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Background: Genital ulcer diseases (GUDs) are a common syndrome associated with sexually transmitted infections. Genital ulcer diseases increase the risk of HIV transmission, necessitating appropriate diagnosis and treatment. We provide an updated GUD etiology assessment in Malawi to guide diagnostic development and treatment algorithms., Methods: We enrolled patients 18 years or older presenting with GUD at a sexually transmitted infection clinic in Lilongwe, Malawi, between May and October 2021. We purposively sampled by HIV status. Swabs of ulcers were tested for Treponema pallidum, herpes simplex virus (HSV)-1 and HSV-2, Haemophilus ducreyi, and Chlamydia trachomatis using polymerase chain reaction. Blood was collected for syphilis and HSV-2 serologies and acute HIV testing. Participants were treated per Malawi guidelines. Ulcer resolution (size reduced by >50%) was evaluated 14 days later., Results: Fifty participants enrolled (30 without HIV, 2 with acute HIV infection, 18 with HIV seropositivity; 32 men, 18 women). Forty-six (92%) had an etiology identified. Syphilis was more common among those without HIV (22 of 30 [73%]) than participants with HIV (PWH; 8 of 20 [40%]; P = 0.04). Herpes simplex virus was more common among PWH (11 of 20 [55%]) than participants without (2 of 30 [7%]; P = 0.0002). One-fifth (9 of 50 [18%]) had H. ducreyi. Among those who returned for follow-up (n = 45), 9 (20%) had unresolved ulcers; persistent GUD was slightly more common in PWH (6 of 19 [32%]) than participants without (3 of 26 [12%]; P = 0.14)., Conclusions: We observed a dramatic increase in syphilis ulcer proportion in a population whose GUDs were previously HSV predominant. Observed differences in etiology and resolution by HIV status could play an important role in the ongoing transmission and treatment evaluation of GUD., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Option 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., Methods: We 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., Results: Women 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., Conclusion: This 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., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Advances in trauma care in high-income countries have significantly reduced late deaths following trauma, challenging the classical trimodal pattern of trauma-associated mortality. While studies from low and middle-income countries have demonstrated that the trimodal pattern is still occurring in many regions, there is a lack of data from sub-Saharan Africa evaluating the temporal epidemiology of trauma deaths., Methods: We conducted a retrospective analysis of the trauma registry at Kamuzu Central Hospital in Lilongwe, Malawi, including all injured patients presenting to the emergency department (ED) from 2009 to 2021. Patients were compared based on timing of death relative to time of injury. We then used a modified Poisson regression model to identify adjusted predictors for early mortality compared to late mortality., Results: Crude mortality of patients presenting to the ED in the study period was 2.4% (n = 4,096/165,324). Most patients experienced a pre-hospital death (n = 2,330, 56.9%), followed by death in the ED (n = 619, 15.1%). Early death (pre-hospital or ED) was associated with transportation by police (RR1.52, 95% CI 1.38, 1.68) or private vehicle (RR1.20, 95% CI 1.07, 1.31), vehicle-related trauma (RR1.10, 95% CI 1.05, 1.14), and penetrating injury (RR1.11, 95% CI 1.04, 1.19). Ambulance transportation was associated with a 40% decrease in the risk of early death., Conclusions: At a busy tertiary trauma center in Malawi, most trauma-associated deaths occur within 48 h of injury, with most in the pre-hospital setting. To improve clinical outcomes for trauma patients in this environment, substantial investment in pre-hospital care is required through first-responder training and EMS infrastructure., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Introduction: Sex disparities in access to health care in low-resource settings have been demonstrated. Still, there has been little research on the effect of sex on postoperative outcomes. We evaluated the relationship between sex and mortality after emergency abdominal surgery., Methods: We performed a retrospective cohort study using the acute care surgery database at Kamuzu Central Hospital (KCH) in Malawi. We included patients who underwent emergency abdominal surgery between 2013 and 2021. We created a propensity score weighted Cox proportional hazards model to assess the relationship between