Rural District Of Malawi Research Articles

Characteristics of Patients Diagnosed with Tuberculosis in a Rural District of Malawi: A Retrospective Analysis of Secondary Data

Characteristics of Patients Diagnosed with Tuberculosis in a Rural District of Malawi: A Retrospective Analysis of Secondary Data

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

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

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.

Parental involvement in children’s primary education: A case study from a rural district in Malawi

In the study reported on here, we analysed parents’ involvement in their children’s primary education in 4 primary schools in rural Malawi, focusing on the home and the school. Through interviews and focus-group discussions, information was obtained from 19 parents, 24 teachers (6 from each school), and 4 head teachers. Bronfenbrenner’s ecological systems theory was used to design the study and to interpret the data, focusing mainly on the micro- and mesosystem elements. The home and school settings represent the autonomous microsystem, whereas parental involvement is part of the mesosystem. The microsystem appeared to be active both with learner-parent and learner-teacher actions; however, mesosystemic interactions were limited. We found that parents and teachers needed to develop stronger mutual relationships and interactions to support learners better. Schools also need to communicate positive aspects of children’s learning to the parents. Enhancing positive reinforcement could enhance parental involvement.

Cost of community-led larval source management and house improvement for malaria control: a cost analysis within a cluster-randomized trial in a rural district in Malawi

BackgroundHouse improvement (HI) to prevent mosquito house entry, and larval source management (LSM) targeting aquatic mosquito stages to prevent development into adult forms, are promising complementary interventions to current malaria vector control strategies. Lack of evidence on costs and cost-effectiveness of community-led implementation of HI and LSM has hindered wide-scale adoption. This study presents an incremental cost analysis of community-led implementation of HI and LSM, in a cluster-randomized, factorial design trial, in addition to standard national malaria control interventions in a rural area (25,000 people), in southern Malawi.MethodsIn the trial, LSM comprised draining, filling, and Bacillus thuringiensis israelensis-based larviciding, while house improvement (henceforth HI) involved closing of eaves and gaps on walls, screening windows/ventilation spaces with wire mesh, and doorway modifications. Communities implemented all interventions. Costs were estimated retrospectively using the ‘ingredients approach’, combining ‘bottom-up’ and ‘top-down approaches’, from the societal perspective. To estimate the cost of independently implementing each intervention arm, resources shared between trial arms (e.g. overheads) were allocated to each consuming arm using proxies developed based on share of resource input quantities consumed. Incremental implementation costs (in 2017 US$) are presented for HI-only, LSM-only and HI + LSM arms. In sensitivity analyses, the effect of varying costs of important inputs on estimated costs was explored.ResultsThe total economic programme costs of community-led HI and LSM implementation was $626,152. Incremental economic implementation costs of HI, LSM and HI + LSM were estimated as $27.04, $25.06 and $33.44, per person per year, respectively. Project staff, transport and labour costs, but not larvicide or screening material, were the major cost drivers across all interventions. Costs were sensitive to changes in staff costs and population covered.ConclusionsIn the trial, the incremental economic costs of community-led HI and LSM implementation were high compared to previous house improvement and LSM studies. Several factors, including intervention design, year-round LSM implementation and low human population density could explain the high costs. The factorial trial design necessitated use of proxies to allocate costs shared between trial arms, which limits generalizability where different designs are used. Nevertheless, costs may inform planners of similar intervention packages where cost-effectiveness is known.Trial registration Not applicable. The original trial was registered with The Pan African Clinical Trials Registry on 3 March 2016, trial number PACTR201604001501493

Integrated delivery of family planning and childhood immunisation services in routine outreach clinics: findings from a realist evaluation in Malawi

