Disability in childhood and the equity of health services: a cross-sectional comparison of mass drug administration strategies for soil-transmitted helminths in southern Malawi.

BACKGROUND: School-based approaches are an efficient mechanism for the delivery of basic health services, but may result in the exclusion of children with disabilities if they are less likely to participate in schooling. Community-based 'door to door' approaches may provide a more equitable strategy to ensure that children with disabilities are reached, but disability is rarely assessed rigorously in the evaluation of health interventions. OBJECTIVES: To describe the prevalence and factors associated with disability among children aged 5-17 years and to assess the relative effectiveness of routine school-based deworming (SBD) compared with a novel intervention of community-based deworming (CBD) in treating children with disabilities for soil-transmitted helminths. SETTING: DeWorm3 Malawi Site (DMS), Mangochi district, Malawi. PARTICIPANTS: All 44 574 children aged 5-17 years residing within the DMS. PRIMARY AND SECONDARY OUTCOME MEASURES: Disability was defined as a functional limitation in one or more domains of the Washington Group/UNICEF Child Functioning Module administered as part of a community-based census. Treatment of all children during SBD and CBD was independently observed and recorded. For both intervention types, we performed bivariate analyses (z-score) of the absolute proportion of children with and without disabilities treated (absolute differences (ADs) in receipt of treatment), and logistic regression to examine whether disability status was associated with the likelihood of treatment (relative differences in receipt of treatment). RESULTS: The overall prevalence of disability was 3.3% (n=1467), and the most common domains of disability were hearing, remembering and communication. Boys were consistently more likely to have a disability compared with girls at all age groups, and disability was strongly associated with lower school attendance and worse levels of education. There was no significant difference in the proportion of children with disabilities treated during SBD when assessed by direct observation (-1% AD, p=0.41) or likelihood of treatment (adjusted risk ratio (aRR)=1.07, 95% CI 0.89 to 1.28). Treatment of all children during CBD was substantially higher than SBD, but again showed no significant difference in the proportions treated (-0.5% AD, p=0.59) or likelihood of treatment (aRR=1.04, 95% CI 0.99 to 1.10). CONCLUSION: SBD does not appear to exclude children with disabilities, but the effect of consistently lower levels of educational participation of children with disabilities should be actively considered in the design and monitoring of school health interventions. TRIAL REGISTRATION NUMBER: NCT03014167.

Single and two-dose typhoid conjugate vaccine safety and immunogenicity in HIV-exposed uninfected and HIV-unexposed uninfected Malawian children.

Vaccine safety and immunogenicity data in human immunodeficiency virus (HIV)-exposed uninfected (HEU) children are important for decision-making in HIV and typhoid co-endemic countries. In an open-label study, we recruited Malawian HEU and HIV unexposed uninfected (HUU) infants aged 9 - 11 months. HEU participants were randomized to receive Vi-tetanus toxoid conjugate vaccine (Vi-TT) at 9 months, Vi-TT at 15 months, or Vi-TT at 9 and 15 months. HUU participants received Vi-TT at 9 and 15 months. Safety outcomes included solicited and unsolicited adverse events (AE) and serious AEs (SAEs) within 7 days, 28 days, and 6 months of vaccination, respectively. Serum was collected before and at day 28 after each vaccination to measure anti-Vi IgG antibodies by enzyme-linked immunosorbent assay (ELISA). Cohort 1 (66 participants) enrollment began 02 December 2019, and follow-up was terminated before completion due to the COVID-19 pandemic. Cohort 2 (100 participants) enrollment began 25 March 2020. Solicited AEs were mostly mild, with no significant differences between HEU and HUU participants or one- and two-dose groups. All six SAEs were unrelated to vaccination. Anti-Vi geometric mean titers (GMT) increased significantly from 4.1 to 4.6 ELISA units (EU)/mL at baseline to 2572.0 - 4117.6 EU/mL on day 28 post-vaccination, and similarly between HEU and HUU participants for both one- and two-dose schedules. All participants seroconverted (>4-fold increase in GMT) by the final study visit. Our findings of comparable safety and immunogenicity of Vi-TT in HUU and HEU children support country introductions with single-dose Vi-TT in HIV-endemic countries.

