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Background: Reaching all people with HIV services, including traders in the informal economy, is critical to meeting UNAIDS’ 95-95-95 goals. However, traders prioritise their business over attendance at health facilities. This limits their access to health services. This study explores market traders’ preferences for the potential type and delivery methods of HIV services at Lilongwe Central market. Method: The study used an exploratory qualitative study design in Lilongwe, Malawi. Sixteen in-depth interviews were conducted among traders at Lilongwe Central market between June and September 2022. In the same period, we also conducted four key informant interviews involving three officers responsible for HIV services at the district and council levels, and the market chairman. Results: HIV services preferred by market traders include HIV testing, antiretroviral therapy, condom dispensation, voluntary medical male circumcision and HIV awareness campaigns. These services should be offered daily or when the market is less crowded, and they could be delivered either in the market or a health facility setting. These services can be provided by both lay and health workers, depending on traders’ preferences, and must be integrated with other health services to mitigate unintended HIV status disclosure concerns. Conclusion: The achievement of UNAIDS’ 95-95-95 goals by 2030 requires that HIV services should be available to all those who require them at times and locations that are convenient for them, through providers they have chosen, and provided as either integrated or standalone services depending on the target group’s perception of the role of these two models in mitigating stigma. This will necessitate the development of new approaches targeting underserved groups, such as traders in markets.

Background Expressed breastmilk (EBM) can support lactation for mothers of preterm infants with underdeveloped feeding skills. However, there may be implementation challenges in resource-limited global health settings. Objective To explore EBM barriers and facilitators perceived by caregivers and healthcare workers in Malawi. Methods A secondary analysis of in-depth interviews exploring breastfeeding support at health facilities conducted at three secondary-level district hospitals and one tertiary-level central hospital in southern Malawi. Interviews underwent content analysis in NVivo 12 (QSR International, Melbourne, Australia). Results There were 58 healthcare workers and 54 caregivers interviewed. Caregiver unfamiliarity, maternal exhaustion, and inadequate clinical support/equipment were barriers to EBM practice. Caregiver acceptance was supported by witnessing infant growth. Demonstrations of EBM by healthcare workers and family support also facilitated practice. Conclusion Raising community awareness and extending counselling to family members upon initiation are vital to supporting mothers practice EBM in resource-limited global health settings with chronic staffing shortages.

IntroductionDespite recommendation that all women receive an ultrasound in pregnancy prior to 24 weeks', this remains unavailable to many women in low-income countries where trained practitioners are scarce. Although many programmes have demonstrated efficacy, few have achieved longterm sustainability, with a lack of information about how best to implement such programmes. This mixed-methods study aimed to evaluate the implementation of a novel education package to teach ultrasound-naive midwives in Malawi basic obstetric ultrasound, assessing its impact in the context of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework.MethodsThe study ran across six sites in Malawi between October 2020 and June 2021, encompassing three phases; pre-implementation, implementation and post-implementation. Twenty nine midwives underwent a bespoke education package with matched pre and post course surveys assessed their knowledge, attitudes and confidence and “hands on” assessments evaluating practical skills. Training evaluation forms and in-depth interviews explored their satisfaction with the package, with repeat assessment and remote image review evaluating maintenance of skills.Results28/29 midwives completed the training, with significant increases in knowledge, confidence and practical skills. Adherence to the education package varied, however many changes to the proposed methodology were adaptive and appeared to facilitate the efficacy of the programme. Unfortunately, despite reporting approval regarding the training itself, satisfaction regarding supervision and follow up was mixed, reflecting the difficulties encountered with providing ongoing in-person and remote support.ConclusionThis programme was successful in improving trainees' knowledge, confidence and skill in performing basic obstetric ultrasound, largely on account of an adaptive approach to implementation. The maintenance of ongoing support was challenging, reflected by trainee dissatisfaction. By evaluating the success of this education package based on its implementation and not just its efficacy, we have generated new insights into the barriers to sustainable upscale, specifically those surrounding maintenance.

UNAIDS Fast-Track goals for 2025 include ensuring that 95% of the people with HIV know their HIV status. In 2019, the Malawi Ministry of Health introduced its approach for achieving this: an active index testing (AIT) policy with assisted partner notification services (APNS). Under this policy, health centers can actively reach out to a contact of newly-diagnosed HIV positive client (the index) to offer voluntary HIV testing services. However, APNS uptake has been sub-optimal at many health facilities. This qualitative study considers strategies to optimize the uptake of APNS among newly-diagnosed HIV positive clients at Ndirande Health Center in Blantyre, Malawi. We conducted in-depth interviews, between February and April 2020, with 24 participants, including new HIV positive index clients, their sexual partners, and key health workers. We employ a maximum variation purposive sampling technique. Thematic inductive and deductive data analysis was done manually according to the social-ecological model. Interviewees discussed various strategies for optimizing APNS uptake among newly diagnosed HIV-infected clients. Interpersonal strategies included maximizing the use of client profiling techniques and sensitization on APNS to create demand. Institutional-level strategies were also suggested, such as providing transportation for home visits, strengthening referral notification approaches, and additional training for health workers. Policy-level recommendations included introducing home-based partner testing and intensifying use of partner notification slips. APNS is a key strategy to maximize HIV case identification. However, achieving optimal APNS in Malawi requires strengthening existing strategies and conducting additional research to identify other APNS strategies tailored to the local context.