BackgroundFamily planning (FP) needs among postpartum women in low- and middle-income countries remain largely unmet. Integrating FP with childhood immunisation services could partially reduce this unmet need by creating multiple opportunities for timely contact with FP services during the 12 months following childbirth.MethodsA realist evaluation of an intervention integrating FP and childhood immunisation services in routine outreach clinics in two rural districts of Malawi was conducted. A Context-Mechanism-Outcome (CMO) framework was used to describe the drivers of the intervention. A detailed programme theory was developed based on the analysis of semi-structured interviews and focus group discussions with 50 stakeholders.ResultsA total of 9 core mechanisms were identified, which centred on constructs of access. Findings revealed that on the demand side, women were motivated to attend outreach clinics due to shorter travel distances; they felt confident they could access FP services and use contraceptive methods covertly if needed; and when supported by their husband, they were empowered to take up the use of contraceptive methods. On the supply side, providers were empowered through the training they received to provide integrated services; they were confident in their ability to provide essential services; and they were motivated by teamwork and by the recognition they received for their work. Additionally, some providers were found to be unwilling to walk long distances to reach remote clinics, which was seen to negatively affect the availability of services.ConclusionsThe delivery of integrated FP and childhood immunisation services in the context of routine outreach clinics in rural Malawi was seen to trigger mechanisms of accessibility and to improve the acceptability and availability of FP services. However, further research is needed to understand how the integration of these services in a routine outreach clinic setting may affect other dimensions of accessibility, including the approachability, appropriateness and affordability of services.

Increasing utilisation of perinatal services: estimating the impact of community health worker program in Neno, Malawi

BackgroundBy 2015, Malawi had not achieved Millennium Development Goal 4, reducing maternal mortality by about 35% from 675 to 439 deaths per 100,000 livebirths. Hypothesised reasons included low uptake of antenatal care (ANC), intrapartum care, and postnatal care. Involving community health workers (CHWs) in identification of pregnant women and linking them to perinatal services is a key strategy to reinforce uptake of perinatal care in Neno, Malawi. We evaluated changes in uptake after deployment of CHWs between March 2014 and June 2016.MethodsA CHW intervention was implemented in Neno District, Malawi in a designated catchment area of about 3100 women of childbearing age. The pre-intervention period was March 2014 to February 2015, and the post-intervention period was March 2015 to June 2016. A 5-day maternal health training package was delivered to 211 paid and supervised CHWs. CHWs were deployed to identify pregnant women and escort them to perinatal care visits. A synthetic control method, in which a “counterfactual site” was created from six available control facilities in Neno District, was used to evaluate the intervention. Outcomes of interest included uptake of first-time ANC, ANC within the first trimester, four or more ANC visits, intrapartum care, and postnatal care follow-up.ResultsWomen enrolled in ANC increased by 18% (95% Credible Interval (CrI): 8, 29%) from an average of 83 to 98 per month, the proportion of pregnant women starting ANC in the first trimester increased by 200% (95% CrI: 162, 234%) from 10 to 29% per month, the proportion of women completing four or more ANC visits increased by 37% (95% CrI: 31, 43%) from 28 to 39%, and monthly utilisation of intrapartum care increased by 20% (95% CrI: 13, 28%) from 85 to 102 women per month. There was little evidence that the CHW intervention changed utilisation of postnatal care (− 37, 95% CrI: − 224, 170%).ConclusionsIn a rural district in Malawi, uptake of ANC and intrapartum care increased considerably following an intervention using CHWs to identify pregnant women and link them to care.

Children with hearing impairment in Malawi, a cohort study.

ObjectiveTo assess the outcomes of children diagnosed with hearing impairment 3 years earlier in terms of referral uptake, treatment received and satisfaction with this treatment, and social participation.MethodsWe conducted a population-based longitudinal analysis of children with a hearing impairment in two rural districts of Malawi. Key informants within the community identified the cohort in 2013 (baseline). Informants clinically screened children at baseline, and by questionnaires at baseline and follow-up in 2016. We investigated associations between sociodemographic characteristics and outcomes by multivariate logistic regression.ResultsWe diagnosed 752 children in 2013 as having a hearing impairment and traced 307 (40.8%) children of these for follow-up in 2016. Referral uptake was low (102/184; 55.4%), more likely among older children (odds ratio, OR: 3.5; 95% confidence interval, CI: 1.2–10.2) and less likely for those with an illiterate caregiver (OR: 0.5; 95% CI: 0.2–0.9). Few of the children who attended hospital received any treatment (33/102; 32.4%) and 63.6% (21/33) of caregivers reported satisfaction with treatment. Difficulty making friends and communicating needs was reported for 10.0% (30/299) and 35.6% (107/301) of the children, respectively. Lack of school enrolment was observed for 29.5% (72/244) of children, and was more likely for older children (OR: 28.6; 95% CI: 10.3–79.6), girls (OR: 2.4; 95% CI: 1.2–4.8) and those with an illiterate caregiver (OR: 2.1; 95% CI: 1.0–4.1).ConclusionMore widespread and holistic services are required to improve the outcomes of children with a hearing impairment in Malawi.

