing four crops compared to non-SIMLESA farmers. The SDI values were 0.39 for non-SIMLESA, 0.48 for SIMLESA neighbors, and 0.57 for SIMLESA participants. Access to NGO inputs, larger farm sizes, and participation in research programs were positively associated with diversification, while food insufficiency was negatively associated with its adoption. The study highlights the importance of integrating participatory research methods to promote development initiatives effectively.

Evaluating the impact of HIV pre-exposure prophylaxis on pregnancy, infant, and maternal health outcomes in Malawi: PrIMO study protocol

BackgroundIncident HIV during the perinatal period significantly impedes elimination of Mother-to-Child HIV Transmission (eMTCT) efforts. Pre-Exposure Prophylaxis (PrEP) effectively reduces HIV acquisition, and new agents like injectable Cabotegravir (CAB-LA) offer potential advantages for pregnant and breastfeeding women. The Pregnancy, Infant, and Maternal health Outcomes (PrIMO) study will compare rates of composite adverse pregnancy outcomes, and infant adverse events, growth and neurodevelopment between mother-infant dyads receiving CAB-LA and those receiving oral PrEP in Malawi.MethodsPrIMO is an observational cohort study involving: (1) the development of a PrEP Pregnancy Registry for longitudinal surveillance of pregnant women on PrEP in Malawi; and (2) the enrolment of a prospective safety cohort of 621 pregnant women initiating oral PrEP or CAB-LA and their subsequent infants. The registry will include all women continuing or initiating PrEP during pregnancy across targeted sites in Lilongwe and Blantyre districts. The safety cohort will enrol a subset of those women and their infants from Bwaila District Hospital in Lilongwe, Malawi. We hypothesize that CAB-LA’s safety will be comparable to daily oral PrEP regarding adverse pregnancy outcomes, maternal/infant adverse events, and infant development. Participants in the cohort will choose either oral PrEP or CAB-LA and will be followed until 52 weeks post-delivery. Safety data will be collected from all mother-infant pairs and qualitative interviews will be conducted with a subset of purposively selected women (n = 50) to assess the acceptability of each PrEP modality.DiscussionThe PrIMO study will provide critical data on the safety of CAB-LA in pregnant and breastfeeding women and their infants. Results will guide clinical recommendations as the Malawi Ministry of Health prepares for the rollout of CAB-LA to this population. Evaluation of Registry implementation will inform its expansion to a nationwide safety monitoring system for PrEP use during pregnancy, with implications for similar systems in the region.Trial Registration numberNCT06158126. The study was prospectively registered (5 December 2023) in ClinicalTrials.gov.

Identification of mothers with mental health problems is accidental: perceptions of health care providers on availability, access, and support for maternal mental health care for adolescent mothers in Malawi

BackgroundIntegration of maternal mental health into primary health care is considered a strategy to improve access to mental health support in low- and middle-income countries (LMICs). Health care workers’ (HCWs) and traditional practitioners’ (traditional healers, herbalists, traditional birth attendants, spiritual healers, prophets, and community health volunteers) perceptions of the availability and management of adolescent mothers’ maternal mental health care were explored in rural Malawi. Recognizing and identifying the barriers associated with access to maternal mental health support is essential to improving the mental health of adolescent mothers.MethodsA descriptive qualitative design (DQ) was used to explore HCWs’ and traditional practitioners’ perceptions of maternal mental health services for adolescent mothers. In-depth interviews were conducted with HCWs (n = 6), and three focus group discussions were conducted with 30 community-based traditional practitioners. Participants were purposefully recruited because they provide formal or informal health services to adolescent mothers during the postnatal period at Mitundu Rural Hospital and its catchment area in Lilongwe District, in Malawi. Interviews were analyzed using reflective thematic analysis and inductive thinking.ResultsThematic analysis found four themes to describe access to maternal mental health care for adolescent mothers. Participant perceptions were themed around health system challenges and how cultural background and beliefs influence access to mental health care and support. The themes were: (1) Inadequate staff development; (2) Limited resources (medication and infrastructure); (3) Limited policy and guidelines implementation; and (4) Cultural background and belief influence on help-seeking. HCWs suggested improving pre-service and in-service training to improve mental health assessment of mothers, while traditional practitioners wanted to increase their awareness of mental health issues.ConclusionParticipants emphasized that multifaceted factors influenced access to mental health support. These factors affect the assessment, treatment, and support of adolescent mothers and help-seeking by mothers. Therefore, strengthening the healthcare system and empowering providers with the knowledge and skills to recognize at-risk mothers and provide timely support is essential.