Decentralization of health services entails empowering local governments to take the lead on decision-making and governance of health services provided in their districts. If managed properly, decentralization has the potential to strengthen governance, leadership, management, and accountability of the district health system; improve efficiency and responsiveness of the district healthcare system at all levels; and increase investments in human capital. Undergoing decentralization since 1998, Malawi has made significant progress in devolving human resources for health (health workforce), strengthening governance and leadership, and enhancing accountability through devolved health financing and health information systems. However, challenges remain, including lack of clarity on the roles, responsibilities, and the decision-making process within the context of decentralization, insufficiency of funds, and insufficient human resources for health. Using human resources for health as an entry point, and the case example of Malawi, this chapter demonstrates that systems thinking offers a useful framework through which to understand the process of decentralization in a particular context.

Background Corona Virus disease 2019 (COVID-19) pandemic continues to have serious health and socio-economic consequences. World Health Organisation (WHO) recommends several measures to combat the COVID-19 pandemic. In Malawi, COVID-19 cases are managed at home with hospital admission reserved for severe cases. This study described the lived experiences of caregivers of COVID-19-infected individuals in Blantyre, Malawi. Methods This descriptive qualitative study was conducted from January to June 2021 in Blantyre Malawi, among caregivers of confirmed SARS-COV-2 cases enrolled in the SARS-CoV-2 study aimed to explore infections, transmission dynamics, and household impact. We conducted 37 in-depth interviews with caregivers of SARS-COV-2 cases. We captured data using telephonic interviews, digitally recorded, transcribed verbatim, managed using NVivo, and analysed thematically. Results The economic status of a family largely influenced the caregiving roles and abilities because it determined the resources that a household could access or not. Caregivers were committed to their role despite being ill-prepared to manage a COVID-19 patient at home in addition to fears about the contagious nature of COVID-19. They prioritised their patients’ health by ensuring that they were present to offer nutritional and medical treatment. The implementation of preventive measures was however challenging because of financial limitations and cultural factors. The increase in death rates and the lack of proper information challenged their expectation of having their patients healed. Caregivers managed their role by sharing responsibilities, getting better at their role with time, and also getting support from religious institutions and social networks. Conclusion The economic status of a household determined the experiences of caregivers as they managed their COVID-19 patients at home. Caring for confirmed cases of COVID-19 demanded commitment from the caregivers while ensuring that the transmission of the virus is minimised. There is a need to support households while in isolation with the right information on how to manage their patients and streamline social support for the ultra-poor.

Introduction Kangaroo mother care is known to help save the lives of preterm and low birthweight infants, particularly in resource-limited health settings, yet barriers to implementation have been documented. Mothers and their families are very involved in the process of providing kangaroo mother care and the impact on their well-being has not been well explored. The objective of this research was to investigate the perspectives and experiences of a mother’s quality of life while delivering facility-based kangaroo mother care. Methods This study is a secondary analysis of the qualitative data collected within the “Integrating a neonatal healthcare package for Malawi” project. Twenty-seven health workers and 24 caregivers engaged with kangaroo mother care at four hospitals in southern Malawi were interviewed between May–August 2019. All interviews were face-to-face and followed a topic guide. Content analysis was conducted on NVivo 12 (QSR International, Melbourne, Australia) based on the six World Health Organization Quality of Life domains (physical, psychological, level of independence, social relationships, environment, spirituality). Results Fifty-one interviews were conducted with 24 caregivers and 14 health workers. Mothers experienced multidimensional challenges to their quality of life while delivering facility-based KMC. Though kangaroo mother care was considered a simple intervention, participants highlighted that continuous kangaroo mother care was difficult to practice. Kangaroo mother care was an exhausting experience for mothers due to being in one position for prolonged periods, compromised sleep, restricted movement, boredom, and isolation during their stay at the hospital as well as poor support for daily living needs such as food. Discussion A heavy burden is placed on mothers who become the key person responsible for care during kangaroo mother care, especially in resource-limited health settings. More focus is needed on supporting caregivers during the delivery of kangaroo mother care through staff support, family inclusion, and conducive infrastructure.