sex and inpatient survival., Results: We included 2052 patients in the study, and 76% were males. The most common admission diagnosis in both groups was bowel obstruction. Females had a higher admission shock index than males (0.91 vs. 0.81, p < 0.001) and a longer delay from admission until surgery (1.47 vs. 0.79 days, p < 0.001). Females and males had similar crude postoperative mortality (16.3% vs. 15.3%, p = 0.621). The final Cox proportional hazards regression model was based on the propensity-weighted cohort. The mortality hazard ratio was 0.65 among females compared to males (95% CI 0.46-0.92, p = 0.014)., Conclusions: Our results show a survival advantage among female patients undergoing emergency abdominal surgery despite sex-based disparities in access to surgical care that favors males. Further research is needed to understand the mechanisms underlying these findings., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Purpose: While mental health stigma research is sparse in Malawi, research in other settings suggests that stigma represents a barrier to mental health treatment and recovery. Accordingly, we conducted an analysis to understand the role of treatment-related stigma in depression care in Malawi by estimating the effect of patients' baseline anticipated treatment-related stigma on their 3-month probability of depression remission when newly identified with depression., Methods: We conducted depression screening and treatment at 10 noncommunicable disease (NCD) clinics across Malawi from April 2019 through December 2021. Eligible cohort participants were 18-65 years with depressive symptoms indicated by a PHQ-9 score ≥5. Questionnaires at the baseline and 3-month interviews included a vignette-based quantitative stigma instrument that measured treatment-related stigma, i.e., concerns about external stigma because of receiving depression treatment. Using inverse probability weighting to adjust for confounding and multiple imputation to account for missing data, this analysis relates participants' baseline levels of anticipated treatment stigma to the 3-month probability of achieving depression remission (i.e., PHQ-9 score < 5)., Results: Of 743 included participants, 273 (37%) achieved depression remission by their 3-month interview. The probability of achieving depression remission at the 3-month interview among participants with high anticipated treatment stigma (0.31; 95% Confidence Interval [CI]: 0.23, 0.39)) was 10 percentage points lower than among the low/neutral stigma group (risk: 0.41; 95% CI: 0.36, 0.45; RD: -0.10; 95% CI: -0.19, -0.003)., Conclusion: In Malawi, a reduction in anticipated depression treatment-related stigma among NCD patients initiating depression treatment could improve depression outcomes. Further investigation is necessary to understand the modes by which stigma can be successfully reduced to improve mental health outcomes and quality of life among people living with depression., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Background: Trauma scoring systems can identify patients who should be transferred to referral hospitals, but their utility in LMICs is often limited. The Malawi Trauma Score (MTS) reliably predicts mortality at referral hospitals but has not been studied at district hospitals. We sought to validate the MTS at a Malawi district hospital and evaluate whether MTS is predictive of transfer to a referral hospital., Methods: We performed a retrospective study using trauma registry data from Salima District Hospital (SDH) from 2017 to 2021. We excluded patients brought in dead, discharged from the Casualty Department, or missing data needed to calculate MTS. We used logistic regression modeling to study the relationship between MTS and mortality at SDH and between MTS and transfer to a referral hospital. We used receiver operating characteristic analysis to validate the MTS as a predictor of mortality., Results: We included 2196 patients (84.3% discharged, 12.7% transferred, 3.0% died). These groups had similar ages, sex, and admission vitals. Mean (SD) MTS was 7.9(3.0) among discharged patients, 8.4(3.9) among transferred patients, and 14.2(8.0) among patients who died (p < 0.001). Higher MTS was associated with increased odds of mortality at SDH (OR 1.21, 95% CI 1.14-1.29, p < 0.001) but was not related to transfer. ROC area for mortality was 0.73 (95% CI 0.65-0.80)., Conclusions: MTS is predictive of district hospital mortality but not inter-facility transfer. We suggest that MTS be used to identify patients with severe trauma who are most likely to benefit from transfer to a referral hospital., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Background: Perinatal depression (PND) is prevalent and negatively impacts HIV care among women living with HIV (WLHIV), yet PND remains under-identified in Malawian WLHIV. Accordingly, this formative study explored perceptions of the feasibility and acceptability of an integrated, task-shifted approach to PND screening and treatment in maternity clinics., Methods: We completed consecutive PND screenings of HIV+ women attending pre- or post-natal appointments at 5 clinics in Lilongwe district, Malawi. We conducted in-depth interviews with the first 4-5 women presenting with PND per site (n = 24 total) from July to August 2018. PND classification was based on a score ≥ 10 on the Edinburgh Postnatal Depression Scale (EPDS). We conducted 10 additional in-depth interviews with HIV and mental health providers at the 5 clinics., Results: Most participants endorsed the feasibility of integrated PND screening, as they believed that PND had potential for significant morbidity. Among providers, identified barriers to screening were negative staff attitudes toward additional work, inadequate staffing numbers and time constraints. Suggested solutions to barriers were health worker training, supervision, and a brief screening tool. Patient-centered counselling strategies were favored over medication by WLHIV as the acceptable treatment of choice, with providers supporting the role of medication to be restricted to severe depression. Providers identified nurses as the most suitable health workers to deliver task-shifted interventions and emphasized further training as a requirement to ensure successful task shifting., Conclusion: Improving PND in a simple, task-shifted intervention is essential for supporting mental health among women with PND and HIV. Our results suggest that an effective PND intervention for this population should include a brief, streamlined PND screening questionnaire and individualized counselling for those who have PND, with supplemental support groups and depression medication readily available. These study results support the development of a PND intervention to address the gap in treatment of PND and HIV among WLHIV in Malawi., (© 2022. The Author(s).)

Introduction: Drowning is a public health problem that is under-reported in Africa. We sought to evaluate the epidemiology and risk factors for drownings in Malawi., Methods: We performed a retrospective review of all pediatric (≤15 years old) patients who presented following a drowning incident to Kamuzu Central Hospital in Lilongwe, Malawi, from 2009-19. Demographics and outcomes were compared between survivors and non-survivors. Logistic multivariate regression analysis was used to identify factors associated with increased odds of mortality., Results: There were 156 pediatric drowning victims during the study period. The median age at presentation was 3 (IQR: 2-7 years). Survivors were younger [median age: 2 years (IQR: 2-5) vs. 5 years (IQR: 2-10), p = 0.004], with a higher proportion of drownings occurring at home (85.6% vs. 58.3%, p = 0.001) compared to non-survivors. Patients who had a drowning event at a public space had increased odds of mortality (OR 8.17, 95% CI 2.34-28.6). Patients who were transferred (OR 0.03, 95% CI 0.003-0.25) and had other injuries (OR 0.20, 95% CI 0.06-0.70) had decreased odds of mortality following drowning., Conclusion: Over half of pediatric drowning victims at a tertiary-care facility in Malawi survived. Drowning survivors were significantly younger, more likely to have drowned at home, and transported by private vehicles and minibus than non-survivors. There is a need for scalable, cost-effective drowning prevention strategies that focus on water safety education and training community members and police officers in basic life support and resuscitation., (© The Author(s) [2022]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: There are no validated tools in Malawi to measure mental health stigma. Accordingly, this study evaluates the validity and reliability of a short quantitative instrument to measure depression-related stigma in patients exhibiting depressive symptoms in Malawi., Methods: The SHARP study began depression screening in 10 NCD clinics across Malawi in April 2019; recruitment is ongoing. Eligible participants were 18-65 years, had a patient health questionnaire (PHQ-9) score ≥ 5, and were new or current diabetes or hypertension patients. Participants completed a baseline questionnaire that measured depression-related stigma, depressive symptoms, and sociodemographic information. The stigma instrument included a vignette of a depressed woman named