A systems serology approach to identifying key antibody correlates of protection from cerebral malaria in Malawian children.

BACKGROUND: Plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1) proteins are expressed on the surface of infected erythrocytes, mediating parasite sequestration in the vasculature. PfEMP1 is a major target of protective antibodies, but the features of the antibody response are poorly defined. METHODS: In Malawian children with cerebral or uncomplicated malaria, we characterized the antibody response to 39 recombinant PfEMP1 Duffy binding like (DBL) domains or cysteine-rich interdomain regions (CIDRs) in detail, including measures of antibody classes, subclasses, and engagement with Fcγ receptors and complement. Using elastic net regularized logistic regression, we identified a combination of seven antibody targets and Fc features that best distinguished between children with cerebral and uncomplicated malaria. To confirm the role of the selected targets and Fc features, we measured antibody-dependent neutrophil and THP-1 cell phagocytosis of intercellular adhesion molecule-1 (ICAM-1) and endothelial protein C (EPCR) co-binding infected erythrocytes. RESULTS: The selected features distinguished between children with cerebral and uncomplicated malaria with 87% accuracy (median, 80-96% interquartile range) and included antibody to well-characterized DBLß3 domains and a less well-characterized CIDRγ12 domain. The abilities of antibodies to engage C1q and FcγRIIIb, rather than levels of IgG, correlated with protection. In line with a role of FcγRIIIb binding antibodies to DBLß3 domains, antibody-dependent neutrophil phagocytosis of ICAM-1 and EPCR co-binding IE was higher in uncomplicated malaria (15% median, 8-38% interquartile range) compared to cerebral malaria (7%, 30-15%, p < 0.001). CONCLUSIONS: Antibodies associated with protection from cerebral malaria target a subset of PfEMP1 domains. The Fc features of protective antibody response include engagement of FcγRIIIb and C1q, and ability to induce antibody-dependent neutrophil phagocytosis of infected erythrocytes. Identifying the targets and Fc features of protective immunity could facilitate the development of PfEMP1-based therapeutics for cerebral malaria.

"When selling anything to an audience, visible publicity is key:" experiences, barriers, and enablers to participate in a COVID-19 study in Malawi.

BACKGROUND: Many studies in infectious diseases struggle to recruit participants. The SARS-CoV-2 infection, transmission dynamics, and household impact in Malawi (SCATHIM) study reported a refusal rate of 57.2%. Adequate publicity can lead to more people participating in studies. This study explored the reasons for participating in the SCATHIM study. METHODS: A descriptive qualitative study informed by the theory of reasoned action was conducted in Blantyre between January 2022 and March 2022 to assess factors that influence participation in a COVID-19 study among 10 index cases, 10 caregivers, 10 study decliners, and 5 research staff. The data were collected via in-depth interview guides, audio recorded, transcribed, managed via NVIVO and analysed via a thematic approach. RESULTS: The factors that motivated participation in the study included one's knowledge of COVID-19; potential access to medical services, including free COVID-19 tests for members of the household; financial reimbursements; and the ability to contribute scientific knowledge. The barriers to participation included minimal publicity of the study amidst a novel condition, perceived stigma and discrimination, perceived invasion of privacy, discomfort with the testing procedures, and suboptimal financial reimbursements. CONCLUSION: Effective publicity and outreach strategies have the potential to decrease refusal rates in study participation, especially if a condition is novel. Studies on infectious diseases should address stigma and discrimination to promote participation and ensure participant safety.

Cross-cultural adaptation and psychometric validation of the Chichewa (Malawi) PedsQL™ 4.0 Generic Core Scales child self-report and PedsQL™ 4.0 GCS teen self-report.