Cultural and social factors associated with generalized anxiety disorder among adolescent mothers during the postpartum period in Malawi: a cross-sectional survey

BackgroundThe postnatal period is an important time for adolescent mothers to regain their health as they adjust to life with their infants. However, it is also a time when mothers are vulnerable to mental health problems. Generalized anxiety disorders (GADs) are among the common mental disorders that can impact mothers. Anxiety disorders can have adverse effects on a child’s cognitive development. However, there is a scarcity of studies pertaining to anxiety disorders among adolescent mothers in Malawi.MethodsA cross-sectional survey was conducted among adolescent postnatal mothers aged ≤ 19 years to establish the prevalence of probable GAD and identify cultural and social factors that influence anxiety in this population. Adolescent mothers were recruited from the Mitundu Rural Hospital catchment area in Lilongwe district, Malawi. A two-stage random sampling method was employed: clinics were randomly selected, and participants were recruited via systematic random sampling. The Generalized Anxiety Disorder (GAD-7) scale was used to assess anxiety. Data were analyzed using SPSS version 27.ResultsOf the 395 adolescent mothers who participated, 34% were aged 14–17. The prevalence of probable GAD (GAD-7 ≥ 10) was 31.9%. Increased social support decreased the odds of probable GAD (aOR 0.95, 95% CI: 0.91–0.98, p < 0.001). Experiencing intimate partner violence (IPV) increased the likelihood of probable GAD (aOR 4.80, 95% CI: 1.23–18.82, p = 0.02), while those who had contact with a health worker postnatally (aOR 0.38, 95% CI: 0.17–0.83, p = 0.02) and those who were “not prayerful” (aOR, 0.43, 95% CI: 0.21–0.87, p = 0.02) were less likely to report probable GAD.ConclusionsGiven that the prevalence of probable GAD among adolescent mothers in Malawi is higher compared to the global estimates of their peers, policies and guidelines that prioritize the maternal mental health of adolescent mothers in Malawi are required. The findings also highlight the importance of enhancing social support among family and community. Co-designed mental health promotion, prevention, and early interventions to involve health workers and religious leaders are recommended.

Harvesting “development minerals” for local needs in sub-Saharan Africa: The case of Malawi

This paper critically reflects on the impact of “development minerals” on rural livelihoods in sub-Saharan Africa, focusing on the case of Malawi. It does so by analysing data collected at multiple quarrying sites in Lilongwe District, with the objective of assessing how production of these commodities can help meet Malawi’s commitments to the Sustainable Development Goals (SDGs). Findings indicate that despite their extraction being associated with environmental problems, development minerals do impact positively on the livelihoods of Malawians in rural areas where very few viable alternative income-earning opportunities. To maximise the sector’s contribution to the SDGs in Malawi, however, greater emphasis must be placed on formalising and supporting quarrying operations and other activities oriented around development minerals.

Acceptability and feasibility of using a blended quality improvement strategy among health workers to monitor women engagement in Option B+ program in Lilongwe Malawi

