A peer group intervention implemented by community volunteers increased HIV prevention knowledge.

BACKGROUND: HIV prevention knowledge levels are low in sub-Saharan Africa. In our efficacy study, the Mzake ndi Mzake (Friend-to-Friend; hereafter Mzake) 6-session peer group intervention, delivered by health workers, improved HIV prevention knowledge and other outcomes in Malawi. To expand HIV prevention approaches, this implementation study tested whether the intervention remained effective when implemented by trained community volunteers. HIV prevention knowledge findings are presented. METHODS: Using a stepped wedge design, three communities implemented the Mzake program sequentially in randomly assigned order. Repeated surveys assessed outcomes, and participants served as controls until they completed the program. At Time 2, Community 1 became the intervention group, and at Time 3, Communities 1 and 2 were the intervention group. HIV prevention knowledge, the primary outcome, was assessed through two indicators: UNAIDS comprehensive knowledge (UNAIDS Knowledge), defined as correctly answering five HIV prevention questions (Yes/No), and a 9-item HIV/PMTCT Knowledge Index (number correct). Multivariate generalized estimating equation logistic regression (UNAIDS Knowledge) and mixed-effects regression models (HIV/PMTCT Knowledge Index) were used to assess knowledge controlling for five sociodemographic factors. RESULTS: In bivariate analyses of UNAIDS Knowledge, more persons answered correctly in the intervention group than the control group at Time 2 (56.8% vs. 47.9%, p < 0.01), but the difference was not significant at Time 3. In logistic regression, there was a significant linear increase in the proportion who correctly answered all questions in the control group, but the increase was significantly higher in the intervention group (log-odds estimate = 0.17, SE = 0.06, p-value < 0.01). The HIV/PMTCT Knowledge Index scores increased over time for both groups, but in the intervention group the increase was significantly higher than the control group (0.11 at Time 2; 0.21 at Time 3). In youth and adult subsamples analyses, the intervention was highly effective in increasing knowledge for youth, but not for adults. CONCLUSION: This implementation study showed that Mzake was effective in increasing HIV prevention knowledge when delivered by community members. Community approaches offer an important strategy to increase HIV prevention in rural communities without burdening healthcare systems. TRIAL REGISTRATION: ClinicalTrials.gov NCT02765659. Registered 06/05/2016.

Status of information, education, and communication as perceived by clients receiving antenatal care at Chiradzulu District Hospital in Malawi.

BACKGROUND: Information, education, and communication is a strategy to spread awareness through communication channels to a target audience to achieve a desired positive result. Women are supposed to receive information, education, and communication at each contact with the health worker during antenatal care. In Malawi, information, education, and communication for antenatal care is inadequate despite high antenatal care coverage. Most women do not receive it as stipulated. This could be one of the reasons that maternal and neonatal mortality is high. The provision of information, education, and communication is supposed to help in reducing maternal mortality because it is intended to develop positive attitudes towards health behaviours to support pregnant women accessing health services when required. This study, therefore, assessed the status of information, education, and communication as perceived by clients receiving antenatal care at Chiradzulu District Hospital in Malawi. METHODS: A descriptive study design with a sample of 384 pregnant women attending antenatal care was used. The sample size for the study was calculated using Lemeshow, Hosmer, Klar and Rwanga's formula. Systematic random sampling method was used to select the study participants. Data were analysed using a statistical package for social sciences software version 20.0. RESULTS: Findings revealed that information, education, and communication provided during antenatal care were inadequate. Most information was offered. However, no topic was rated adequate by 80% of the respondents according to the Likert Scale that was used. The majority of the respondents (71.4%, n = 274) (95% CI 66.5. 75.8) preferred to receive information, education, and communication from midwives who are in the category of skilled attendants. Results further showed that more than half of the respondents participated passively and spent little time receiving information, education, and communication. CONCLUSION: The findings signify that information, education, and communication provided to women receiving antenatal care at Chiradzulu District Hospital had some gaps. It was inadequate and some topics were not taught. The target audience participated passively. It is recommended that midwives should provide the information, education, and communication and must have adequate contact time with the women. This is so because they are believed to be trusted sources of information.

Systematic mapping on availability, extent and distribution of mental health research in Malawi.