Thandi, and participants rated their level of agreement with statements about Thandi's situation in nine prompts on a 5-point Likert scale. Inter-item reliability was assessed with Cronbach's alpha. Exploratory factor analysis (EFA) was used to assess structural validity, and OLS regression models were used to assess convergent and divergent validity between measured levels of depression-related stigma and covariates., Results: The analysis of patient responses (n = 688) to the stigma tool demonstrated acceptable inter-item reliability across all scales and subsequent subscales of the instrument, with alpha values ranging from 0.70 to 0.87. The EFA demonstrated clustering around three domains: negative affect, treatment carryover, and disclosure carryover. Regression models demonstrated convergence with several covariates and demonstrated divergence as expected., Conclusion: This study supports the reliability and validity of a short stigma questionnaire in this population. Future studies should continue to assess the validity of this stigma instrument in this population., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: Inguinal hernias are one of the most common surgical conditions worldwide. Due to limited surgical access in low- and middle-income countries, many hernias present emergently; however, data on the resultant outcome disparities is limited. We, therefore, sought to describe the epidemiology, clinical features, and outcomes of incarcerated inguinal hernias at a tertiary center in Malawi., Methods: This is a retrospective analysis of the acute care surgery registry at Kamuzu Central Hospital in Lilongwe, Malawi. All patients > 13 years admitted with a non-reducible inguinal hernia from 2013 to 2019 were included. The primary outcome was in-hospital mortality. A Poisson multivariable regression determined factors associated with increased risk of mortality., Results: A total of 297 patients presented with non-reducible inguinal hernias, the majority of which were young (median age 38), male (93.6%), farmers (47.8%). Of the 81% who underwent surgery, 55% were delayed ≥ 24 h. 19.5% of hernias were strangulated. Overall mortality was 5.4%. Increased age (RR 1.06, 95% CI 1.01-1.12), shock index ≥ 1 (RR 4.82, 95% CI 1.45-16.09), and delay ≥ 24 h from presentation to operative intervention (RR 11.24, 95% CI 1.55-81.34) resulted in an increase in relative risk of mortality., Conclusion: Non-reducible inguinal hernias largely affect young male farmers in Malawi. Delays to care can limit economic productivity for this rural population, as well as, yield considerable risk of mortality. While specific patient and institutional factors must be further elucidated, increased awareness, public health prioritization, and surgical capacity building is needed to reduce further hernia-related morbidity and mortality., (© 2020. Springer-Verlag France SAS, part of Springer Nature.)

Introduction: As a proportion of the overall population, sub-Saharan Africa (SSA) has the highest youth demographic, composing 60% of Africa's unemployed. With the worsening economic crisis in low- and middle-income countries, unengaged youth are susceptible to gang violence and anti-government demonstrations, resulting in political instability., Methods: We performed a retrospective review of the Kamuzu Central Hospital Trauma Registry from 2008-2018. All adult patients (>14 years) injured by interpersonal violence (IPV) were included. Age was categorized as 15-24 (youth), 25-45, and >45 years. A bivariate analysis (IPV versus unintentional injury), and Poisson multivariable analysis were performed to identify factors increasing the risk of IPV., Results: During the study, 87,338 trauma patients presented; 30,532 (35.0%) were injured following IPV. Patients injured following IPV (28 years, IQR 23-34) were younger than those unintentionally injured (30 years, IQR 23-39, p < 0.001). More patients injured following IPV were unemployed (n = 7,178, 23.6% vs. n = 10,148, 17.9%, p < 0.001), injured at night (n = 19,346, 63.7% vs. n = 10,148, 17.9%, p < 0.001), and reported alcohol use (n = 4.973, 16.4% vs n = 2,461, 4.4%, p < 0.001). Being unemployed (RR 1.25, 95% CI 1.22-1.27), youth compared to age >45 years (RR 1.72, 1.66-1.79), and those injured at night (RR 2.18, 95% CI 2.14-2.23) had increased the risk of being victims of IPV., Conclusion: In Malawi, there is an interrelationship between unemployment and IPV, particularly in the youth population. Given impending demographic realities, government and non-government organizations should prioritize youth employment to help defer political instability in vulnerable nation-states.