Option B + provides lifelong ART to pregnant and breastfeeding women with HIV to reduce mother-to-child transmission of HIV (eMTCT) and improve maternal health. The effectiveness of Option B + relies on continuous engagement, but suboptimal monitoring of HIV care hinders our measurements of engagement. Process mapping and quality improvement (PROMAQI) is a quality improvement strategy for healthcare workers (HCWs) to optimize complex processes such as monitoring HIV care. We assessed the acceptability and feasibility of the PROMAQI among HCWs and identified barriers and facilitators for PROMAQI implementation. A cross-sectional study using a mixed method approach was conducted from August 2021 to March 2022 across five urban health facilities participating in PROMAQI implementation n the Lilongwe district, Malawi. We assessed PROMAQI acceptability and feasibility at the end of the study. A 5-point Likert (1 = worst to 5 = best) scale tool was administered to 110 HCWs (n = 15–33 per facility) involved in PROMAQI implementationThese data were analysed using descriptive statistics Among the 110 HCWs, twenty-two (QI team (n = 11) and QI implementers (n = 11)) were purposively selected for in-depth interviews. Thematic analysis was conducted using deducted and inductive approaches. The theoretical framework for acceptability (TFA) was used to identify reasons for acceptability. The Consolidated Framework for Implementation Research (CFIR) was used to characterize the barriers and facilitators of PROMAQI implementation. HCWs recruited had a median age of 37 (32–43) years, 82.0% of whom were female. Most (42%) had completed secondary education, and 84% were nurses and community health workers. The median (IQR) acceptability and feasibility scores for the PROMAQI were 5 (IQR 4–5) and 4 (IQR 4–5), respectively. Reasons for high PROMAQI acceptability included addressing a relevant gap and improving performance. Perceived implementation barriers included poor work attitudes, time constraints, resource limitations, knowledge gaps, and workbook difficulties. The facilitators included communication, mentorship, training, and financial incentives. PROMAQI is a highly acceptable and feasible tool for monitoring engagement of women in Option B + . Addressing these barriers may optimize the implementation of PROMAQI. Scaling up PROMAQI may enhance retention in the Option B + program and facilitate eMTCT.

Patterns and drivers of antibiotic use in small-scale broiler production systems in Lilongwe District, Malawi

Reducing the inappropriate use of antibiotics in food animals is a global priority to address antimicrobial resistance (AMR). We investigated practices and factors associated with antibiotic use in small-scale commercial broiler farms in Lilongwe district, Malawi. We used structured questionnaires to collect data on recent antibiotic use practices among 128 broiler farmers, who kept between 50 and 1 000 birds, from December 2022 to March 2023. Logistic regression analysis was used to identify risk factors associated with antibiotic use. Over half (53.1 %, n=68) of the farms reported using antibiotics at least once in the previous production cycle. Overall, 11 different types of antibiotics were used either for treatment and/or preventive purposes, with oxytetracycline (88.2 %), erythromycin (29.4 %), and enrofloxacin (26.5 %) reported as the frequently used. One-third of all antibiotic formulations contained multiple active antibiotic ingredients, with 12 % containing four antibiotics. Covariates associated with an increased likelihood of antibiotic use include disease incidence (OR=13.8, 95 % CI 5.27–42.50, p<0.001) and entry of wild birds into poultry houses (OR=3.56, 95 % CI =1.44–9.61, p=0.008). Our study highlights inappropriate usage of antibiotics, largely associated with reduced biosecurity and disease incidence. These findings underscore the need to strengthen veterinary services, reinforce regulations on antibiotic access and use, and farmer education programs promoting proper husbandry, biosecurity, and responsible antibiotic use.

Piloting a psychosocial intervention for perinatal depression, the Thinking Healthy Programme-Peer delivered (THPP), in a primary care setting in Lilongwe District, Malawi.

Despite the evidence for the effectiveness of psychosocial interventions for perinatal depression, their uptake is low in Low- and Middle-Income Countries. Reasons for this include the lack of contextually adapted interventions and mental health specialists to deliver them. This study aimed to test the acceptability and feasibility of a psychosocial intervention for perinatal depression, the Thinking Healthy Programme-Peer Delivered, adapted for use in rural Malawi. A multi-method evaluation of feasibility and acceptability of the intervention was conducted using a one-group pretest-posttest quasi-experimental design and an exploratory qualitative study. Pre-post intervention change in depression scores (paired t-test) and recruitment, retention and session adherence rates were calculated. Qualitative data were collected through 29 in-depth interviews (22 mothers and 7 peer volunteers) and 1 Focus Group Discussion (18 mothers). Thematic analysis approach was used to analyse qualitative data. Seven (7) out of 8 peer volunteers were successfully trained to deliver the intervention. A total of 31 pregnant women with Edinburgh Postnatal Depression Scale (EPDS) score ≥12 were offered intervention, of whom 24 were enrolled (recruitment rate 77.4%). Out of these 24 women, 22 completed the intervention (retention rate 91.6%). Mean difference between pre- and post-test EPDS scores one week after 8th session was 7.59 (95% CI 4.98 to 10.19), p<0.001. Qualitative evaluation showed that the intervention was acceptable despite some challenges including stigma and issues around incentivization of peer volunteers. The Thinking Healthy Programme-Peer Delivered, adapted for use in Malawi, was feasible to deliver and acceptable to its target population. The intervention may be useful in management of perinatal depression in primary care settings in Malawi. However, definitive trials are needed to evaluate its effectiveness.