Background The Covid – 19 pandemic overwhelmed health systems, especially, those with poor infrastructure and limited workforces. Healthcare workers face an increased workload, burnout, stress, and increasing incidence of violence as a direct result of the pandemic. If not effectively dealt with, violence against healthcare workers during the pandemic could derail the public health response. In this study, we estimated the prevalence of violence toward healthcare workers during the pandemic in Malawi. We also described the forms and perpetrators, evaluated the predictors, and determined the impact of violence on healthcare workers. Methods We conducted a multicenter, cross-sectional study in six health facilities across three districts in central and southern Malawi. Data collection took place from 22 February – 27 July 2022. We recruited all consenting doctors, clinical officers, nurses, ambulance drivers, health surveillance assistants, and patient attendants who were present on the day of recruitment. Standardized questionnaires were used to collect data on sociodemographic factors and professional characteristics of the healthcare workers. The main outcome measures were personal experiences of physical violence, verbal abuse, and bullying or mobbing during the pandemic. Results We recruited 200 study participants and 70.5% were female. The age range was 20 – 59 with the most common age category being the 25 – 29 age group (24.5%). The overall prevalence of violence was 93% (95% CI: 88.5 – 96.1). The prevalence of physical attacks was 5.5% (95% CI: 2.8 – 9.6%), verbal abuse was 91.5% (95% CI: 86.7 – 95.0), and bullying/mobbing was 79.2% (95% CI: 72.8 – 84.6). Being married (OR: 19, 95% CI: 1.9 – 185.3) and having 6 – 10 staff members working at the same time (OR: 13.8, 95% CI: 1.8 – 107.6) were significantly associated with a physical attack. Being married (OR: 4.7, 95% CI: 1.2 – 18.2), a regular member of staff (OR: 22.6, 95% CI: 1.4 – 410.4), and working with over 15 people at the same time (OR: 25.2, 95% CI: 5.2 – 122.7) were significantly associated with verbal abuse Conclusions The prevalence of violence against healthcare workers was extremely high during the Covid – 19 pandemic. The levels of violence were higher than pre-pandemic levels in the country and higher than levels in other countries during the same period. We recommend immediate actions to address this violence and inclusion of different stakeholders for a multi-sectoral appaorach.

Background The World Health Organization introduced a new model of care, ‘The 2016 WHO ANC Model’ to overcome challenges encountered during the implementation of the Focused Antenatal Care Approach. For any new intervention to achieve its objective, it must be widely accepted by both the deliverers and recipients. Malawi rolled out the model in 2019 without carrying out acceptability studies. The objective of this study was to explore the perceptions of pregnant women and health care workers on the acceptability of 2016 WHO’s ANC model in Phalombe District, Malawi using the Theoretical Framework of Acceptability. Methodology We conducted a descriptive qualitative study between May and August 2021. The Theoretical Framework of Acceptability was used to guide the development of study objectives, data collection tools, and data analysis. We purposely conducted 21 in-depth interviews (IDIs) among pregnant women, postnatal mothers, a safe motherhood coordinator, and Antenatal care (ANC) clinic midwives, and two focus group discussions (FGDs) among Disease Control and Surveillance Assistants. All IDIs and FGDs were conducted in Chichewa, digitally recorded, and simultaneously transcribed and translated into English. Data was analysed manually using content analysis. Results The model is acceptable among most pregnant women and they reckoned that it would help reduce maternal and neonatal deaths. Support from a husband, peers, and health care workers facilitated acceptability of the model while the increased number of ANC contacts which resulted in fatigue and increased transportation cost incurred by the women was a deterrent. Conclusion This study has shown that most pregnant women have accepted the model despite facing numerous challenges. Therefore, there is a need to strengthen the enabling factors and address the bottlenecks in the implementation of the model. Furthermore, the model should be widely publicised so that both intervention deliverers and recipients of care implement the model as intended. This will in turn help to achieve the model’s aim of improving maternal and neonatal outcomes and creating a positive experience with health care among pregnant women and adolescent girls.

Globally, remarkable progress has been made in the fight against malaria over the last two decades, yet the rate of reduction of malaria case incidence and mortality seems stalled. Globally, malaria case incidence (i.e., cases per 1000 population at risk) reduced from 80 in 2000 to 58 in 2015 and only to 57 in 2019. Mosquirix (RTS, S/AS01), a four-dose malaria vaccine with an effectiveness of 39%, was piloted by the WHO in three countries including Malawi where it was integrated into the EPI as a regular schedule dose. Fidelity was assessed to evaluate the degree of adherence to the planned protocol for the roll out of the program. This is a qualitative study that used the implementation fidelity framework (2007) where 12 healthcare workers were interviewed, 47 parents attended 2 focused group discussions, and a non-participatory observation checklist determined the status of vaccine storage and administration, in 2 separate health centers serving as immunization clinics. Framework approach analysis was used in this study. 59 participants were interviewed in this study. 12 health workers that were interviewed, 2 (17%) were female and 10 (83%) were male whereas all 47 (100%) parents were female. The average age of HCWs was 38 years while for the parents it was 29 years. The study demonstrated fidelity to the malaria vaccine protocol but to a much lesser extent. It has to some extent been implemented with fidelity and there is demonstrable adherence to the vaccine protocol, nevertheless, numerous gaps still exist.

