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.

Factors that influence the uptake of human papillomavirus vaccine among preadolescent girls in South Africa: A Scoping Review.

Human papillomavirus (HPV) infection is a sexually transmitted infection which causes cancer, especially cervical cancer. HPV infection and cervical cancer are a public health concern in South Africa. Primary prevention interventions, such as vaccination against cervical cancer, have been rolled out in the country. However, the uptake of the vaccine faces challenges due to various factors. The aim of the review was to identify factors which influence the uptake of the vaccine. A six-step framework developed by Levac, Colquhon and O'Brien was adopted to guide this scoping review. The articles were searched in the following databases: EBSCOhost, PubMed, CINAHL and Google scholar. The search, conducted from May to July 2023 was limited to articles published in English between 2008-2023 and those conducted in Africa. The results showed that most studies were conducted in sub-Saharan Africa, with majority of the studies being from Nigeria. Subthemes were extracted from the articles and categorised under the four themes of the Social Ecological Model. The four themes used from the Social Ecological Model were individual factors; interpersonal factors; community and societal factors, and organisational factors and public policy. The subthemes were socioeconomic and sociodemographic of parents, knowledge, fear and mistrust, family structure and proximity to cancer/STI, misinformation from social media, religion, culture and tradition, free vaccination programme and lack of engagement. The identified gap in literature was a lack of studies of factors which influence HPV vaccination uptake in South Africa and qualitative studies that explore and provide the factors influencing uptake. We conclude that in designing effective interventions for the uptake of HPV vaccines, it is important to consider influential factors that are tailor-made for specific demographics.

L'infection par le virus du papillome humain (VPH) est une infection sexuellement transmissible qui provoque le cancer, notamment le cancer du col de l'utérus. L'infection au VPH et le cancer du col de l'utérus constituent un problème de santé publique en Afrique du Sud. Des interventions de prévention primaire, telles que la vaccination contre le cancer du col de l'utérus, ont été déployées dans le pays. Cependant, l'adoption du vaccin se heurte à des difficultés dues à divers facteurs. Le but de l'examen était d'identifier les facteurs qui influencent l'adoption du vaccin. Un cadre en six étapes élaboré par Levac, Colquhon et O'Brien a été adopté pour guider cet examen de la portée. Les articles ont été recherchés dans les bases de données suivantes : EBSCOhost, PubMed, CINAHL et Google Scholar. La recherche, menée de mai à juillet 2023, s'est limitée aux articles publiés en anglais entre 2008-2023 et à ceux menés en Afrique. Les résultats ont montré que la plupart des études ont été menées en Afrique subsaharienne, la majorité des études provenant du Nigeria. Les sous-thèmes ont été extraits des articles et classés sous les quatre thèmes du modèle socio-écologique. Les quatre thèmes utilisés dans le modèle socio-écologique étaient des facteurs individuels ; facteurs interpersonnels; les facteurs communautaires et sociétaux, ainsi que les facteurs organisationnels et les politiques publiques. Les sous-thèmes étaient socio-économiques et sociodémographiques des parents, connaissances, peur et méfiance, structure familiale et proximité du cancer/IST, désinformation provenant des médias sociaux, religion, culture et tradition, programme de vaccination gratuit et manque d'engagement. La lacune identifiée dans la littérature était le manque d'études sur les facteurs qui influencent le recours à la vaccination contre le VPH en Afrique du Sud et d'études qualitatives qui explorent et fournissent les facteurs qui influencent le recours à la vaccination. Nous concluons que lors de la conception d'interventions efficaces pour l'adoption des vaccins contre le VPH, il est important de prendre en compte les facteurs influents adaptés à des données démographiques spécifiques.

Factors that influence locum practice in public and faith-based hospitals in Malawi.