Facilitators of Skilled Birth Attendants’ Utilization in Government and Christian Health Association of Malawi Hospitals: A Cross-Section Study of Lilongwe Rural

Background: Every woman must have access to a Skilled Birth Attendant (SBA) for routine care and management of complications during labour, childbirth, and early postnatal period. SBA utilization has been identified as an essential approach of reducing maternal morbidity and mortality among reproductive age group of 15-49. Malawi as a developing country is also utilizing skilled birth attendants in an effort to reduce maternal death by 70 per 100,000 births. Report of 2020 from Demographic and Health Survey (DHS) on skilled birth attendants (SBA) revealed that Malawi was 89.8% by 2018, while Lilongwe District, the study area, was 67% of SBA utilization against a target of skilled birth attendant utilization of 95% by the year 2022. Purpose: To evaluate the facilitators of skilled birth attendants’ utilization in government and CHAM hospitals and their relationship to hospital delivery. Methods: This research used logistic regression test and quantitative cross-sectional approach. Questionnaires were used to collect data from December 2021 to February 2022 in 390 participants. The sampling techniques used were cluster and random sampling. Results: Based on logistic regression marital status (p=0.001, OR 14.56), pregnancy complication (p=0.000, OR 12.21), and ANC three times (p=0.010, OR 2.11) and four times (p=0.000 OR 0.76) were found to be significantly associated with hospital delivery. On the other hand ANC once (p=0.005, OR -2.33) and twice (P=0.008, OR -1.94) did not significantly influence utilization skilled birth attendants by pregnant mothers Conclusion: Based on the results, it is concluded that age from 15 to 30 and employment, marital status, education, complication, antenatal clinic, are the facilitators for pregnant mothers to utilize skilled birth attendant. These facilitators might be of importance for policy makers to consider when coming up with programs to increase skilled birth attendants utilization at rural area of Lilongwe District.

Using community-based, participatory qualitative research to identify determinants of routine vaccination drop-out for children under 2 in Lilongwe and Mzimba North Districts, Malawi

ObjectiveIn recent years, full childhood routine immunisation coverage has fallen by 5% to levels not seen since 2008; between 2019 and 2021, 67 million children were undervaccinated. We aimed to...

Radio Listenership of Zokonda Amayi phone-in programme among women in rural Malawi

This study’s objective was to assess radio listenership among disadvantaged pastoral women on the outskirts of Lilongwe Malawi. A non-probability purposive sample of 384 women who listen to Zokonda Amayi phone-in radio programme was targeted. The respondents were identified by publicizing the study through village chiefs. Only female listeners who were intrigued in taking part registered for the survey. A mixed approach prototype was used to elucidate the aptness of phone-in radio programmes in elevating HIV and AIDS responsiveness in rural Malawian ladies as well as ascertaining the impact of Zokonda Amayi phone-in radio programme in combating the spread of HIV and AIDS. Data was assembled in a standardized fashion harnessing questionnaires, interviews and focus group discussions on the research subjects. The investigation revealed that the majority of respondents were youthful. This study concluded that radio listenership among women is very high in the rural areas of Lilongwe. The findings authenticate that Zokonda Amayi phone-in radio programme is fulfilling an important educational function in the lives of rural women in Lilongwe District who have low educational attainment.