Background Inappropriate use of antibiotics is among the major causes of the global emergency of antibiotic resistance among children. The problem of inappropriate use of antibiotics among children is of special concern because they are still developing immunological systems, hence they are susceptible to many infectious diseases. As such, they receive a considerable disproportional amount of antibiotics which exposes them to antibiotic resistance. This study explored the lived experiences of caregivers of children under the age of five years on the use of antibiotics at Zomba central hospital. Objective The main aim of this study was to explore the lived experiences of caregivers of children under the age of five years on antibiotic usage at Zomba Central Hospital, Zomba-Malawi. Methodology This was a descriptive qualitative study with a phenomenological approach to explore the lived experience of caregivers of paediatric patients on antibiotic usage from May 2019 to July 2020. The study used interview guides to conduct in-depth interviews with 16 caregivers and purposive sampling was used to select the participants from the children’s ward. All interviews were audio-recorded and qualitative data was transcribed verbatim and thematically analysed manually to extract major themes and concepts on the subject matter. Results Caregivers had little knowledge about antibiotic use and its resistance. most caregivers use the antibiotics inappropriately through self-medication, use of left-over antibiotics, buying antibiotics without prescription, and sharing of antibiotics. Conclusion Based on the findings of this study, investment in public awareness and organising community-led interventions in antibiotic use related information is key to improve the quality use of antibiotics. The Government should focus on promoting interventions that lessen the indiscriminate use of antibiotics among the caregivers. Stringent laws need to be enforced by the government to restrict the access of antibiotics to parents without a prescription.

BackgroundMalawi has one of the highest incidences of premature birth, and preterm newborns are twice likely to die compared to full-term newborns. Fathers’ involvement could help with the situation because it is associated with positive outcomes. However, there is limited literature on the factors that influence fathers’ involvement in the care of preterm newborns in Malawi.MethodsA phenomenological study was conducted at Balaka District Hospital guided by the components of the model proposed by Lamb on male involvement and the Theory of planned behaviour to explore factors that influenced fathers’ involvement in the care of preterm infants. The district was selected due to its high infant mortality rate, which is above the national average. Sixteen in-depth interviews were conducted with fathers of preterm infants purposively sampled in June 2021. Interviews were digitally recorded and transcribed verbatim. Data were analyzed using thematic analysis guided by the Theory of Planned Behaviour. ResultsSeveral factors influence fathers’ involvement. These are perceived difficulty with care activities and benefits of involvement, gender roles and socio-cultural beliefs, work and other family responsibilities, social support, baby’s physical appearance/nature and health status, feedback from the baby, multiple births, and hospital’s physical environment and provision of basic needs. These were reported as being barriers and facilitators to fathers’ involvement in the care of their hospitalized preterm newborns.ConclusionFathers’ involvement in the care of hospitalized preterm newborns can be improved by finding ways of resolving the barriers. This could be through education, awareness, and encouragement of the fathers and their communities.

Introduction: The COVID-19 pandemic in Malawi emerged amidst widespread anti-government demonstrations and subsequent mass gatherings. This paper describes the incidence and factors associated with the spread of the COVID-19 pandemic in Malawi. Methodology: This was a retrospective study of public data analysing geopolitical and immigration activities that occurred between 02 April and 08 September 2020. The Chi-square test of independence was used to tabulate sex and age-related fatality ratios among deaths due to COVID-19-related complications. Results: The drivers for COVID-19 spread were mass gatherings secondary to the country’s political landscape and repatriation of citizens from high-risk areas coupled with minimum use of public health interventions. The prevalence was higher in people aged 50–59 years, males and in urban areas. Men had an increased risk of COVID-19-related deaths (Case Fatality Ratio: 1.58 (95% CI 1.11–2.22) compared with women. Furthermore, men and women aged ≥40 years were 16.1 times and 7.1 times more likely to die of COVID-related complications, respectively. Men aged ≥40 years had a 62% increased risk of deaths compared with women of the same age group. Conclusion: Mass political gatherings and cross-border immigration from high-risk areas were drivers for infection. Males, older age and urban residence were associated with increased COVID-19 morbidity and mortality. To control the spread of COVID-19 there is a need to regulate mass gatherings and repatriation of citizens, and strengthen the use of preventive health interventions. Men, the older age groups and urban areas should be prioritised for COVID-19 prevention strategies.