Patients experiences of self-management and strategies for dealing with chronic conditions in rural Malawi

Background: The high burden of chronic communicable diseases such as HIV/AIDS, and an escalating rise of non-communicable diseases (NCDs) in Malawi and other African countries, calls for a shift in how healthcare services are designed and delivered. Patient-centred care and patient self-management are critical elements in chronic care, and advocated as global strategies. Further evidence is needed around patient self-management practices, and how to best support patients with chronic conditions in the African context. Our study explored self-management practices of patients with different chronic conditions, and their strategies to overcome care challenges in a resource constrained setting in Malawi. To further unpack self-management mechanisms and patient adjustment processes, we make use of Bandura’s social cognitive theory. Methods: We conducted a mixed methods study, involving patients with different chronic conditions from a rural district in Malawi. Data included a longitudinal survey with 129 patients, 14 in-depth interviews, and four focus-group discussions with patients. We used a framework approach for qualitative data analysis and survey data analysed using descriptive statistics. Results: Patients demonstrated ability to self-manage their conditions, though this varied between conditions, and was influenced by individual and environmental factors. Factors included: ability to acquire appropriate disease-specific knowledge; poverty level; the presence of support from family caregivers and community-based support initiatives; the nature of one's social relations; and the ability to deal with stressors and stigma. NCD and HIV comorbid patients were more disadvantaged in their access to healthcare, as they experienced frequent drug stock-outs and incurred additional out of pocket costs when referred. These barriers contributed to delayed care, poorer treatment adherence and likelihood of poorer treatment outcomes. Patients proved resourceful and made adjustments in the face of (multiple) care challenges. Discussion and conclusion: We found that patient adaptiveness is an individualised process and relies on how well a patient is able to cope with circumstances in their environment. Bandura’s social cognitive theory further elaborates adaptation as a process where patients develop different mechanisms. For instance, patients create internal models based on successful management of past experiences/events to deal with current challenges (symbolising); or choose to avoid situations that cause distress (self-regulation); or observe and learn complex skills from others such as peers in support groups (vicarious learning). We found evidence of the development of such mechanisms, but it proved difficult to delineate them from the broader patient environment, which was characterised by a heavy reliance on family support and restricted access to resources in their external environment. These in turn influenced patient experiences and strategies for self-management. As Malawi strives towards attaining universal healthcare, affordability and access to NCD services through the public sector presents a formidable challenge, particularly for the rural parts of the country. We recommend introducing peer-patient and support group initiatives for patients with NCDs, and further investments in the decentralisation of integrated health services. Limitation: Our research focused on one rural district in Malawi, hence transferability of our findings to contexts with different characteristics, such as urban setting(s), should be taken into consideration.

Patients experiences of self-management and strategies for dealing with chronic conditions in rural Malawi.

BackgroundThe high burden of chronic communicable diseases such as HIV/AIDS, and an escalating rise of non-communicable diseases (NCDs) in Malawi and other sub-Saharan African countries, calls for a shift in how health care services are designed and delivered. Patient-centred care and patient self-management are critical elements in chronic care, and are advocated as universal strategies. In sub-Saharan Africa, there is need for more evidence around the practice of patient self-management, and how to best support patients with chronic conditions in the African context. Our study explored self-management practices of patients with different chronic conditions, and their strategies to overcome care challenges in a resource-constrained setting in Malawi.MethodsThis is primarily a qualitative study, involving patients with different chronic conditions from one rural district in Malawi. Data are drawn from semi-structured questions of a survey with 129 patients (from the third of four-part data collection series), 14 in-depth interviews, and four focus-group discussions with patients (n = 31 respondents). A framework approach was used for qualitative analysis, and descriptive statistical analysis was performed on survey data.ResultsPatients demonstrated ability to self-manage their conditions, though this varied between conditions, and was influenced by individual and external factors. Factors included: 1) ability to acquire appropriate disease knowledge; 2) poverty level; 3) the presence of support from family caregivers and community-based support initiatives; 4) the nature of one’s social relations; and 5) the ability to deal with stressors and stigma. NCD and HIV comorbid patients were more disadvantaged in their access to care, as they experienced frequent drug stock-outs and incurred additional costs when referred. These barriers contributed to delayed care, poorer treatment adherence, and likelihood of poorer treatment outcomes. Patients proved resourceful and made adjustments in the face of (multiple) care challenges.ConclusionOur findings complement other research on self-management experiences in chronically ill patients with its analysis on factors and barriers that influence patient self-management capacity in a resource-constrained setting. We recommend expanding current peer-patient and support group initiatives to patients with NCDs, and further investments in the decentralisation of integrated health services to primary care level in Malawi.