Background: Mental health research is essential in the implementation of evidence-based interventions. This can be impeded by unavailability or limited access to local evidence in low- and middle-income countries (LMICs) such as Malawi. Aim: The aim of this systematic mapping was to describe the availability, extent and distribution of mental health research conducted in Malawi. Setting: The study was conducted at Kamuzu University of Health Sciences in Malawi. Methods: A systematic search of four electronic databases from inception to September 2021 was carried out. All published and unpublished mental health studies in all languages were eligible for inclusion. Studies were screened against inclusion and exclusion criteria, and data were extracted, analysed and presented in tables and as a narrative synthesis. Results: Cross-sectional studies (33.6%, n = 76) were found to be the most common study design for mental health research in Malawi. More studies were conducted on women (21.2%, n = 48) compared to men (1.3%, n = 3). Mental health research was concentrated in the southern region of the country (44.8%, n = 120) and in the three cities of Lilongwe (17.9%, n = 48), Blantyre (16.4%, n = 44) and Zomba (9.0%, n = 24). Conclusion: This systematic mapping suggests that there are few studies on mental health in Malawi which are not equally distributed across the country. There is a pressing need to conduct more mental health research using robust designs across disciplines. Contribution: Research on mental health is urgently needed to produce culturally acceptable data in Malawi.

Experiential Training Workshops for Group Antenatal Care in Malawi.

The positive effects of the CenteringPregnancy group antenatal care (ANC) model on perinatal outcomes in the United States has led to its adaptation and implementation in many low- and middle-income countries. Facilitative discussions are a core component of this group ANC model. Facilitator training lays a critical foundation for delivery of this paradigm-shifting model as practitioners learn to adapt their approach to health education from didactive to facilitative. However, there is little rigorous research focused on best practices for training group health care facilitators and none that is guided by a theoretical framework. Kolb's experiential learning theory offers a theoretical framework to guide the development of training workshops that allow trainees to experience, reflect on, and practice the facilitation skills needed to deliver this evidence-based intervention. This article describes an experiential learning-based training workshop that was implemented as part of an ongoing effectiveness-implementation trial of a Centering-based group ANC model in Blantyre District, Malawi. We provide a blueprint for conducting group ANC facilitator trainings that, in addition to imparting knowledge, effectively builds confidence and buy-in to this paradigm-changing approach to ANC delivery. This blueprint can be adapted for use in designing and implementing group health care across settings in the United States and globally.

Acceptability and feasibility of a screening protocol for antenatal depression (SPADe) in Blantyre District, Malawi.

BACKGROUND: Depression is one of the most common perinatal mental health problems that affect pregnant women. Antenatal depression can adversely affect the well-being of the pregnant woman and her foetus. Depression is rarely detected by midwives due to the unavailability of relevant screening instruments in Malawi. A Screening Protocol for Antenatal Depression (SPADe) was developed and recommended for possible use to screen for depression in antenatal clinics in the country. The acceptability and feasibility of using the SPADe protocol to screen for depression has not been established. The aim of this study was to assess the acceptability and feasibility of screening for depression by midwives using SPADe in antenatal clinics in Blantyre district. METHODS: This study used a quantitative survey design to collect data among 60 midwives in three antenatal clinics in primary care settings. All inclusive sampling of all 60 midwives were used. The Structured Assessment of FEasibility and Ottawa Acceptability of Decision Rules Instruments were used to collect the data. Descriptive statistics and Chi square tests were used to analyse the data. RESULTS: This study found that it was feasible to implement SPADe and the following enablers for screening depression had the highest ratings: the SPADe is applicable to pregnant women (M = 3.9, sd = 0.4); the intended goal of the SPADe matches the prioritised goals of Malawi Ministry of Health (M = 3.9, sd = 0.5); and the SPADe is likely to be effective (M = 3.8, sd = 0.6). On the other hand, barriers for implementing the SPADe were: the need for specific training to deliver the SPADe (M = 3.7, sd = 0.7); ongoing support and supervision (M = 3.5, sd = 0.8); and additional resources (M = 3.0, sd = 0.9). This study also found that the implementation of the SPADe was acceptable to respondents. The overall mean score for respondents on acceptability of screening antenatal depression using SPADe was found to be high (M = 4.6, sd = 0.6). However the differences in the respondents' mean scores on acceptability of screening for depression in antenatal clinics using SPADe in relation to their demographic characteristics were not significant (p > .05). CONCLUSION: This study suggests that midwives feel that it is feasible and acceptable for them to implement the SPADe in antenatal clinics with ongoing training, support and clinical supervision.