Background: Locum practice is a non-standard form of employment used to address the shortage of healthcare workers in hospitals. In Malawi, the locum practice is used to improvre the availability of healthcare workers and promote continuity of care. Despite this, little attention has been paid to the effective and efficient use of locum practice. Aim: To explore the factors influencing locum practices in public and faith-based hospitals in Malawi. Setting: Six public and faith-based hospitals in Malawi. Methods: An exploratory descriptive design was used in the qualitative strand of this larger mixed-methods study. Data were collected through in-depth interviews with hospital managers (n = 15) and focus group discussions (FGD) with nurses, medical officers, and clinical officers (n = 29). All the interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to analyse the data. Results: Locum practice was characterised by challenges related to healthcare workers working beyond the prescribed hours, a lack of orientation for locu staff, inconsistent locum rates, and delayed payments. The consequences of these challenges are compromised quality and safety of patient care. Conclusion: Locum practice is associated with numerous challenges in both public and faith-based hospitals in resource-limited settings. This could be attributed to the lack of regulation, supervision and monitoring of locum practice. Contribution: The findings suggest the need for the development and adherence to guidelines and policies for managing locum practice. Further studies could explore measures to retain permanent staff as a way of reducing the demand for locum staff.

Collaborative design of a health research training programme for nurses and midwives in Tshwane district, South Africa: a study protocol.

INTRODUCTION: Nurses are essential for implementing evidence-based practices to improve patient outcomes. Unfortunately, nurses lack knowledge about research and do not always understand research terminology. This study aims to develop an in-service training programme for health research for nurses and midwives in the Tshwane district of South Africa. METHODS AND ANALYSIS: This protocol outlines a codesign study guided by the five stages of design thinking proposed by the Hasso-Plattner Institute of Design at Stanford University. The participants will include nurses and midwives at two hospitals in the Tshwane district, Gauteng Province. The five stages will be implemented in three phases: Phase 1: Stage 1-empathise and Stage 2-define. Exploratory sequential mixed methods including focus group discussions with nurses and midwives (n=40), face-to-face interviews (n=6), and surveys (n=330), will be used in this phase. Phase 2: Stage 3-ideate and Stage 4-prototype. A team of research experts (n=5), nurses and midwives (n=20) will develop the training programme based on the identified learning needs. Phase 3: Stage 5-test. The programme will be delivered to clinical nurses and midwives (n=41). The training programme will be evaluated through pretraining and post-training surveys and face-to-face interviews (n=4) following training. SPSS V.29 will be used for quantitative analysis, and content analysis will be used to analyse qualitative data. ETHICS AND DISSEMINATION: The protocol was approved by the Faculty of Health Sciences Research Ethics Committee of the University of Pretoria (reference number 123/2023). The protocol is also registered with the National Health Research Database in South Africa (reference number GP_202305_032). The study findings will be disseminated through conference presentations and publications in peer-reviewed journals.

Family members' perception of their needs in critical care units at a tertiary hospital in Malawi: A qualitative study.

BACKGROUND: Family members experience an emotional crisis when their loved one is critically ill and admitted to a critical care unit (CCU). An extensive literature has explored optimal ways to interact with families in the critical care setting, including intervention studies. What is less explored are perceptions of family members in low-income settings including Malawi. In such settings, perceptions may differ as a consequence of different cultural practices and resource limitations (personnel and technology). Therefore, this study explored family members' perceptions of their needs in CCUs at a tertiary hospital in Malawi. STUDY DESIGNS AND METHODS: The study used a qualitative descriptive design. Data were gathered through interviews with 12 participants who were purposively selected from immediate family members of patients hospitalized for 48 h or more in adult intensive care unit (ICU) and high dependency unit (HDU). The interviews were audio recorded and transcribed verbatim. Data analysis followed the steps of content analysis. FINDINGS: The following four themes were identified: perceived information, physical, and psychosocial needs, and coping mechanisms of the family members. The family members needed information about their patient's progress frequently and viewed this as a priority compared to other needs such as comfort and food. CONCLUSION: This study suggests that there should be a collaborative relationship between the CCU team and family members in order to meet their needs. Findings affirm the need for health professionals to develop guidelines or standards that promote frequent discussions with CCU family members as a means to provide support and lessen anxiety.