Evaluation of pests affecting maize imported across Malawi borders

Cross-border trade is one of the major factors that puts maize at risk as it creates pathways for spread of different maize pests in Malawi. This study was carried out to identify pests associated with imported maize in order to improve phytosanitary measures and reduce the introduction of pests. Random sampling technique was used to collect imported maize at selected borders and commercial cities with the aim of identifying pests present during importation. There were no significant differences (p&gt;0.05) in the population of insect pests before and after incubation in all the surveyed districts. Significant differences were observed after incubation for larger grain borer (LGB) and common maize weevil. The highest percentage infestation (32%) of living LGB was recorded in Karonga and the least in Mzuzu (p&lt;0.05). On the other hand, for maize weevil, the highest percentage infestation (20%) was recorded in Nkhatabay while the least was observed in Lilongwe district (p&lt;0.05). Common fungal pathogen species isolated included Fusarium (70%), Aspergillus (29%) and Penicillium (1%). The highest percentage of kernel infection with Fusarium sp. was recorded in Dedza and Lilongwe while for Aspergillus sp. were in Mzuzu. The Aspergillus sp. isolated were A. niger (29%), A. flavus (22%) and A. parasiticus (5%) while Fusarium sp. isolated was Fusarium verticilloides. The study provided the status and causes of storage losses by various pests on maize. It is recommended that the phytosanitary system present at various Malawi borders where maize is imported should be strengthened. This can be achieved through human and infrastructure capacity building, strict compliance with importation regulations and improved funding of organizations mandated to ensure phytosanitary compliance. Key words: Aspergillus sp., consignment, food security, grain storage, random sampling, sanitary and phytosanitary measures.

Factors associated with self-reported diagnosed asthma in urban and rural Malawi: Observations from a population-based study of non-communicable diseases.

The growing burden of asthma in low- and middle-income countries has been linked to urbanisation and lifestyle changes. However, this burden has not been well characterised in adults. Therefore, we investigated the prevalence of self-reported diagnosed asthma and associated factors in urban and rural adults in Malawi, Southern Africa. Within a cross-sectional population-based survey to determine the burden and risk factors for non-communicable diseases (NCDs) in the city of Lilongwe and rural Karonga district, we collected information on self-reported previously diagnosed asthma and asthma-related symptoms using an interviewer-led questionnaire. Other data collected included: demographic characteristics, socioeconomic status indicators, NCD comorbidities, environmental exposures, and anthropometric measurements. We used multivariable logistic regression models to explore factors associated with self-reported asthma adjusting for variables associated with the outcome in univariable analysis. Findings were corrected for multiple comparisons using the Bonferroni method. We analysed data from 30,483 adult participants (54.6% urban,45.4% rural and 61.9% female). A prior asthma diagnosis was reported in 5.1% of urban and 4.5% of rural participants. In urban females, being obese (>30 kg/m2) compared to normal weight (18.5-24.9 kg/m2) was associated with greater odds of asthma (OR = 1.59, 95% CI [1.26-2.01], p<0.001), after adjusting for confounders. We observed associations between previously diagnosed heart disease and asthma in female participants which remained significant in rural females after Bonferroni correction (OR = 2.30,95%CI [1.32-4.02], p = 0.003). Among rural males, current smokers had reduced odds of diagnosed asthma (OR = 0.46,95%CI [0.27-0.79], p = 0.004) compared to those who had never smoked. In Malawi the prevalence of self-reported diagnosed asthma was greatest in females and urban dwellers. Notably, our findings indicate relationships between excess body weight as well as comorbidities and diagnosed asthma in females. Future investigations using longitudinally collected data and clinical measurements of asthma are needed to better understand these associations.