Land reforms and voluntary resettlement: household participation and attrition rates in Malawi

ABSTRACTThis paper examines the factors influencing household participation in and withdrawal from a World Bank-funded voluntary resettlement scheme moving 15,000 low-income farming households within and across rural districts in Malawi. Using a survey of 203 beneficiary households, focus groups and in-depth interviews, we identify a lack of access to land and conflict over land in the area of origin as salient participation factors in resettlement, while withdrawal factors include lower access to infrastructure and poor soil quality in resettlement areas. We also highlight limited prior awareness of actual conditions in resettlement areas, low and biased participation in the decision to move, a greater desire for formal land titles due to loss of customary entitlement as a result of resettlement, and widespread ambiguity and confusion over titles for resettled plots. In this context, we point to a pattern of ‘negative resettlement’, in which households remain resettled despite major grievances, for lack of an alternative option, contrasting with ‘positive resettlement’, where households remain by choice. We suggest that intra-district resettlement is more likely to be successful than inter-district resettlement when there is a risk of informed consent deficiency. These findings point to the relative failures of this particular resettlement scheme, and suggest possible improvements for land redistribution schemes from agro-industrial projects to poor households.

The economic burden of chronic non-communicable diseases in rural Malawi: an observational study.

BackgroundEvidence from population-based studies on the economic burden imposed by chronic non-communicable diseases (CNCDs) is still sparse in Sub-Saharan Africa. Our study aimed to fill this existing gap in knowledge by estimating both the household direct, indirect, and total costs incurred due to CNCDs and the economic burden households bear as a result of these costs in Malawi.MethodsThe study used data from the first round of a longitudinal household health survey conducted in 2012 in three rural districts in Malawi. A cost-of-illness method was applied to estimate the economic burden of CNCDs. Indicators of catastrophic spending and impoverishment were used to estimate the economic burden imposed by CNCDs on households.ResultsA total 475 out of 5643 interviewed individuals reported suffering from CNCDs. Mean total costs of all reported CNCDs were 1,040.82 MWK, of which 56.8 % was contributed by direct costs. Individuals affected by chronic cardiovascular conditions and chronic neuropsychiatric conditions bore the highest levels of direct, indirect, and total costs. Using a threshold of 10 % of household non-food expenditure, 21.3 % of all households with at least one household member reporting a CNCD and seeking care for such a condition incurred catastrophic spending due to CNCDs. The poorest households were more likely to incur catastrophic spending due to CNCDs. An additional 1.7 % of households reporting a CNCD fell under the international poverty line once considering direct costs due to CNCDs.ConclusionOur study showed that the economic burden of CNCDs is high, causes catastrophic spending, and aggravates poverty in rural Malawi, a country where in principle basic care for CNCDs should be offered free of charge at point of use through the provision of an Essential Health Package (EHP). Our findings further indicated that particularly high direct, indirect, and total costs were linked to specific diagnoses, although costs were high even for conditions targeted by the EHP. Our findings point at clear gaps in coverage in the current Malawian health system and call for further investments to ensure adequate affordable care for people suffering from CNCDs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1716-8) contains supplementary material, which is available to authorized users.