Background Despite documented benefits of contraceptives, uptake among young people aged 20–24 years is high compared to adolescents aged 15–19 years in Malawi. As the world’s population of 15–19-year-olds continues to grow the need to meet the increasing demand for contraceptive services and information that address adolescent-specific needs cannot be underestimated. To inform Sexual and Reproductive health services for the youth, we explored strategies for optimizing uptake of contraceptives among this age group. Methods An exploratory qualitative cross-sectional study was conducted at Nsanje District Hospital and Nyamadzere Community Day Secondary School guided by Social-Ecological Framework to understand strategies that may optimize the uptake of contraceptives among adolescents aged 15–19. Nsanje district was purposively selected based on the reason that it is the second district in Malawi with the highest rate of adolescent childbearing of girls aged 15–19 years. We conducted a Focus Group Discussion (FGD) with 9 traditional leaders, 11 Key Informant Interviews (KIIs) with health workers, 20 In-depth Interviews (IDIs) with 12 adolescents, 4 teachers, and 4 parents. All data were digitally recorded, transcribed verbatim into English. The data was analyzed and managed using deductive thematic analysis guided by Social-Ecological Framework. Results Adolescents suggested accessing contraceptives from local drug stores, pharmacies and hospitals at a health system level and through Youth Centres, clubs, and corners at a Community level. There is a need to ensure a continuous supply of various kinds of contraceptives and the presence of youth-friendly health care workers in the specified areas. Conclusion There is no one way of delivering contraceptives to adolescents. Multiple avenues existent at the health facility and community could be leveraged to optimize delivery and uptake of contraceptives in a manner that is not intimidating to an adolescent while involving key stakeholders.

Background Severe neonatal jaundice can result in long term morbidities and mortality when left untreated. Phototherapy is the main-stay intervention for treating moderate jaundice and for prevention of the development of severe jaundice. However, in resource-limited health care settings, phototherapy has been inconsistently used. The objective of this study is to evaluate barriers and facilitators for phototherapy to treat neonatal jaundice at Malawian hospitals. Methods We conducted a convergent mixed-method study comprised of a facility assessment and qualitative interviews with healthcare workers and caregivers in southern Malawi. The facility assessment was conducted at three secondary-level hospitals in rural districts. In-depth interviews following a semi-structured topic guide were conducted at a district hospital and a tertiary-level hospital. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia). Results The facility assessment found critical gaps in initiating and monitoring phototherapy in all facilities. Based on a total of 31 interviews, participants identified key challenges in diagnosing neonatal jaundice, counselling caregivers, and availability of infrastructure. Participants emphasized the need for transcutaneous bilirubinometers to guide treatment decisions. Caregivers were sometimes fearful of potential harmful effects of phototherapy, which required adequate explanation to mothers and family members in non-medical language. Task shifting and engaging peer support for caregivers with concerns about phototherapy was recommended. Conclusion Implementation of a therapeutic intervention is limited if accurate diagnostic tests are unavailable. The scale up of therapeutic interventions, such as phototherapy for neonatal jaundice, requires careful holistic attention to infrastructural needs, supportive services such as laboratory integration as well as trained human resources.

Background: Global health research partnerships have been scrutinised for how they operate and criticised for perpetuating inequities. Guidance to inform fair partnership practice has proliferated and the movement to decolonise global health has added momentum for change. In light of this evolving context, in this study we sought to document contemporary experiences of partnership from the perspective of stakeholders in a sample of sub-Saharan African research institutions. Methods: We conducted qualitative interviews with 20 stakeholders at four research institutions in four countries in anglophone eastern and southern Africa. Interview questions were informed by published guidance on equitable research partnerships. Data was analysed through an iterative process of inductive and deductive coding, supported by NVivo software.Results: Early to mid-career and senior researchers and research administrators from four sub-Saharan African research institutions described wide-ranging experiences of partnership with high-income country collaborators. Existing guidelines for partnership provided good coverage of issues that participants described as being the key determinants of a healthy partnership, including mutual respect, role clarity and early involvement of all partners. However, there was almost no mention of guidelines being used to inform partnership practice. Participants considered the key benefits of partnership to be capacity strengthening and access to research funding. Meanwhile, participants continued to experience a range of well-documented inequities, including exclusion from agenda setting, study design, data analysis and authorship; and relationships that were exploitative and dominated by high-income country partners’ interests. Participants also reported emerging issues where their institution had been the prime recipient of funds. These included high-income country partners being unwilling to accept a subordinate role and failing to comply with reporting requirements. Conclusions: Contemporary global health research partnerships generate considerable benefits but continue to exhibit longstanding inequities and reveal emerging tensions. Long-term support targeted towards institutions and national research systems remains essential to fulfil the potential of research led from sub-Saharan Africa. High-income country stakeholders need to find new roles in partnerships and stakeholders from sub-Saharan Africa must continue to tackle challenges presented by the resource-constrained contexts in which they commonly operate.