Goat health and management for improved smallholders’ livelihoods in central Malawi – A socioeconomic analysis of rural households

The true value of goats, their management systems, and the limitations of smallholdings have not been fully explored in the context of sustainable livelihoods among rural smallholders in central Malawi. However, goats are an essential part of rural livelihoods as transferable assets and sources of household nutrition, especially at times of food insecurity aligned to an ever more variable climate. To study the impact and limitations of goat ownership in Malawi’s Lilongwe district, surveys were performed across four villages covering 148 households from October-November 2019. Surveys were designed to identify linkages between household demographics, livelihoods, goat ownership, and management practices. Findings revealed goats are highly valued compared to other livestock. However, herds were small (median = 3) with only 62% reported kidding in the last year, while 50% reported deaths due to diseases, predation (such as by hyenas), and dog bites. Odds-ratio analyses identified farmers (as a primary occupation) were more likely to successfully breed goats to increase their herd size. Larger herds were associated with those who could accumulate wealth and utilise goats for ceremonies. However, diseases were a major contributor to losses and increased the risk of household food insecurity. Limiting disease impacts through anthelmintics and supplementation were correlated to an increased likelihood of sustainable offtake from smallholdings and improved livelihoods. With limited access to veterinary services, smallholders utilise a diversity of medicinal plants and ash to treat diarrhoea in their herd. The results highlight that goat security and health is fundamental to realising smallholding livelihood gains. Future efforts should aim to empower smallholders through providing tools to monitor goat health and to assess the effects of local practices, including the use of medicinal plants, for goat health.

Food choice responses to changes in the price of a staple crop: a discrete choice experiment of maize in rural Malawi

Price and affordability are important drivers of food choice, particularly for rural smallholder farming households in Malawi, experiencing extreme poverty, food insecurity, and lack of dietary diversity. Lowering the cost of staple crops such as maize targeted by agricultural input subsidy programmes (AISPs) may potentially increase consumption of the staple crop, but it might also lead to consumption of a more diverse range of foods. Using a discrete choice experiment, this study investigated food choice responses to changes in maize price in rural Malawi. Study participants (n = 400) were given a series of choice tasks for which they were asked to choose between food baskets with varying cost, reflecting local prices and with maize at both high and low price. Baskets contained different types of foods including maize, rice, cabbage, small-dried fish, and/or a soft drink. The data were analysed using mixed logit models including investigation of heterogenous effects based on socio-demographic characteristics, food security and actual market purchases. Individuals revealed a preference, as expected, for lower cost food baskets. Small-dried fish and cabbage were the highest valued food products. At a low cost of maize, the expected utility from a basket with maize was greater than a basket with other items, particularly among households with high- and low-food purchases, low socioeconomic status, living in Phalombe District, and experiencing food insecurity, indicating that among such populations a low price of maize will not necessarily lead to increases in dietary diversity. In contrast, among households living in Lilongwe District, with high SES and food secure, a lower maize price will not lead to a loss in dietary diversity as they prefer a basket containing non-maize products over maize. The findings suggest that achieving food security and dietary diversity may require a range of policy approaches addressing different pathways of impact as opposed to relying on subsidizing inputs for staple crop production.

Preferences for enhanced treatment options to address HIV care engagement among women living with HIV and perinatal depression in Malawi

BackgroundOption B + offers lifelong ART to pregnant or breastfeeding mothers, but postpartum loss to HIV care, partially driven by perinatal depression (PND), threatens the impact of this policy. This study aims to understand women’s and providers’ preferences for developing a feasible intervention to address PND and support engagement in HIV care among women living with PND and HIV.MethodsWe conducted a total of 6 focus group discussions (FGDs) involving 4 clinics in Lilongwe District from December 2018 through February 2019. We conducted 2 FGDs each among 3 stakeholder groups: clinical staff, prenatal women, and postnatal women. Perinatal participants were living with HIV and screened positively for PND using the validated Edinburgh Postnatal Depression Scale (EPDS). Clinical staff were nurses who were trained antiretroviral therapy (ART) providers. Interviewers led FGDs in Chichewa using a semi-structured guide. Data were analyzed using deductive and inductive coding in NVivo 12 software.ResultsWomen favored ART linkage services, but providers said they already offered such services, with mixed results. Individual counselling was universally supported. A perceived benefit of group counselling was peer support, but there were concerns among women regarding confidentiality and stigma. Women liked mobile appointment reminders but identified low phone ownership as a barrier. Participants recommended home visits as an additional care engagement strategy. Women consistently discussed the need for social support from family members and friends to address PND and support engagement in HIV care.ConclusionThis study highlights the importance of peer encouragement to support perinatal HIV care engagement among women with HIV and PND. The results from this study can be used to support intervention development to increase HIV care engagement and improve long-term HIV outcomes in women with PND.