BACKGROUND: The PedsQL™ 4.0 Generic Core Scales (GSC) have been translated into over 60 languages, but use in the sub-Saharan African region is limited. This study aimed to cross-culturally adapt and validate the PedsQL™ 4.0 GCS child self-report and teen self-report versions into the Chichewa language for Malawi. METHODS: The English (USA) versions were adapted (translation, back translation and cognitive interviews to evaluate conceptual equivalence) into Chichewa. We recruited 289 children (8-17 years) in Blantyre, Malawi. Classical psychometrics at the item level (missing data, endorsement frequencies, item redundancy) and scale level (internal consistency, convergent, discriminant and known groups validity) was used to evaluate the new Chichewa versions. RESULTS: Six items were found to need cultural adaptation for Malawi. There were problems with missing data (< 5%) and adjacent endorsement frequency (< 10%) among younger children. Internal consistency reliability was acceptable (Cronbach α > 0.7). Convergent validity was generally strong (correlations > 0.4). Discriminant validity (p > 0.05) was evident with respect to gender and age, but not for school grade (p < 0.05). Effect sizes indicating known groups validity were in the expected direction but of variable magnitude. CONCLUSION: We have successfully adapted the PedsQL™ 4.0 GCS child self-report and teen self-report into Chichewa for use in Malawi. Many aspects of the psychometric evaluation were promising, though some elements were more mixed and we have not yet been able to evaluate test-retest reliability or responsiveness. We suggest that the PedsQL™4.0 GCS child and teen self-reports should be used with caution among children and adolescents in Malawi.

A whole-body micro-CT scan library that captures the skeletal diversity of Lake Malawi cichlid fishes.

Here we describe a dataset of freely available, readily processed, whole-body µCT-scans of 56 species (116 specimens) of Lake Malawi cichlid fishes that captures a considerable majority of the morphological variation present in this remarkable adaptive radiation. We contextualise the scanned specimens within a discussion of their respective ecomorphological groupings and suggest possible macroevolutionary studies that could be conducted with these data. In addition, we describe a methodology to efficiently µCT-scan (on average) 23 specimens per hour, limiting scanning time and alleviating the financial cost whilst maintaining high resolution. We demonstrate the utility of this method by reconstructing 3D models of multiple bones from multiple specimens within the dataset. We hope this dataset will enable further morphological study of this fascinating system and permit wider-scale comparisons with other cichlid adaptive radiations.

Identifying and prioritising barriers to injury care in Northern Malawi, results of a multifacility multidisciplinary health facility staff survey.

INTRODUCTION: The burden of injuries globally and in Malawi is substantial. Optimising both access to, and quality of, care in health systems requires attention. We aimed to establish how health facility staff in Karonga, Malawi, perceive barriers to seeking (delay 1), reaching (delay 2) and receiving (delay 3) injury care. METHOD: We conducted a cross-sectional survey of health facility staff who treat patients with injuries in all health facilities serving the Karonga Demographic Surveillance Site population. The primary outcome was participant perceptions of the importance of delays 1 to 3 following injury. Secondary outcomes were the barriers within each of these delays considered most important and which were considered the most important across all delays stages. RESULTS: 228 staff completed the survey: 36.8% (84/228) were female and 61.4% (140/228) reported being involved in caring for an injured person at least weekly. Delay 3 was most frequently considered the most important delay 35.1% (80/228), with 19.3% (44/228) and 16.6% (38/228) reporting delays 1 and 2 as the most important respectively; 28.9% (66/228) of respondents either did not know or answer. For delay 1 the barrier, "the perceived financial costs associated with seeking care are too great", was considered most important. For delay 2, the barrier "lack of timely affordable emergency transport (formal or informal)" was considered most important. For delay 3, the barrier, "lack of reliably available necessary physical resources (infrastructure, equipment and consumable material)" was considered most important. When considering the most important overall barrier across all delays, the delay 3 barrier, "lack of reliably available necessary physical resources" received the most nominations (41.7% [95/228]). CONCLUSIONS: Given the awareness of health facility staff of the issues facing their patients, these findings should assist in informing health system planning.