Doctors' experiences of referring and admitting patients to the intensive care unit: a qualitative study of doctors' practices at two tertiary hospitals in Malawi.

OBJECTIVE: To explore doctors' experiences of referring and admitting patients to the intensive care unit (ICU) at two tertiary hospitals in Malawi. DESIGN: This was a qualitative study that used face-to-face interviews. The interviews were audiotaped and transcribed verbatim into English. The data were analysed manually through conventional content analysis. SETTING: Two public tertiary hospitals in the central and southern regions of Malawi. Interviews were conducted from January to June 2021. PARTICIPANTS: Sixteen doctors who were involved in the referral and admission of patients to the ICU. RESULTS: Four themes were identified namely, lack of clear admission criteria, ICU admission requires a complex chain of consultations, shortage of ICU resources, and lack of an ethical and legal framework for discontinuing treatment of critically ill patients who were too sick to benefit from ICU. CONCLUSION: Despite the acute disease burden and increased demand for ICU care, the two hospitals lack clear processes for referring and admitting patients to the ICU. Given the limited bed space in ICUs, hospitals in low-income countries, including Malawi, need to improve or develop admission criteria, severity scoring systems, ongoing professional development activities, and legislation for discontinuing intensive care treatments and end-of-life care.

Healthcare workers' experiences in caring for critically ill COVID-19 patients at a tertiary hospital in Malawi.

Introduction: The coronavirus pandemic overwhelmed the healthcare landscape, placing a strain on healthcare workers worldwide. In addition to directly causing the deaths of people, the COVID-19 pandemic disrupted critical health services in developing countries. The study aimed to explore the experiences of healthcare workers who cared for critically ill COVID-19 patients at a tertiary hospital in Malawi. Methods: A qualitative descriptive design was used. Data were gathered through in-depth interviews with doctors, clinical officers, nurses, and allied staff (n=25) who were involved in the care of critically ill COVID-19 patients at the hospital's COVID-19 treatment centres during the first and second waves of the pandemic in Malawi. The interviews were conducted in English, audiotaped, and later transcribed verbatim. Conventional content analysis was used to analyse the data following the steps proposed by Hsieh and Shannon1. Results: The overall experience of the health workers was negative. However, delivering care to critically ill COVID-19 patients was associated with positive and negative experiences. The positive experience was a result of teamwork among staff and support from hospital authorities and the community. Negative experiences, on the other hand, were attributed to a lack of knowledge and skills in managing critically ill COVID-19 patients, a lack of resources, and abuse by some patients and members of the community. Furthermore, there was fear of contracting the virus from patients and fellow health workers while providing care. Conclusion: The findings point to the need for adequate preparedness within the health sector to support and protect the healthcare workers and individuals they look after. There is a need for disease awareness strategies for health workers and the general public for future pandemics.

Effect of an educational programme on critical care nurses' competence at two tertiary hospitals in Malawi.

Background: Critical care specialty deals with the complex needs of critically ill patients. Nurses who provide critical care are expected to possess the appropriate knowledge and skills required for the care of critically ill patients. The aim of this study was to assess the effect of an educational programme on the competence of critical care nurses at two tertiary hospitals in Lilongwe and Blantyre, Malawi. Methods: A quantitative pre- and post-test design was applied. The training programme was delivered to nurses (n = 41) who worked in intensive care and adult high dependency units at two tertiary hospitals. The effect of the training was assessed through participants' self-assessment of competence on the Intensive and Critical Care Nursing Competence Scale and a list of 10 additional competencies before and after the training. Results: The participants' scores on the Intensive and Critical Care Nursing Competence Scale before the training, M = 608.2, SD = 59.6 increased significantly after the training, M = 684.7, SD = 29.7, p <.0001 (two-tailed). Similarly, there was a significant increase in the participants' scores on the additional competencies after the training, p <.0001 (two-tailed). Conclusion: The programme could be used for upskilling nurses in critical care settings in Malawi and other developing countries with a similar context.