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.

Analysing urban and peri-urban youth employment in agribusiness in Malawi.

The study aims to analyse key determinants of urban and peri-urban youth employment in agribusiness in Malawi to support youth policies. A mixed-methods approach is used, which combines both quantitative and qualitative analyses. The quantitative method involved a Bivariate Logit Model and Multinomial Logit Model to analyse nationally representative survey data from the Fourth Integrated Household Survey in 2016-2017. The qualitative method employed thematic analysis to data generated through Focus Group Discussions and Key Informant Interviews for key stakeholders involved in agri-business in Lilongwe district. The qualitative analysis, which focuses on a case study for urban and peri-urban youth in agribusiness, was used to validate, and provide context for the quantitative analysis. The results revealed that a majority of the urban and peri-urban youth engaged in agribusiness across Malawi work in sole farming (family farms or ganyu); in addition, women outnumber men in terms of engagement in agribusiness, and this stems from tradition. In addition, the determinants that affect youth's engagement in agribusiness consist of demographic factors, institutional support, assets, and shocks. It was also shown that men were more likely than women to be engaged in sole farming, but they were as likely as women to be engaged in other forms of agribusiness. The policy recommendation from this study is that programs aimed at supporting youth engagement in agribusiness should consider a variety of factors; If resources are limited, the programs should ensure that they offer capacity strengthening for the youth in the form of extension services and practical training in agribusiness.

Low-cost molecular methods to characterise gastrointestinal nematode co-infections of goats in Africa

BackgroundVeterinary diagnostics aid intervention strategies, track zoonoses, and direct selective breeding programs in livestock. In ruminants, gastrointestinal nematode (GIN) parasites are a major cause of production losses, but morphologically similar species limit our understanding of how specific GIN co-infections impact health in resource-limited settings. To estimate the presence and relative abundance of GINs and other helminths at the species level, we sought to develop a low-cost and low-resource molecular toolkit applied to goats from rural Malawi smallholdings.MethodsGoats were subjected to health scoring and faecal sampling on smallholdings in Lilongwe district, Malawi. Infection intensities were estimated by faecal nematode egg counts with a faecal subsample desiccated for DNA analysis. Two DNA extraction methods were tested (low-resource magbead kit vs high-resource spin-column kit), with resulting DNA screened by endpoint polymerase chain reaction (PCR), semi-quantitative PCR, quantitative PCR (qPCR), high-resolution melt curve analysis (HRMC), and ‘nemabiome’ internal transcribed spacer 2 (ITS-2) amplicon sequencing.ResultsBoth DNA isolation methods yielded comparable results despite poorer DNA purity and faecal contaminant carryover from the low-resource magbead method. GINs were detected in 100% of samples regardless of infection intensity. Co-infections with GINs and coccidia (Eimeria spp.) were present in most goats, with GIN populations dominated by Haemonchus contortus, Trichostrongylus colubriformis, Trichostrongylus axei, and Oesophagostomum columbianum. Both multiplex PCR and qPCR were highly predictive of GIN species proportions obtained using nemabiome amplicon sequencing; however, HRMC was less reliable than PCR in predicting the presence of particular species.ConclusionsThese data represent the first ‘nemabiome’ sequencing of GINs from naturally infected smallholder goats in Africa and show the variable nature of GIN co-infections between individual animals. A similar level of granularity was detected by semi-quantitative PCR methods, which provided an accurate summary of species composition.Assessing GIN co-infections is therefore possible using cost-efficient low-resource DNA extraction and PCR approaches that can increase the capacity of molecular resources in areas where sequencing platforms are not available; and also open the door to affordable molecular GIN diagnostics. Given the diverse nature of infections in livestock and wildlife, these approaches have potential for disease surveillance in other areas.Graphical

The knowledge and practice of nurse midwives concerning the provision of postnatal care at primary health care facilities in Lilongwe District, Malawi

The knowledge and practice of nurse midwives concerning the provision of postnatal care at primary health care facilities in Lilongwe District, Malawi