High rate of uncontrolled hypertension among adults receiving integrated HIV and hypertension care with aligned multi-month dispensing in Malawi: results from a cross-sectional survey and retrospective chart review.

INTRODUCTION: People living with HIV have high rates of hypertension. Integrated HIV and hypertension care with aligned multi-month dispensing of medications (MMD) could decrease the burden of care for individuals and health systems. We sought to describe hypertension control and evaluate its association with different durations of MMD among Malawian adults receiving integrated care with aligned dispensing of antiretroviral therapy (ART) and antihypertensive medication. METHODS: We conducted a cross-sectional survey and retrospective chart review of adults (≥18 years) receiving integrated HIV and hypertension care on medications for both conditions for at least 1 year, with aligned MMD at seven clinics in Malawi. Data were collected from July 2021 to April 2022 and included socio-demographics, clinical characteristics, antihypertensive medications and up to the three most recent blood pressure measurements. Bivariate analyses were used to characterize associations with hypertension control. Uncontrolled hypertension was defined as ≥2 measurements ≥140 and/or ≥90 mmHg. Chart reviews were conducted for a random subset of participants with uncontrolled hypertension to describe antihypertensive medication adjustments in the prior year. RESULTS: We surveyed 459 adults receiving integrated care with aligned dispensing (58% female; median age 54 years). Individuals most commonly received a 3-month aligned dispensing of ART and antihypertensive medications (63%), followed by every 6 months (16%) and every 4 months (15%). Hypertension control was assessed in 359 respondents, of whom only 23% had controlled hypertension; 90% of individuals in this group reported high adherence to blood pressure medications (0-1 missed days/week). Control was more common among those with longer aligned medication dispensing intervals (20% among those with 1- to 3-month dispensing vs. 28% with 4-month dispensing vs. 40% with 6-month dispensing, p = 0.011). Chart reviews were conducted for 147 individuals with uncontrolled hypertension. Most had high self-reported adherence to blood pressure medications (89% missing 0-1 days/week); however, only 10% had their antihypertensive medication regimen changed in the prior year. CONCLUSIONS: Uncontrolled hypertension was common among Malawian adults receiving integrated care with aligned MMD and was associated with shorter refill intervals and few antihypertensive medication escalations. Integrated care with aligned MMD is promising, but further work is needed to understand how to optimize hypertension outcomes.

Evaluating the impact of the global evidence, local adaptation (GELA) project for enhancing evidence-informed guideline recommendations for newborn and young child health in three African countries: a mixed-methods protocol.

BACKGROUND: Poverty-related diseases (PRD) remain amongst the leading causes of death in children under-5 years in sub-Saharan Africa (SSA). Clinical practice guidelines (CPGs) based on the best available evidence are key to strengthening health systems and helping to enhance equitable health access for children under five. However, the CPG development process is complex and resource-intensive, with substantial scope for improving the process in SSA, which is the goal of the Global Evidence, Local Adaptation (GELA) project. The impact of research on PRD will be maximized through enhancing researchers and decision makers' capacity to use global research to develop locally relevant CPGs in the field of newborn and child health. The project will be implemented in three SSA countries, Malawi, South Africa and Nigeria, over a 3-year period. This research protocol is for the monitoring and evaluation work package of the project. The aim of this work package is to monitor the various GELA project activities and evaluate the influence these may have on evidence-informed decision-making and guideline adaptation capacities and processes. The specific project activities we will monitor include (1) our ongoing engagement with local stakeholders, (2) their capacity needs and development, (3) their understanding and use of evidence from reviews of qualitative research and, (4) their overall views and experiences of the project. METHODS: We will use a longitudinal, mixed-methods study design, informed by an overarching project Theory of Change. A series of interconnected qualitative and quantitative data collections methods will be used, including knowledge translation tracking sheets and case studies, capacity assessment online surveys, user testing and in-depth interviews, and non-participant observations of project activities. Participants will comprise of project staff, members of the CPG panels and steering committees in Malawi, South Africa and Nigeria, as well as other local stakeholders in these three African countries. DISCUSSION: Ongoing monitoring and evaluation will help ensure the relationship between researchers and stakeholders is supported from the project start. This can facilitate achievement of common goals and enable researchers in South Africa, Malawi and Nigeria to make adjustments to project activities to maximize stakeholder engagement and research utilization. Ethical approval has been provided by South African Medical Research Council Human Research Ethics Committee (EC015-7/2022); The College of Medicine Research and Ethics Committee, Malawi (P.07/22/3687); National Health Research Ethics Committee of Nigeria (01/01/2007).