Admissions to a Low-Resource Neonatal Unit in Malawi Using a Mobile App and Dashboard: A 1-Year Digital Perinatal Outcome Audit.

Introduction: Understanding the extent and cause of high neonatal deaths rates in Sub-Saharan Africa is a challenge, especially in the presence of poor-quality and inaccurate data. The NeoTree digital data capture and quality improvement system has been live at Kamuzu Central Hospital, Neonatal Unit, Malawi, since April 2019. Objective: To describe patterns of admissions and outcomes in babies admitted to a Malawian neonatal unit over a 1-year period via a prototype data dashboard. Methods: Data were collected prospectively at the point of care, using the NeoTree app, which includes digital admission and outcome forms containing embedded clinical decision and management support and education in newborn care according to evidence-based guidelines. Data were exported and visualised using Microsoft Power BI. Descriptive and inferential analysis statistics were executed using R. Results: Data collected via NeoTree were 100% for all mandatory fields and, on average, 96% complete across all fields. Coverage of admissions, discharges, and deaths was 97, 99, and 91%, respectively, when compared with the ward logbook. A total of 2,732 neonates were admitted and 2,413 (88.3%) had an electronic outcome recorded: 1,899 (78.7%) were discharged alive, 12 (0.5%) were referred to another hospital, 10 (0.4%) absconded, and 492 (20%) babies died. The overall case fatality rate (CFR) was 204/1,000 admissions. Babies who were premature, low birth weight, out born, or hypothermic on admission, and had significantly higher CFR. Lead causes of death were prematurity with respiratory distress (n = 252, 51%), neonatal sepsis (n = 116, 23%), and neonatal encephalopathy (n = 80, 16%). The most common perceived modifiable factors in death were inadequate monitoring of vital signs and suboptimal management of sepsis. Two hundred and two (8.1%) neonates were HIV exposed, of whom a third [59 (29.2%)] did not receive prophylactic nevirapine, hence vulnerable to vertical infection. Conclusion: A digital data capture and quality improvement system was successfully deployed in a low resource neonatal unit with high (1 in 5) mortality rates providing and visualising reliable, timely, and complete data describing patterns, risk factors, and modifiable causes of newborn mortality. Key targets for quality improvement were identified. Future research will explore the impact of the NeoTree on quality of care and newborn survival.

Contextual issues that influence preparedness of nurses for critical care nursing practice in Malawi.

Background: There are no critical care nurse training programs in Malawi despite the high burden of diseases which culminate in critical illness. This paper presents contextual issues that influence preparedness of nurses for critical care nursing practice in Malawi. The qualitative findings presented are part of a larger mixed methods study which explored learning needs of critical care nurses as a way of informing the development of a training program for the critical care nurses in Malawi. Methods: Interpretive descriptive design was used. Data were gathered through 10 key informant interviews with nurse leaders (n=8) and anaesthetists (n=2); and two focus group discussions with registered nurses and nurse midwife technicians working in intensive care and adult high dependency units at two tertiary hospitals. Transcribed data were analyzed manually and through the use of NVivo data management software utilizing Thorne's steps of analysis1. Results: Being unprepared to work in intensive care and high dependency units was a dominant theme. Factors that contributed to this sense of unpreparedness were lack of educational preparation, organisational factors and workforce issues. The consequences of nurses' perceptions of being unprepared were fearfulness, a change of nurses' attitudes and elevation of risk to patients. The nurses managed unpreparedness by relying on other health professionals and learning on the job. Conclusion: The findings illuminated contextual issues to be considered when developing programs for upskilling nurses in hospitals within Malawi and contributes to the developing body of knowledge related to nursing education and practice development within developing countries.