Experiences of nurse managers and practitioners on implementation of an evidence-based practice intervention.

Background: An evidence based practice (EBP) research project was undertaken to implement EBP interventions utilising the Iowa model in order to build the capacity of the nurses in using research evidence to improve decision making and quality care. Aim: Exploring and understanding the experiences of nurse managers and practitioners who participated in the EBP change project. Setting: The study was conducted in the intensive care unit (ICU) of a tertiary hospital in Lilongwe district in Malawi. Methods: A qualitative approach and an exploratory-descriptive design was employed. The ICU was purposively selected as a unit where the EBP change project was implemented. A purposive sample of 10 nurse managers and practitioners was selected. Semi-structured interviews were conducted. All interviews were audio-recorded with a digital recorder and transcribed verbatim. Thematic analysis was applied to the transcripts. Results: The participants' experiences of implementing EBP interventions were underpinned by four themes namely, evidence-based patient management, effective nursing care, competence in delivering EBP, and factors interplaying in EBP. Use of model, protocol and availability of supportive managers and team were major determinants of EBP. Conclusion: It is recommended to continue utilising the Iowa Model to facilitate building the EBP capacities of providers during scale up. Contribution: Utilising the Iowa Model facilitates building of the capacity and empowers frontline nurses to effectively develop, implement and evaluate discipline specific EBP changes needed to improve practice and optimum care.

Healthcare workers' perceptions on collaborative capacity at a Referral Hospital in Malawi.

BACKGROUND: Lack of collaborative capacity results in provision of fragmented health services that do not meet the needs of patients. Collaborative capacity refers to the extent to which providers have influence over other healthcare workers' decision-making, and can be assessed by measuring perceptions of task interdependence, quality of interaction and collaborative influence. However, each healthcare worker may present differing perceptions that can influence their ability to collaborate effectively during provision of care. No studies that specifically assessed healthcare workers' perception of collaborative capacity in Malawi were identified. AIM: To assess the perceptions of healthcare workers regarding collaborative capacity in Malawi. SETTING: The study was conducted at a tertiary public hospital in Blantyre city, Malawi. METHODS: The study employed a quantitative cross-sectional correlational design. The instrument used was a Care Coordination survey that had been used previously in similar studies in the United States of America. Descriptive statistics as well as univariate and multivariate analysis were computed using Statistical Package for Social Science (SPSS) program version 21.0 (IBM, Armonk, NY, USA). RESULTS: A total of 384 healthcare workers participated in the study, with a response rate of 100%. There were differences in perceptions of collaborative capacity based on the cadre of the respondent (p < 0.005). Medical staff reported higher mean scores on quality of interaction (2.94) and collaborative influence (2.65), whereas technical support staff reported the lowest mean scores across all three measures of collaborative capacity (≤ 2.4). CONCLUSION: Differences in perceptions about collaborative capacity suggest the need for interventions to enhance interprofessional collaboration. CONTRIBUTION: The study will inform strategies to promote interprofessional collaboration.

Protocol for assessing feasibility, acceptability and fidelity of screening for antenatal depression (FAFSAD) by midwives in Blantyre District, Malawi.

BACKGROUND: Depression is often underdiagnosed by treating health professionals. This is a situation in Malawi where there is no routine screening of depression at antenatal clinics. Recently, a Screening Protocol for Antenatal Depression (SPADe) that can be used by midwives to screen for antenatal depression was developed in Blantyre District. SPADe proposes multistage screening of antenatal depression by midwives which may enable early detection and treatment of pregnant women with depression. Proper treatment of antenatal depression can assist in achieving Sustainable Development Goals (SDGs). However, utilisation of SPADe in clinical practice to screening for depression in antenatal clinics has not been established yet. Therefore, the primary aim of this study is to assess feasibility of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. The secondary aim was to assess acceptability and fidelity of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. METHODS: This will be a feasibility study which will consist of scientific investigations that will support movement of evidence-based, effective health care approach, SPADe, from the clinical knowledge base into routine use. This study will consist three phases: phase 1 will introduce SPADe in antenatal clinics in Blantyre District where screening of depression is almost none existent; phase 2 will implement screening of depression using SPADe in antenatal clinics in Blantyre District; and phase 3 will evaluate the screening of antenatal depression using SPADe to establish its feasibility, acceptability and fidelity in antenatal clinics in Blantyre District. DISCUSSION: This study will establish and document feasibility, acceptability and fidelity of screening for depression by midwives using SPADe in antenatal clinics in Blantyre District. It is expected that midwives will develop more confidence in detecting and dealing with antenatal depression. Consequently, there will be increased numbers of pregnant women detected with depression by midwives and increased accessibility to mental health care by pregnant women in antenatal clinics.