Background Postnatal care (PNC) ensures early assessments for danger signs during the postpartum period and is to be provided within 24 hours of birth, 48–72 hours, 7–14 days, and six weeks after birth. This study assessed the uptake of and the barriers and facilitators to receiving PNC care among mothers and babies Methods A concurrent mixed-method study employing a retrospective register review and a qualitative descriptive study were conducted in Thyolo from July to December 2020. Postnatal registers of 2019 were reviewed to estimate the proportion of mothers and newborns that received PNC respectively. Focus Group Discussions (FGDs) among postnatal mothers, men, health care workers, and elderly women and in-depth interviews with Midwives, and key health care workers were conducted to explore the barriers and enablers to PNC. Observations of the services that mothers and babies received within 24 hours of birth, at 48–72 hours, 7–14 days, and six weeks after birth was conducted. Descriptive statistics were tabulated for the quantitative data using Stata while the qualitative data were managed using NVivo and analysed following a thematic approach Results The uptake of PNC services was at 90.5%, 30.2%, and 6.1% among women and 96.5%, 78.8%, and 13.7% among babies within 48 hours of birth, 3 to 7 and 8 to 42 days respectively. The barriers to PNC services included the absence of a baby or mother, limited understanding of PNC services, lack of male involvement, and economic challenges. Cultural and religious beliefs, advice from community members, community activities, distance, lack of resources, and poor attitude of health care workers also impeded utilization of PNC services. The enablers included the mothers’ level of education, awareness of the services, economic resources, community-based health support, adequacy and attitude of health workers, seeking treatment for other conditions, and other clinic activities. Conclusion Optimization of uptake and utilization of PNC services for mothers and neonates will require the involvement of all stakeholders. The success of PNC services lies in the communities, health services, and mothers understanding the relevance, timepoints, and services that need to be delivered to create demand for the services.

Background: Type II diabetes mellitus (T2DM) significantly impacts the quality of life (QoL) yet data on quality of life among these patients in Malawi are lacking. This study was conducted to assess QoL among patients with T2DM. Methods: A mixed-method cross-section study was carried out at Kamuzu Central Hospital (KCH), Lilongwe, Malawi. A systematic sampling method was used for quantitative data and purposive sampling was used for qualitative data. A modified diabetes quality of life (MDQoL)-17 questionnaire was used for quantitative data while in-depth interviews and diary methods were used for qualitative data. Demographic data were summarized using descriptive statistics and inferential statistics using t-test and ANOVA. Thematic content analysis guided by Braun and Clark (2006) was utilized to analyze qualitative data. Ethical approval was obtained from the College of Medicine Research and Ethics Committee (CoMREC) reference number P.09.20.3122.Results: A sample of 339 participants with a mean age of 50.3±15.5 was recruited. Overall, the mean QoL score was moderate (63.91±19.54). Those with tertiary education and those on health insurance had better QoL (QoL 73.8, C.I. 68.56-79.04, p-value 0.005), (QoL 76.71, C.I. 69.22-84.19, p-value 0.005) respectively compared to those with lower education and those without health insurance. Furthermore, the absence of comorbidities was associated with having better QoL (QoL 71.18, C.I. 66.69-75.67, p-value < 0.0001). Qualitatively, the participants referred to QoL as an absence of disease and leading an independent life. T2DM was associated with patients’ health status, increased stress levels, loss of independence as well as lifestyle changes. There were QoL-promoting factors among T2DM patients such as diabetes health talks, having a supportive family, accepting one’s condition positively, and following hospital advice such as doing physical exercises and following a prescribed diet. Inhibiting factors include drug shortages, societal perceptions, sedentary lifestyle, stress, and despising hospital advice.Conclusion: Overall the QoL in patients with T2DM receiving treatment at KCH is moderate. The QoL of patients with T2DM is influenced by interrelated factors and this requires multidisciplinary team care to optimize the QoL among these patients. Health workers need to adopt a holistic approach when treating patients with T2DM, such as managing comorbidities and including assessment of QoL, behavioral change measures like physical exercises, and a healthy diet. The government and various stakeholders need to promote education and mandatory national health insurance which improve health status.

Background Global health research partnerships have been scrutinised for how they operate and criticised for perpetuating inequities. Guidance to inform fair partnership practice has proliferated and the movement to decolonise global health has added momentum for change. In light of this evolving context, we sought in this study to document contemporary experiences of partnership from the perspective of stakeholders in four sub-Saharan African research institutions. Methods We conducted qualitative interviews with 20 stakeholders at research institutions in four countries in anglophone eastern and southern Africa. Interview questions were informed by published guidance on equitable research partnerships. Data was analysed through an iterative process of inductive and deductive coding, supported by NVivo software. Results Early-career, mid-career and senior researchers and research administrators from four sub-Saharan African research institutions described wide-ranging experiences of partnership with high-income country collaborators. Existing guidelines for partnership provided good coverage of issues that participants described as being the key determinants of a healthy partnership, including mutual respect, role clarity and early involvement of all partners. However, there was almost no mention of guidelines being used to inform partnership practice. Participants considered the key benefits of partnership to be capacity strengthening and access to research funding. Meanwhile, participants continued to experience a range of well-documented inequities, including exclusion from agenda setting, study design, data analysis and authorship; and relationships that were exploitative and dominated by high-income country partners’ interests. Participants also reported emerging issues where their institution had been the prime recipient of funds. These included high-income country partners being unwilling to accept a subordinate role and failing to comply with reporting requirements. Conclusions Insights from stakeholders in four sub-Saharan African research institutions suggest that contemporary global health research partnerships generate considerable benefits but continue to exhibit longstanding inequities and reveal emerging tensions. Our findings suggest that long-term support targeted towards institutions and national research systems remains essential to fulfil the potential of research led from sub-Saharan Africa. High-income country stakeholders need to find new roles in partnerships and stakeholders from sub-Saharan Africa must continue to tackle challenges presented by the resource-constrained contexts in which they commonly operate.