Applying a Reading Program Based on Cognitive Science in Rural Areas of Malawi: Preliminary Results

Reading fluency is a skill foundational to academic performance, and acquiring this skill in early grades is crucial. Throughout sub-Saharan Africa, reading levels of students are far below grade level, and Malawi is no exception. Research suggests that students, particularly in consistently spelled languages, acquire automaticity most easily by starting from individual letters, combining them in increasingly larger chunks, and getting plenty of practice in decoding them. Due to working memory capacity limits, students must attain a minimum reading speed in order to understand text. These concepts were tested in a rural district in Malawi. The study helps to explain the components of this science-based “learning package” needed for reading fluency. Volunteers held the classes in communities as an after school program for children from grades 1 to 5. The goal behind this innovative six-month program is students’ recognition of all letters used in Chichewa language and progress in text decoding. This study helps to explain the various components of the learning intervention and the results show that there has been improvement in knowledge of letter sounds. This study uses an already tried and tested cognitive neuroscience model, which was contextualized and implemented in the Malawi setting.

Social determinants of health: Social forces that shape women and men's knowledge of reproductive health in a resource-limited setting

abstractSocial forces shape people's reproductive health in many ways. We examined people's knowledge about reproductive health using focus group data collected from 93 participants in rural districts of Malawi. Participants' perspectives were contextualized by explaining the socioeconomic, cultural, and gender factors that determine reproductive health for rural Malawians. Strategies to improve reproductive health care in environments lacking in health infrastructure, staff, and economic resources are then provided. We call for a reproductive health agenda to target preventive care by providing information about anatomy and biology, communicating information in culturally competent ways, and educating men and women over the life course.

Living with disabled children in Malawi: Challenges and rewards.

BackgroundRehabilitation personnel need to be sensitive to the cultural aspects that constitute the environment of a disabled child’s family life.ObjectivesThe aim of this study was to gain insight on how families experience parenting of disabled children and how the families experience the support provided by the rehabilitation system in Malawi.MethodAn anthropological field study combining interviews and observations was conducted in a rural district of Malawi in 2011. Permission was granted to follow four families, and this study presents the stories of two families, whose children have severe disabilities. We used phenomenological and narrative analyses to make sense of the stories.ResultsThe findings indicate that families with disabled children invest time and emphasise care for their disabled children. They feel enriched by their experience despite challenging situations with little support from the rehabilitation services. High standards of care demonstrating positive and moral attitudes have earned these families respect in their communities. Storytelling has created an opportunity for the families to understand and interpret their challenging situation with inherent contextual meaning.ConclusionThis study shows that families with disabled children draw on cultural and structural strengths that rehabilitation professionals should be aware of in their support to mothers and other caregivers of children with disabilities.

Farmers and forest conservation in Malawi: the disconnect between attitudes, intentions and behaviour

Malawi’s unique flora and fauna are threatened by high levels of deforestation and forest degradation. In addition to the many ecosystem services provided by the country’s forests, most of the rural population of this poor country are highly dependent on forests for provision of food, firewood, medicine, building materials and income. This study examined farmers’ attitudes and behaviour in relation to cutting down forest trees in two rural districts in Malawi using the theory of planned behaviour as a conceptual framework. A survey was administered to 200 household heads in Mzimba and Chiradzulu districts. With strongly negative attitudes, subjective norms and perceived behavioural control, farmers were aware of the negative consequences associated with cutting down forest trees, the lack of social support and obstacles encountered when cutting down forest trees. The intention to cut down forest trees was generally low. However, farmers were highly dependent on forest resources, especially in the north, which is caused by high levels of poverty and a lack of alternative income opportunities. We conclude that poverty alleviation and livelihood diversification are crucial for addressing the overexploitation of forest trees in Malawi.

Agroforestry and deforestation in Malawi: inter-linkages between attitudes, beliefs and behaviours

Farm-level tree planting has been suggested to have potential to decrease pressures on natural forests and, consequently, contribute towards reducing deforestation and forest degradation. However, the scientific evidence for such a link is limited. We examined farmers’ beliefs, attitudes and behaviours in relation to tree planting on farms and cutting down trees from the forest, as one way of establishing this link. A household survey was administered to 200 farmers in two rural districts in Malawi, which included an attitude scale based on the theory of planned behaviour. The results showed that farmers in Malawi recognise the benefits of planting trees, feel encouraged by fellow farmers, and feel capable of planting trees on their land. In addition, they believe cutting down trees from the forest will result in mainly negative outcomes, and feel discouraged by others and hindered by control factors to cut down trees from the forest. In total, 76 % of respondents planted trees in the past 5 years, 50 % collected firewood from the forest and 21 % collected poles. There was no evidence for a direct relationship between attitudes towards planting trees and cutting down trees, nor were the behaviours in relation to tree planting and cutting down trees from the forest significantly associated. However, there was evidence for an indirect relationship between tree planting behaviour and cutting down trees from the forest, as respondents who had planted trees had more negative attitudes towards cutting down trees from the forest. Future research should further explore the direct relationship between agroforestry and deforestation to establish if and under what conditions such a relationship might exist.