Clinical audit of cases and outcomes of patients admitted to the intensive care unit at Kamuzu Central Hospital, Lilongwe, Malawi.

In 2016, a new, improved and modern intensive care unit was constructed at Kamuzu Central Hospital in Lilongwe, Malawi. Having been operational for about 4 years, there has not been a systematic audit to gauge its performance. Therefore, this quantitative retrospective cohort study aimed at investigating the performance of the intensive care unit at Kamuzu Central Hospital in Lilongwe, Malawi. We analysed the patterns of admission through 250 clinical cases and their respective outcomes spanning from 1st January 2019 to 31st December 2019 using STATA. Descriptive and inferential statistics were computed. We also had a follow-up discussion with the Head of the unit to better understand the unit's functioning. Out of the 250 admissions, we evaluated 249 case files. About 30.8% of all patients were referred from the main operating theatre, and 20.7% from the casualty (emergency medicine). Head injury (26.7%) and peritonitis (15.7%) were the commonest causes of admission. The overall mortality was 52.2% with more females (57.5%) dying than males (47.9%). Head injury and peritonitis had the highest contribution to the mortality accounting for 25.3% and 16.9% of all deaths respectively. In conclusion, despite the new unit registering an improved performance compared to the old unit's 2012 mortality of 60.9%, the current mortality rate of 52.2% generally reflects a suboptimal performance. The intensive care unit is still grappling with a number of challenges that need immediate attention including few working beds, shortage of critical care specialists and nursing staff and lack of standard admission criteria.

Application of multivariate binary logistic regression grouped outlier statistics and geospatial logistic model to identify villages having unusual health-seeking habits for childhood malaria in Malawi.

BACKGROUND: Early diagnosis and prompt treatment of malaria in young children are crucial for preventing the serious stages of the disease. If delayed treatment-seeking habits are observed in certain areas, targeted campaigns and interventions can be implemented to improve the situation. METHODS: This study applied multivariate binary logistic regression model diagnostics and geospatial logistic model to identify traditional authorities in Malawi where caregivers have unusual health-seeking behaviour for childhood malaria. The data from the 2021 Malawi Malaria Indicator Survey were analysed using R software version 4.3.0 for regressions and STATA version 17 for data cleaning. RESULTS: Both models showed significant variability in treatment-seeking habits of caregivers between villages. The mixed-effects logit model residual identified Vuso Jere, Kampingo Sibande, Ngabu, and Dzoole as outliers in the model. Despite characteristics that promote late reporting of malaria at clinics, most mothers in these traditional authorities sought treatment within twenty-four hours of the onset of malaria symptoms in their children. On the other hand, the geospatial logit model showed that late seeking of malaria treatment was prevalent in most areas of the country, except a few traditional authorities such as Mwakaboko, Mwenemisuku, Mwabulambya, Mmbelwa, Mwadzama, Zulu, Amidu, Kasisi, and Mabuka. CONCLUSIONS: These findings suggest that using a combination of multivariate regression model residuals and geospatial statistics can help in identifying communities with distinct treatment-seeking patterns for childhood malaria within a population. Health policymakers could benefit from consulting traditional authorities who demonstrated early reporting for care in this study. This could help in understanding the best practices followed by mothers in those areas which can be replicated in regions where seeking care is delayed.