Background: In sub-Saharan Africa, trauma is a leading cause of mortality in people less than 45 years. Injury mechanism and cause of death are difficult to characterize in the absence of pre-hospital care and a trauma surveillance database. Pre-hospital deaths (PHD) and in-hospital deaths (IHD) of trauma patient were compared to elucidate comprehensive injury characteristics associated with mortality., Methods: A retrospective, descriptive analysis of adults (≥ 13 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi, from February 2008 to May 2018 was performed. Utilizing an emergency department-based trauma surveillance database, univariate and bivariate analysis was performed to compare patient and injury characteristics of pre-hospital and in-hospital deaths. A Poisson multivariate regression was performed, predicting the relative risk of PHD., Results: Between February 2008 and May 2018, 131,020 adult trauma patients presented to KCH, with 2007 fatalities. Of those patients, 1130 (56.3%) and 877 (43.7%) were PHD and IHD, respectively. The majority were men, with a mean age of 33.4 years (SD 12.1) for PHD and 37.4 years (SD 15.5) for IHD, (p < 0.001). Head injuries (n = 545, 49.2% vs. n = 435, 49.7%) due to assaults (n = 255, 24.7% vs. n = 178, 21.8%) and motor vehicle collisions (MVC) (n = 188, 18.2% vs. n = 173, 21.2%) were the leading cause of both groups (PHD vs. IHD). Transportation to the hospital was primarily police (n = 663, 60.1%) for PHD and ambulance (n = 401, 46.4%) for IHD. Patients who were transported to KCH by the police (RR 1.97, 95% 1.52-2.55, p < 0.001) when compared to transport via minibus had an increased relative risk of PHD. Patients with a head or spine (RR 1.32, 95% CI 1.34-1.53, p < 0.001), chest (RR 1.34, 95% CI 1.11-1.62, p = 0.002) or abdomen and pelvis (RR 1.30, 95% CI 1.14-1.53, p = 0.004) when compared to extremity injury had an increased relative risk of PHD., Conclusions: Head injury from assaults and MVC is the leading cause of PHD and IHD in Malawi. The majority of patients are transported via police if PHD. Of IHD patients, the majority are transported by ambulance, most often from outside hospitals. Both are consistent with the absence of a pre-hospital system in Malawi. Improving pre-hospital care, with a particular focus on head injury and strategies for vehicular injury prevention within a trauma system, will reduce adult trauma mortality in Malawi.

Background: Perinatal depression (PND) can interfere with HIV care engagement and outcomes. We examined experiences of PND among women living with HIV (WLWH) in Malawi., Methods: We screened 73 WLWH presenting for perinatal care in Lilongwe, Malawi using the Edinburgh Postnatal Depression Scale (EPDS). We conducted qualitative interviews with 24 women experiencing PND and analyzed data using inductive and deductive coding and narrative analysis., Results: Women experienced a double burden of physical and mental illness, expressed as pain in one's heart. Receiving an HIV diagnosis unexpectedly during antenatal care was a key contributor to developing PND. This development was influenced by stigmatization and social support., Conclusions: These findings highlight the need to recognize the mental health implications of routine screening for HIV and to routinely screen and treat PND among WLWH. Culturally appropriate mental health interventions are needed in settings with a high HIV burden., Competing Interests: The authors have declared that no competing interests exist.

Introduction: There is a paucity of data regarding sex-based disparities in surgical care delivery, particularly in low- and middle-income countries. This study sought to determine whether sex disparities are present among patients presenting with surgical conditions in Malawi. Hypothesis compared to men, fewer women present to Kamuzu Central Hospital (KCH) with peritonitis and have longer delays in presentation for definitive care., Methods: This study performs a retrospective analysis of prospectively collected data of all general surgery patients with peritonitis presenting to KCH in Lilongwe, Malawi, from September 2013 to April 2016. Multivariable linear and logistic regressions were used to assess the effect of sex on mortality, length of stay, operative intervention, complications, and time to presentation., Results: Of 462 patients presenting with general surgery conditions and peritonitis, 68.8% were men and 31.2% were women. After adjustments, women had significantly higher odds of non-operative management when compared to men (OR 2.17, 95%CI 1.30-3.62, P = 0.003), delays in presentation (adjusted mean difference 136 h, 95%CI 100-641, P = 0.05), delays to operation (adjusted mean difference 1.91 days, 95%CI 1.12-3.27, P = 0.02), and longer lengths of stay (adjusted mean difference 1.67 days, 95%CI 1.00-2.80, P = 0.05). There were no differences in complications or in-hospital or Emergency Department mortality., Conclusion: Sex disparities exist within the general surgery population at KCH in Lilongwe, Malawi. Fewer women present with surgical problems, and women experience delays in presentation, longer lengths of stay, and undergo fewer operations. Future studies to determine mortality in the community and driving factors of sex disparities will provide more insight.