Dynamics of community participation, student achievement and school management: the case of primary schools in a rural area of Malawi

School management in many sub-Saharan African countries has been enhanced through community participation in an attempt to improve education quality. This study uses field research in a rural district of Malawi to assess how community and parent participation differs between schools, the intentions of communities and parents when carrying out activities in schools, and the mechanism promoting active participation in schools. In high-achieving schools, but not in low-achieving schools, communities and parents were actively involved in events aimed at improving student achievement. Communities and parents considered most highly prioritised activities that directly influenced student achievement, including hiring volunteer teachers, arranging extra classes and holding mock examinations. Community participation did not directly improve student achievement. Instead, when communities and parents actively participated in a school, school management improved, ensuring better student achievement. The implications of this finding are discussed in relation to community participation.

Water, Sanitation and Hygiene (WASH) and Breastfeeding Contribute to Child Stunting in Rural Malawi

Evidence linking water, sanitation and hygiene (WASH) to stunting has been mixed but constitutes a possibly important contributor to chronic undernutrition in low and middle income countries. Using cross‐sectional baseline data of an impact evaluation of a nutrition program targeted at reducing maternal and child undernutrition, we assessed the extent to which optimal WASH practices contribute to reduced odds of stunting (length‐for‐age z‐score <‐2 SD) among children 6 to 24 months of age living in two rural districts of Malawi. We used multivariable logistic regression with robust standard error estimation to measure the relationship between stunting and a composite of six WASH indicators (measured as an unweighted score ranging from 0‐11, with scores of 0, 1 or 2 assigned for levels of optimal water source and treatment, sanitation facility and cleanliness, handwashing with soap, and safe disposal of child feces), controlling for potential health, dietary, and socioeconomic confounders. 53% of children were stunted in this population. The median (IQR) of the WASH score was 5.5 (4‐6). A high WASH score (蠅8) (OR=0.71, 95% CI 0.51‐1.00) and breastfeeding 蠅10 times per day in the last 7 days (OR=0.50, 95% CI 0.27‐0.92) were associated with a reduced odds of stunting in an adjusted analysis; diarrhea, child age, sex, and maternal education, were all significantly associated with stunting in this population. Integration of WASH and infant and young child feeding interventions in nutrition programs may contribute to reductions in stunting in Malawi. Funded by the Children's Investment Fund Foundation, UK.

Out-of-pocket expenditure on chronic non-communicable diseases in sub-Saharan Africa: the case of rural Malawi.

In Sub-Saharan Africa (SSA) the disease burden of chronic non-communicable diseases (CNCDs) is rising considerably. Given weaknesses in existing financial arrangements across SSA, expenditure on CNCDs is often borne directly by patients through out-of-pocket (OOP) payments. This study explored patterns and determinants of OOP expenditure on CNCDs in Malawi. We used data from the first round of a longitudinal household health survey conducted in 2012 on a sample of 1199 households in three rural districts in Malawi. We used a two-part model to analyze determinants of OOP expenditure on CNCDs. 475 respondents reported at least one CNCD. More than 60% of the 298 individuals who reported seeking care incurred OOP expenditure. The amount of OOP expenditure on CNCDs comprised 22% of their monthly per capita household expenditure. The poorer the household, the higher proportion of their monthly per capita household expenditure was spent on CNCDs. Higher severity of disease was significantly associated with an increased likelihood of incurring OOP expenditure. Use of formal care was negatively associated with the possibility of incurring OOP expenditure. The following factors were positively associated with the amount of OOP expenditure: being female, Alomwe and household head, longer duration of disease, CNCDs targeted through active screening programs, higher socio-economic status, household head being literate, using formal care, and fewer household members living with a CNCD within a household. Our study showed that, in spite of a context where care for CNCDs should in principle be available free of charge at point of use, OOP payments impose a considerable financial burden on rural households, especially among the poorest. This suggests the existence of important gaps in financial protection in the current coverage policy.