Improvement of temperature surveillance of neonates in low-resource settings by a simple low-cost device: a descriptive study.

INTRODUCTION: Neonatal hypothermia in low-resource settings is prevalent and closely associated with high morbidity and mortality. We examined if an easy-to-read temperature detector device improves health outcomes. METHODS: In a descriptive study, 1009 admissions to a neonatal ward in a tertiary care hospital in Lilongwe, Malawi, were analysed and divided into a baseline and a trial group. The data of 531 newborns with standard care (SC) before the trial were compared with 478 newborns during the implementation of the device (device care=DC). Staff and caregivers were trained on using the device and how to react in case of hypothermia. Data were collected from patient files, device documentation sheets, interviews and focus group discussions. Hypothermia was defined as a body temperature <36.5°C. RESULTS: During the trial, body temperatures throughout the hospital stay were significantly more often obtained (p<0.0001). The median temperature measurements per newborn per day were 1.3 times with SC and 1.6 times with DC, and mild hypothermia was more frequently detected. Moderate hypothermia was avoided in the lightest weight group possibly contributing to significantly shorter hospital stays of surviving newborns (p=0.007). Many caregivers had difficulties using and interpreting the device correctly, and 47% of the reported colours did not match the registered temperatures. Contrary to the above, a questionnaire and focus group discussions with caregivers and health workers showed a high acceptance and the overall opinion that the device was beneficial. CONCLUSION: With more frequent temperature checks, infants with lower birth weight possibly benefited from implementing an easy-to-read continuous temperature indicator, but hypothermia rates remained high. Our data and experiences reveal structural, communicational and consistency/interpretation deficits. Although specifically designed for low-resource settings, the implementation of the device needs a well-working and structured environment, especially regarding staff and caregiver communication.

The Interest in Betting, Smoking, Alcohol, and Drugs in Malawi: Changing Trends between 2012-2022.

Background: In recent years, the online gambling market has rapidly developed, and betting has become one of the most popular forms of gambling. The aim of this study was to analyse the interest of the Malawian population in terms related to betting, sports betting, alcohol, cigarettes, and some psychoactive drugs through the relative search volumes of Google Trends. Methods: Internet search query data related to betting, sports betting, alcohol, cigarettes, and psychoactive drugs were obtained monthly from Google Trends for the period 2010-2022. Comparisons of interest levels in these topics were conducted in Malawi, and correlation coefficients were calculated. Results: In Malawi, relative search volumes for betting and sports betting terms were the highest (average RSVs: 66% and 30%). It was found that from 2019 onwards, the interest in betting and sports-related search topics and keywords increased significantly (p < 0.001). Strong positive correlations were found between betting-related keywords and alcohol and gross domestic product (r = 0.831 and r = 0.901, p < 0.001). A positive correlation was found between betting and psychoactive drug-related terms (minimum r = 0.417, p < 0.01). Conclusions: This study concludes that the interest of the Malawian population in betting has increased in recent years, while interest in psychoactive drugs and alcohol remains high. Gross domestic product is highly correlated with society's interest in betting. It was additionally found that Google Trends can be used as a tool to predict and monitor future risky behaviours, such as gambling disorder.

Consumption and adverse reaction reporting of herbal medicines among people living with HIV at University teaching hospitals in Blantyre, Malawi and Ibadan, Nigeria.