Background: Inappropriate use of antibiotics is among the major causes of the global emergency of antibiotic resistance among children. The problem of inappropriate use of antibiotics among children is of special concern because they are still developing immunological systems, hence they are susceptible to many infectious diseases. As such, they receive a considerable disproportional amount of antibiotics which exposes them to antibiotic resistance. This study explored the lived experiences of caregivers of children under the age of five years on the use of antibiotics at Zomba central hospital. Objective: The main aim of this study was to explore the lived experiences of caregivers of children under the age of five years on antibiotic usage at Zomba Central Hospital, Zomba-Malawi.Methodology This was a descriptive qualitative study with a phenomenological approach to explore the lived experience of caregivers of paediatric patients on antibiotic usage from May 2019 to July 2020. The study used interview guides to conduct in-depth interviews with 16 caregivers and purposive sampling was used to select the participants from the children’s ward. All interviews were audio-recorded and qualitative data was transcribed verbatim and was thematically analysed manually to extract major themes and concepts on the subject matter. Results: Caregivers had little knowledge about antibiotic use and its resistance. most caregivers use the antibiotics inappropriately through self-medication, use of left-over antibiotics, buying antibiotics without prescription, and sharing of antibiotics. Conclusion.Based on the findings of this study, investment in public awareness and organising community-led interventions in antibiotic use related information is key to improve the quality use of antibiotics. The Government should focus on promoting interventions that lessen the indiscriminate use of antibiotics among the caregivers. Stringent laws need to be enforced by the government to restrict the access of antibiotics to parents without a prescription.

Background Alcohol contributes to poor health, social and economic outcomes among adolescents. In Malawi, alcohol consumption among young people significantly increased after the introduction of alcohol sachets. A government ban on the sale of alcohol sachets affected in 2012 aimed to reduce prevalence of alcohol among users. We explored adolescents perceptions regarding the effectiveness of the ban towards reducing alcohol consumption among the under aged in the country. Methods Using a descriptive phenomenological school-based approach, we recruited 44 school-going adolescents, 15–17 year olds using snow ball sampling and conducted 12 individual semi-structured interviews and four group discussions differentiated by sex. We sought a waiver from College of Medicine Ethics Committee (COMREC) to obtain verbal consent from adolescents. All interviews and discussions were digitally recorded and simultaneously transcribed and translated verbatim into English. Data management and analysis was done manually using thematic approach. Results Aggressive packaging, and marketing tendencies and lack of restrictive measures in Malawi have rendered the ban ineffective through increased affordability and availability to different income population groups and the underage. Results indicate that even though adolescents perceive the ban as a significant step towards reducing under age alcohol use, personality and drinking motives precede any interventions. Adolescents emphasized on strong personality as a significant factor for reduced alcohol intake or abstinence. Conclusions We recommend strict alcohol policy and enforcement regarding packaging, pricing, positive role modelling by parents and enhanced adolescent personality development through schools and families.

Background Bubble continuous positive airway pressure (CPAP) has been shown to be effective in supporting breathing in newborns with respiratory distress. The factors that influence implementation in resource-constrained settings remain unclear. The objective of this review is to evaluate the barriers and facilitators of CPAP implementation for newborn care at sub-Saharan African health facilities and how different facility levels and types of bubble CPAP systems may impact utilization. Methods A systematic search (database inception to July 2019) was performed on MEDLINE Ovid, EMBASE, CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), the WHO Regional Database for Africa, African Index Medicus (AIM), African Journals Online, grey literature and the references of relevant articles. Studies that met the inclusion criteria (primary research, bubble CPAP implementation with neonates ≤ 28 days old at a health facility in sub-Saharan Africa) were included in the review and assessed with National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) quality assessment tools. The review protocol was published to PROSPERO (CRD42018116082). Results Seventeen studies were included in the review. Reliable availability of equipment, effectively informing and engaging caregivers and staffing shortages were frequently mentioned barriers to the implementation of bubble CPAP. Understaffed neonatal units and high turnover of nurses and doctors compromised effective training. Provider-to-provider clinical mentorship models as well as affordability and cost-effectiveness of innovative bubble CPAP systems were identified as frequently mentioned facilitators of implementation. Conclusions With a strong recommendation by the World Health Organization for its use with premature infants with respiratory distress, it is important to understand the barriers and facilitators that can inform the implementation of bubble CPAP. More research is needed into health system factors that can support or impede the use of this potentially promising intervention.