The roles and experiences of preceptors in clinical teaching of undergraduate nursing and midwifery students in Malawi.

Introduction: Clinical teaching is essential for undergraduate nursing and midwifery students. Registered nurses/midwives trained as preceptors (an experienced nursing/midwifery professional who teaches, supervises and serves as a role model for a student), guide the students during clinical practices. Literature is scanty on the roles and experiences of the preceptors in Malawi. This study explored the roles and experiences of preceptors during clinical teaching of the students. Methods: A cross-sectional study utilising quantitative research design was conducted at four tertiary level hospitals; a mental hospital; one mission hospital and five district hospitals. A total of 87 preceptors completed a Clinical Preceptor Experience Evaluation Tool. Data were analysed using SPSS version 20 and descriptive statistics were computed. Analysis of variance (ANOVA) and post hoc analysis were used to determine and test significant differences. Results: The study revealed that respondents were confident in performing their preceptor role; with good level of experience and education qualification of BSc in Nursing. ANOVA and post hoc comparisons using the Tukey HSD test indicated that the role domain mean scores for the respondents with 4-5 years of post-registration experience (M = 6.61, SD = 0.36) was significantly different (p=0.02) with those with >9 years (M = 6.13, SD = 0.60). The results showed that respondents with 4 -5 years experience were more confident in their preceptorship role than those with >9 years. Conclusion: This study indicates the roles of preceptors in Malawi to involve facilitating students' clinical teaching and learning. It suggests that registered nurses/midwives with a BSc in Nursing are suitable preceptors to facilitate students' clinical teaching and learning. There is revelation that preceptors with more years of post-registration experience are less confident in their preceptorship role performance.

Experiences of health care workers' on interprofessional collaborative practice at Mzuzu Central and Ntcheu District hospitals.

Background: Interprofessional collaborative practice (ICP) is a new approach to delivery of health care. It is the practice which happens when healthcare providers work together with different professionals such as nurse/midwives, medical officers towards a common goal to improve patient outcomes.There is no evidence on healthcare workers' experiences on ICP in Malawi and a study on healthcare workers experiences would provide insight towards ICP. The objective of this study was to describe healthcare workers' experiences on ICP in model wards. Methods: We conducted a qualitative exploratory descriptive study at Mzuzu Central and Ntcheu District Hospitals. We purposely selected nurses, clinical officers and medical doctors out of 25 sampled healthcare workers working in model wards. Data were collected through in-depth interviews using a semi-structured interview guide. Hospital authorities provided permission to conduct the study in their sites. Informed consent was obtained from participants before interviews. The study was approved by College of Medicine Research Committee (COMREC). Content analysis was utilized to analyse data. Results: Four key themes emerged describing healthcare workers experiences on ICP:Increased management/leadership support in terms of resources and structures, good communication among staff, learning together as group of qualified healthcare workers and students and increased teamwork. Conclusion: This study highlights healthcare workers' experiences on ICP: management support, communication, learning together of healthcare workers and teamwork. Findings can be used to inform management and practice for the development and implementation of ICP in service delivery.

"Youth Photovoice": Promoting Youth-Driven Community Changes for HIV Prevention in Rural Malawi.

ABSTRACT: To meet the Joint United Nations Programme on HIV/AIDS global goal of no new HIV infections by 2030, it is imperative to reduce new infections among youth. Youth Photovoice was a 10-month, participatory, community-action research project developed to engage rural Malawi youth in an HIV prevention project focused on community-level outcomes. In this study, we describe how participants in Youth Photovoice engaged adults and community leaders to implement action plans, as well as the community and individual changes that occurred as a result of these collaborative efforts. Youth Photovoice participants, their parents, and local leaders in the community participated in focus groups and individual interviews. Community-level changes, such as moving initiation ceremonies to churches and changes to local business practices, were observed, along with increased community and parental involvement in youth monitoring for local events and activities. This youth-led project led to changes in the community environment that reduced exposure to situations supporting unsafe sex, uncovered ways that youth can lead collaborations with adults, and informed the implementation of plans for community action.