Background: Consumption of herbal medicines among people living with HIV is a common practice in Sub-Saharan Africa. The utilization of herbal medicines was at 17.5% and 67.9% in Malawi and Nigeria, respectively. There is inadequate data on use and adverse reactions (ADRs) reporting of herbal medicines among people living with HIV (PLWHIV). This study was designed to investigate use and ADRs reporting of herbal medicines among PLWHIV at the University Teaching Hospitals in Blantyre, Malawi and Ibadan, Nigeria. Methodology: A cross-sectional study was conducted among PLWHIV attending Antiretroviral Therapy (ART) clinic at Queen Elizabeth Central Hospital, Blantyre, Malawi and University College Hospital, Ibadan, Nigeria. A structured questionnaire was administered to 360 and 370 participants in Blantyre and Ibadan respectively, through face-to-face interviews after obtaining their informed consent. Results: The prevalence of herbal medicines use among PLWHIV in Malawi and Nigeria was at 80.6% and 55.7% (p<0.001), respectively. The most frequently used herbal medicines in Malawi were Aloe vera (14.0%), Moringa oleifera (14.0%), Zingiber officinale (13.0%) and Allium sativum (7.0%). Likewise, in Nigeria, the most commonly used herbal medicines were Zingiber officinale (15.0%), Vernonia amygdalina (14.0%), Moringa oleifera (9.0%), and Allium sativum (11.0%). The major reason for herbal medicines' use in Malawi was ready availability (42.1%) and perception that it boosts immunity (44.6%) in Nigeria. The PLWHIV reported experiencing suspected herbal medicine ADRs in Malawi (3.9%) and in Nigeria (8.0%). Conclusion: A higher percentage of people living with HIV are using herbal medicines in Malawi as well as in Nigeria. In both countries, a few participants reported experiencing suspected ADRs related to herbal medicines.

Clinical features and Surgical Outcomes of Thyroid Goitre Presenting to Ear, Nose and Throat Department of Queen Elizabeth Central Hospital, Blantyre, Malawi.

Introduction: In Malawi there is a perception that goitre is common and causes significant public health and economic burdens. The purpose of this study was to assess the demographic distribution, clinical presentation, investigations, management, outcomes and complications of goitre seen at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi. Method: A single hospital-based descriptive retrospective study from January 2017 to December 2018 for all patients presenting with goitre. Results: Out of 9073 patients who presented to ENT department, 105 patients presented with goitre representing 1% of all patients seen during the study period. The Male: Female ratio was 1:25. The mean symptom duration with goitre was 4 years (SD +/- 6.4). Thyroid function test results were available in 54 patients and out of these, 53(98%) patients were euthyroid. Ultrasound scan (USS) reports were available in 44 patients, of these 32(73%) were multinodular goitres. In 70 cases, pathology results were available and showed that 20% were thyroid cancers and that papillary thyroid carcinoma was the commonest cancer (64%). Two recurrent laryngeal nerve injuries were recorded in 79 surgical procedures representing 2.5% of patients (6.3% overall complication rate). Inpatient stay ranged from 2 days to 49 days (median 3 days). Conclusion: Goitre at our centre is more common in women than in men. One in five patients in this cohort had thyroid cancers. This prevalence is higher than other areas in the world highlighting the need for cytology services on every patient before surgery and histology services after surgery. Recurrent laryngeal nerve injury and other complications were infrequent demonstrating local high safety of thyroid surgery, despite late presentation to the ENT department.

Comparing motor development in children with hydrocephalus after treatment with ventriculoperitoneal shunt and endoscopic third ventriculostomy: a cross-sectional study.

Introduction: Ventriculoperitoneal shunt insertion (VPSI) and endoscopic third ventriculostomy (ETV) are the major procedures for treating pediatric hydrocephalus. However, studies comparing motor development following the two treatments are limited. Objective: We aimed to determine motor development outcomes in children with hydrocephalus up to 2 years of age after undergoing VPSI or ETV, to identify which surgical approach yields better motor outcomes and may be more effective for Malawian children. Methods: This was a cross-sectional study where we recruited two groups of participants: one group consisted of children with hydrocephalus treated with VP shunt whilst the other group were treated with ETV, at least 6 months prior to this study. Participants were identified from the hospital records and were called to come for neurodevelopmental assessment using the Malawi Development Assessment Tool (MDAT). Results: A total 152 children treated for hydrocephalus within an 18-month period met the inclusion criteria. Upon follow up and tracing, we recruited 25 children who had been treated: 12 had VPSI and 13 had ETV. MDAT revealed delays in both assessed motor domains: 19 out of the 25 children had delayed gross motor whilst 16 of 25 had delayed fine motor development. There was no significant difference between the shunted and the ETV groups. Conclusion: Children with hydrocephalus demonstrate delays in motor development six to 18 months after treatment with either VPSI or ETV. This may necessitate early and prolonged intensive rehabilitation to restore motor function after surgery. Long-term follow-up studies with bigger sample sizes are required to detect the effect of the two treatment approaches.