Background There has been an unprecedented explosion in the popularity of herbal preparations during the last few decades. Herbal medicines are commonly used by HIV/AIDs clients. There is limited data on the prevalence of herbal medicine and correlating factors of herbal medicine use in Malawi. This study establishes prevalence and factors contributing to the use of herbal medicine among HIV/AIDS clients attending the ART clinic at QECH, Blantyre Malawi.Methods A cross-sectional study design was used to interview 211 conveniently sampled clients at QECH ART clinic. The questionnaire addressed socio-demographic, clinical characteristics, NCD-HIV comorbidity, and herbal medicine utilization. The main outcome of the study was herbal medicine use since the initiation of ART. Logistic regression analysis was done in Stata version 16. Both unadjusted and adjusted models were fitted for potential confounders. ResultsThe prevalence of use of herbal medicine was reported in 17.5% (n=37) of the ART clients. The adjusted logistic regression analysis showed that urban residence was statistically associated with reduced use of herbal medicine (adjusted Odds Ratio –AOR: 0.04, 95% CI: 0.169, 0.976).ConclusionThere is a high prevalence of use of herbal medicine among clients taking ART. Herbal Medicine has the potential to cover the gaps in health coverage in rural communities.

Background Obesity is increasingly a public health concern in low- and middle-income countries, including Malawi where 36% of women have body mass index in overweight/obese categories in urban areas. Eating behaviors, attitudes, and beliefs are associated with body size, but have not been studied in-depth in sub-Saharan African countries. This study therefore, explored eating behaviors, attitudes, and beliefs of women in Lilongwe, Malawi. Methods This was a descriptive ancillary qualitative study utilising in-depth interviews with 27 women (13 in normal weight range and 14 in overweight/obesity ranges) puporsively selected in Lilongwe City, Malawi from October to November 2017. The concept of data saturation guided data collection, and it was reached with the 27 interviewed participants when there was no new information coming from the participants. All interviews were conducted in the local language, transcribed verbatim, and translated into English. The transcripts were analysed manually using thematic content analysis. Results Majority of participants perceived overweight as an indication of good health such that with food affordability, women deliberately gain weight to demonstrate their good health. Most normal weight respondents said they ate less food than they wanted to because of financial constraints. Most women in overweight/obese ranges in our sample reported that they eat large portions and eat frequently due to the desire to portray a good image of their marital life since there is a societal expectation that when a woman is married, her weight should increase to show that the marriage is successful. The perceived contributors to weight gain include eating behaviors, feelings about weight gain, and gender roles and social expectations to gain weight. Conclusion Beliefs and attitudes related to eating behaviors may have contributed to women being in overweight range and should be considered in designing obesity prevention interventions targeting women in Malawi.

Background Human milk insufficiency is a significant barrier to implementing breastfeeding, and it is identified as a prevalent concern in 60–90% of mothers in low-and-middle-income countries. Breastmilk insufficiency can lead to hypoglycemia, hypernatremia, nutritional deficiencies, and failure to thrive in newborns and infants. Studies investigating the impact of breastfeeding interventions to improve milk production highlight inconsistencies between healthcare workers and mothers perceived support, as well as gaps in practical knowledge and training. The aim of this study was to determine perceptions surrounding human milk insufficiency from Malawian healthcare workers. Methods This study is a secondary analysis of 39 interviews with healthcare workers from one tertiary and three district hospitals in Malawi employing content analysis. Interviewed healthcare workers included nurses, clinical officers, midwives, and medical doctors. An inclusive coding framework was developed to identify themes related to human milk insufficiency, which were analyzed using an iterative process with NVivo12 software. Researchers focused on themes emerging from perceptions and reasons given by healthcare workers for human milk insufficiency. Results Inability to produce adequate breastmilk was identified as a prevalent obstacle mothers face in the early postpartum period in both district and tertiary facilities in Malawi. The main reasons given by participants for human milk insufficiency were mothers’ perceived normalcy of milk insufficiency, maternal stress, maternal malnutrition, and traditional beliefs around food and eating. Three focused solutions were offered by participants to improve mother’s milk production – improving education for mothers and training for healthcare providers on interventions to improve mother’s milk production, increasing breastfeeding frequency, and ensuring adequate maternal nutrition pre- and post-partum. Conclusion Health care workers perspectives shed light on the complexity of causes and solutions for human milk insufficiency in Malawi. This research highlights that a respectful professional relationship between health care workers and mothers is an essential bridge to improving communication, detecting human milk insufficiency early, and implementing appropriate interventions. The results of this study may help to inform research, clinical practice, and education in Malawi to improve human milk production.