Knowledge deficit on health promotion activities during pregnancy: the case for adolescent pregnant women at Chiladzulu District, Malawi.

BACKGROUND: Adolescent pregnancy is a public health concern in Malawi as it is associated with high risks of adverse pregnancy outcomes. Almost 29% of adolescent women aged 15-19 years are already mothers and adolescent fertility rate is also high estimated at 136 per 1000 women. Therefore, the aim of the study was to explore knowledge of pregnant adolescents on importance of antenatal care and health promotion during pregnancy. METHODS: A qualitative descriptive design was used to solicit information on significance of antenatal care and how adolescents promote their health during pregnancy. Data was collected from 77 pregnant adolescents, purposively sampled from Namitambo and Namadzi Heath Centres in Chiladzulu District, Malawi. A semi-structured interview guide was used for data collection. Data were analysed manually following principles of qualitative content analysis. RESULTS: Themes that emerged from the qualitative data included: knowledge deficit on the purpose and benefits of antenatal care; knowledge deficit on services offered at antenatal care clinic; knowledge deficit on danger signs during antenatal period and antenatal emergency care; knowledge deficit on effects of alcohol and smoking; knowledge deficit on nutrition during pregnancy; and knowledge deficit on importance of rest during pregnancy. CONCLUSION: This study has shown knowledge deficit among adolescent mothers that may contribute to poor pregnancy outcomes. Several factors could be attributed to such knowledge deficit. Therefore, healthcare systems and healthcare professionals have a responsibility to enhance health literacy of pregnant adolescents with an ultimate goal of improving maternal and neonatal health outcomes.

An effectiveness-implementation hybrid type 1 trial assessing the impact of group versus individual antenatal care on maternal and infant outcomes in Malawi.

BACKGROUND: Sub-Saharan Africa has the world's highest rates of maternal and perinatal mortality and accounts for two-thirds of new HIV infections and 25% of preterm births. Antenatal care, as the entry point into the health system for many women, offers an opportunity to provide life-saving monitoring, health promotion, and health system linkages. Change is urgently needed, because potential benefits of antenatal care are not realized when pregnant women experience long wait times and short visits with inconsistent provisioning of essential services and minimal health promotion, especially for HIV prevention. This study answers WHO's call for the rigorous study of group antenatal care as a transformative model that provides a positive pregnancy experience and improves outcomes. METHODS: Using a hybrid type 1 effectiveness-implementation design, we test the effectiveness of group antenatal care by comparing it to individual care across 6 clinics in Blantyre District, Malawi. Our first aim is to evaluate the effectiveness of group antenatal care through 6 months postpartum. We hypothesize that women in group care and their infants will have less morbidity and mortality and more positive HIV prevention outcomes. We will test hypotheses using multi-level hierarchical models using data from repeated surveys (four time points) and health records. Guided by the consolidated framework for implementation research, our second aim is to identify contextual factors related to clinic-level degree of implementation success. Analyses use within and across-case matrices. DISCUSSION: This high-impact study addresses three global health priorities, including maternal and infant mortality, HIV prevention, and improved quality of antenatal care. Results will provide rigorous evidence documenting the effectiveness and scalability of group antenatal care. If results are negative, governments will avoid spending on less effective care. If our study shows positive health impacts in Malawi, the results will provide strong evidence and valuable lessons learned for widespread scale-up in other low-resource settings. Positive maternal, neonatal, and HIV-related outcomes will save lives, impact the quality of antenatal care, and influence health policy as governments make decisions about whether to adopt this innovative healthcare model. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT03673709. Registered on September 17, 2018.

Developing Action Plans in Youth Photovoice to Address Community-Level HIV Risk in Rural Malawi.