The World Health Organization has selected Malawi as one of three sites to pilot the roll-out of RTS,S/AS01 in phase 4 trials. As policy discussions for the expanded use of RTS,S/AS01 continue, it will be critical to determine the performance of the vaccine according to seasonal patterns of malaria transmission in regions of Africa. Given waning vaccine efficacy over time, this secondary analysis demonstrates that administering the vaccine to children in the months prior to malaria season could maximize impact of the vaccine. We followed children (5-17 months) and infants (6-12 weeks) assigned to one of three groups: (1) vaccine with four doses; (2) vaccine with three doses; (3) control. The primary endpoint was defined as episodes of clinical malaria. During the 4-years of follow-up, 658 of 1544 (42.6%) children and infants had at least one episode of clinical malaria. With each 1-inch increase in rainfall per month there was an associated increase in the rate of malaria by 12.6% (95% CI 9.6%, 15.6%, P < 0.0001) among children and 15.9% (95% CI 12.8%, 18.9%, P < 0.0001) among infants. There was no evidence of effect modification of vaccine efficacy by precipitation (89% power).

Objective: To validate the use of photographic burn wound assessment in evaluation of burn size and wound characteristics., Methods: Feasibility study of agreement between methods of measurement of burn size and characteristics, in patients admitted to the burn unit at Kamuzu Central Hospital (KCH), Malawi, over two months in 2011. Burn wounds were photographed and assessed clinically, concurrently, by an experienced clinician. Photographs reviewed by two blinded burn clinicians after 4-6 weeks. Correlation between clinical assessment and photographic evaluation was calculated using kappa score and Pearson's correlation coefficient., Results: Thirty-nine patients were included in evaluation of TBSA, and fifty wounds assessed for their characteristics. Pearson's correlation coefficient for agreement of TBSA between clinical exam and photograph review by expert#1, and #2, was 0.96, 0.93 (p<0.001), respectively. Pearson's correlation coefficients comparing expert#1 and #2 to the gold standard were: proportion of full-thickness burn (0.88 and 0.81, p<0.001), and epithelialized superficial burn (0.89 and 0.55, p<0.001). Kappa scores were significant for wound evolution (expert#1 0.57, expert#2 0.64, p<0.001), and prognosis (expert#1 0.80, expert#2 0.80, p<0.001)., Conclusions: Burn assessment with digital photography is a valid and affordable alternative to direct clinical exam, alleviating access issues to burn care in developing countries., (Copyright © 2012 Elsevier Ltd and ISBI. All rights reserved.)

Aim: Like most of sub-Saharan Africa, Malawi suffers from a paucity of human resources in the health sector. With an average of one physician for every 50,000 persons, and a health care professional to in-patient population ratio of 1:277, patient care suffers. At Kamuzu Central Hospital (KCH) of Lilongwe, Malawi, family members, termed Hospital Guardians, are utilized to provide basic care for patients. The aim of our study is to characterize this population and explore their role in the health care system of KCH., Methods: Seventy three semi-qualitative surveys and nineteen in-depth interviews were conducted with hospital administrators, Guardians, nurses, and physicians from these wards. The results were analyzed using descriptive analysis and emergent coding., Results: It was found that Hospital Guardians were primarily female family members of patients and have a low literacy rate. They performed a wide range of daily tasks in patient care from wound care to advocacy. Despite their essential role in the health care system, the Guardians were provided with little support from the hospital. There was often conflict between the Guardians and hospital personnel due to overcrowding with more than one Guardian per patient; a lack of understanding of hospital rules and regulations; and a lack of respect for the Guardian role by hospital staff., Conclusions: Until their role can be reduced by additional trained health care professionals, patient care could be improved by institutional support including a clarification of the role of the Hospital Guardians. Recommendations include a one-patient one-guardian policy; Guardian education; and enhancing Guardian resources.