Cost of transport is a barrier to access to headache care in sub-Saharan Africa: An observational study in an HIV-positive population.

INTRODUCTION: Headache disorders are the largest contributor to all years lived with disability attributed to neurological disorders. In sub-Saharan Africa (SSA), with 1.2 billion inhabitants, headache prevalence is similar to that of Western countries but with widely inadequate access to care. Cost of transport to healthcare facilities hampers access to care, leading to abandonment and low retention. The aim of this observational study in Malawi was to investigate cost of transport and its likely impact on implementation of WHO's-Intersectoral Global Action Plan (IGAP) in an HIV+ population also complaining of, and requiring treatment for, an active headache disorder. METHODS: The study was conducted at the Disease Relief through Excellent and Advanced Means (DREAM) centre in Blantyre, Malawi, in collaboration with the Global Campaign against Headache as an extension of a previous study. Enquiries about distance and costs of travel were added to the previously published questionnaire. RESULTS: We included 495 consecutive HIV+ patients aged 6-65 years who had been followed for at least 1 year. One-year prevalence of any headache was 76.6%; 28.7% missed at least one appointment because of transport costs. Higher costs of transport were associated with higher probability of missing visits (p < 0.001), while costs were higher for those living in rural areas than for those in urban (p < 0.001). CONCLUSIONS: Awareness of cost and affordability of transport in SSA may suggest strategies to improve access to headache care. Given the disability attributable to headache, this is necessary if the IGAP strategic objectives and targets are to be achieved.

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

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

Effects of solvent extraction on the phytoconstituents and in vitro antioxidant activity properties of leaf extracts of the two selected medicinal plants from Malawi.

This study evaluated and compared the phytochemical and antioxidant properties of the solvent extracts of Azadirachta indica A. Juss and Vernonia amygdalina Del leaves. Methanolic and aqueous extracts showed high (P ≤ 0.05) extract yields (in %), compared to chloroform and ethyl acetate extracts from both V. amygdalina and A. indica leaves. The study exhibited high phytochemical content in methanol and aqueous extracts compared to chloroform and ethyl acetate extracts, confirming the potential for medicinal use. V. amygdalina methanol and aqueous extracts had higher (P ≤ 0.05) total phenolic content (TPC), in mg GAE/gDW, (158.810±0.846 and 217.883±0.265, respectively) than chloroform (37.574±0.118) and ethyl acetate (104.758±0.236) but higher ethyl acetate content in A. indica extracts. Low polar solvents extracted high (P ≤ 0.05) total flavonoids, in mgQE/gDW, (367.051±0.858 and 149.808±0.009) compared to high polar solvents (14.863±0.071 and 54.226±0.014 ) in V. amygdalina while as in A. indica leaf extracts, low polar solvents showed high TFC ( 658.469±3.451 and 275.288±10.490) compared to high polar solvents (26.312±0.063 and 48.858±0.063) respectively. In vitro total antioxidant capacity, in mg/g, was higher in polar solvents than in low-polar solvents, ranging from 34.300±1.784 to 121.015±6.839 for A. indica ethyl acetate and methanolic extracts. A strong correlation between TPC and tannic acid content was observed, except in A. indica methanolic extracts of A. indica. Ferric reducing power was high, except for V. amygdalina chloroform and methanol leaf extracts, which were lower (P≤ 0.05) than that of the standard ascorbic acid. The study revealed that high polar solvents, such as methanol and water, are more efficient in the extraction of antioxidants from A. indica but lower in V. amygdalina extracts. High phytochemical content and antioxidative capacity could be significant in treating various diseases in humans.