Youth-driven approaches to HIV prevention can engage youth and improve health outcomes. Photovoice has been used to engage youth in identifying the assets and challenges in their communities. In sub-Saharan Africa, youth remain vulnerable to HIV infection. This article describes a photovoice project, named Youth Photovoice, conducted in rural Malawi, which focused on community places and situations relating to risky sexual behaviors that place youth at risk of HIV infection. Twenty-four youth, ages 13-17 (12 males and 12 females), participated in Youth Photovoice. During the photovoice process, youth identified five community situations and places that put them at risk of unsafe sex and thus HIV infection: initiation ceremonies, isolated places, community celebrations, local businesses such as bars and rest houses, and church-sponsored activities. Youth used a systematic action planning process to develop action plans. They presented their action plans to local leaders and parents. Parents and leaders responded positively and agreed to help the youth carry out their plans. If their plans to address community situations that put them at risk of unsafe sex succeed, there will be a direct impact on reducing the risk of HIV infection among youth. Youth Photovoice provided the opportunity for youth to obtain new skills, build new partnerships, and present their ideas to community leaders. Integrating this action planning process into photovoice helped to guide the youth toward actualizing their HIV prevention plans in their community. This process can increase the effectiveness of photovoice initiatives to address other community issues in a wide variety of settings.

A hybrid design testing a 3-step implementation model for community scale-up of an HIV prevention intervention in rural Malawi: study protocol.

BACKGROUND: Scaling-up evidence-based behavior change interventions can make a major contribution to meeting the UNAIDS goal of no new HIV infections by 2030. We developed an evidence-based peer group intervention for HIV prevention and testing in Malawi that is ready for wider dissemination. Our innovative approach turns over ownership of implementation to rural communities. We adapted a 3-Step Implementation Model (prepare, roll-out and sustain) for communities to use. Using a hybrid design, we simultaneously evaluate community implementation processes and program effectiveness. METHODS: Three communities in southern Malawi begin implementation in randomly-assigned order using a stepped wedge design. Our evaluation sample size of 144 adults and 144 youth per community provides sufficient power to examine primary outcomes of condom use and HIV testing. Prior to any implementation, the first participants in all three communities are recruited and complete the Wave 1 baseline survey. Waves 2-4 surveys occur after each community completes roll-out. Each community follows the model's three steps. During Prepare, the community develops a plan and trains peer group leaders. During Roll-Out, peer leaders offer the program. During Sustain, the community makes and carries out plans to continue and expand the program and ultimately obtain local funding. We evaluate degree of implementation success (Aim 1) using the community's benchmark scores (e.g, # of peer groups held). We assess implementation process and factors related to success (Aim 2) using repeated interviews and observations, benchmarks from Aim 1 and fidelity assessments. We assess effectiveness of the peer group intervention when delivered by communities (Aim 3) using multi-level regression models to analyze data from repeated surveys. Finally, we use mixed methods analyses of all data to assess feasibility, acceptability and sustainability (Aim 4). DISCUSSION: The project is underway, and thus far the first communities have enthusiastically begun implementation. We have had to make several modifications along the way, such as moving from rapid-tests of STIs to symptoms screening by a nurse due to problems with test reliability and availability. If successful, results will provide a replicable evidence-based model for future community implementation of this and other health interventions. TRIAL REGISTRATION: Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Substance Use and Risky Sexual Behaviors Among Young Men Working at a Rural Roadside Market in Malawi.

Using an ecological model, we describe substance use and sexual risk behaviors of young male laborers at a roadside market in Malawi. Data included observations and interviews with 18 key market leaders and 15 laborers (ages 18-25 years). Alcohol, marijuana, and commercial sex workers (CSWs) were widely available. We identified three patterns of substance use: 6 young men currently used, 6 formerly used, and 3 never used. Substance use was linked to risky sex, including sex with CSWs. The market supported risky behaviors through availability of resources; supportive norms, including beliefs that substance use enhanced strength; and lack of restraints. Community-level poverty, cultural support for alcohol, interpersonal family/peer influences, early substance use, and school dropout also contributed to risky behaviors. Parental guidance was protective but not often reported. Local programs addressing substance use and risky sex simultaneously and better national substance use policies and mental health services are needed.

Participation and diffusion effects of a peer-intervention for HIV prevention among adults in rural Malawi.

This paper examines whether a peer group intervention that reduced self-reported risky behaviors for rural adults in Malawi also had impacts on non-participants in the same communities. We randomly assigned two districts to the intervention and control conditions, and conducted surveys at baseline and 18 months post-intervention using unmatched independent random samples of intervention and control communities in 2003-2006. The six-session peer group intervention was offered to same-gender groups by trained volunteers. In this analysis, we divided the post-intervention sample into three exposure groups: 243 participants and 170 non-participants from the intervention district (total n = 415) and 413 control individuals. Controlling for demographics and participation, there were significant favorable diffusion effects on five partially overlapping behavioral outcomes: partner communication, ever used condoms, unprotected sex, recent HIV test, and a community HIV prevention index. Non-participants in the intervention district had more favorable outcomes on these behaviors than survey respondents in the control district. One behavioral outcome, community HIV prevention, showed both participation and diffusion effects. Participating in the intervention had a significant effect on six psychosocial outcomes: HIV knowledge (two measures), hope, condom attitudes, and self-efficacy for community HIV prevention and for safer sex; there were no diffusion effects. This pattern of results suggests that the behavioral changes promoted in the intervention spread to others in the same community, most likely through direct contact between participants and non-participants. These findings support the idea that diffusion of HIV-related behavior changes can occur for peer group interventions in communities, adding to the body of research supporting diffusion of innovations theory as a robust approach to accelerating change. If diffusion occurs, peer group intervention may be more cost-effective than previously realized. Wider implementation of peer group interventions can help meet the global goal of reducing new HIV infections.

HIV Risk Reduction Intervention for Rural Adolescents in Malawi.

Malawian adolescents are at risk for HIV infection. Using a quasi-experimental two group research design, we determined the efficacy of Mzake ndi Mzake Kuunikira Achinyamata (MMKA) in enhancing 13-19 year old Malawian males' and females' HIV knowledge, attitude about HIV, self-efficacy for condom use and for safer sex, and HIV risk reduction behaviors. The regression analyses revealed that compared to their cohorts in the control community, the adolescents in the MMKA community had significantly better scores on the outcome variables. The intervention had significant benefits for male and 16-19 year old adolescents, but not for 13-15 year old female adolescents. Tailored interventions are needed for these females.

Changes in clients' care ratings after HIV prevention training of hospital workers in Malawi.

OBJECTIVE: To examine the changes in clients' health-care ratings before and after hospital workers received an HIV prevention intervention in Malawi, which increased the workers' personal and work-related HIV prevention knowledge, attitudes and preventive behaviors. DESIGN: Pre- and post-intervention client surveys. SETTING: A large urban referral hospital in Malawi. PARTICIPANTS: Clients at purposefully selected inpatient and outpatient units on designated days (baseline, n = 310 clients; final, n = 683). INTERVENTION: Ten-session peer-group intervention for health workers focused on HIV transmission, personal and work-related prevention, treating clients and families respectfully and incorporating HIV-related teaching. MAIN OUTCOME MEASURES: Brief face-to-face clients' interview obtaining ratings of confidentiality of HIV, whether HIV-related teaching occurred and ratings of service quality. RESULTS: Compared with baseline, at the final survey, clients reported higher confidence about confidentiality of clients' HIV status (83 vs. 75%, P < 0.01) and more clients reported that a health worker talked to them about HIV and AIDS (37 versus 28%, P < 0.01). More clients rated overall health services as 'very good' (five-item mean rating, 68 versus 59%, P < 0.01) and this was true for both inpatients and outpatients examined separately. However, there was no improvement in ratings of the courtesy of laboratory or pharmacy workers or of the adequacy of treatment instructions in the pharmacy. CONCLUSIONS: HIV prevention training for health workers can have positive effects on clients' ratings of services, including HIV-related confidentiality and teaching, and should be scaled-up throughout Malawi and in other similar countries. Hospitals need to improve laboratory and pharmacy services.

Outcomes of an HIV prevention peer group intervention for rural adults in Malawi.

This study used a quasi-experimental design to evaluate a six-session peer group intervention for HIV prevention among rural adults in Malawi. Two rural districts were randomly assigned to intervention and control conditions. Independent random samples of community adults compared the districts at baseline and at 6 and 18 months postintervention. Using multiple regressions controlling for six demographic factors, intervention district adults had significantly more favorable outcomes at 6- and 18-month evaluations for condom attitudes, self-efficacy for community prevention, self-efficacy for practicing safer sex, partner communication, using condoms ever in the past 2 months, and community prevention activities. Knowledge and hope for controlling the epidemic were significantly higher in the intervention district only at the 6-month evaluation; having a recent HIV test was significantly higher only at 18 months. Levels of stigma and the number of risky sex practices did not decrease when demographic factors were controlled. Expanding peer group intervention for HIV prevention would benefit rural adults.