Potential barriers to healthcare in Malawi for under-five children with cough and fever: a national household survey.

Failure to access healthcare is an important contributor to child mortality in many developing countries. In a national household survey in Malawi, we explored demographic and socioeconomic barriers to healthcare for childhood illnesses and assessed the direct and indirect costs of seeking care. Using a cluster-sample design, we selected 2,697 households and interviewed 1,669 caretakers. The main reason for households not being surveyed was the absence of a primary caretaker in the household. Among 2,077 children aged less than five years, 504 episodes of cough and fever during the previous two weeks were reported. A trained healthcare provider was visited for 48.0% of illness episodes. A multivariate regression model showed that children from the poorest households (p = 0.02) and children aged > 12 months (p = 0.02) were less likely to seek care when ill compared to those living in wealthier households and children of higher age-group respectively. Families from rural households spent more time travelling compared to urban households (68.9 vs 14.1 minutes; p < 0.001). In addition, visiting a trained healthcare provider was associated with longer travel time (p < 0.001) and higher direct costs (p < 0.001) compared to visiting an untrained provider. Thus, several barriers to accessing healthcare in Malawi for childhood illnesses exist. Continued efforts to reduce these barriers are needed to narrow the gap in the health and healthcare equity in Malawi.

Assessing the use of an essential health package in a sector wide approach in Malawi.

BACKGROUND: The sector wide approach (SWAp) used in many developing countries is difficult to assess. One way is to consider the essential health package (EHP) which is commonly the vehicle for a SWAp's policies and plans. It is not possible to measure the impact of an EHP by measuring health outcomes in countries such as Malawi. But it is possible to assess the choice of interventions and their delivery in terms of coverage. This paper describes an attempt to assess the Malawi SWAp through its EHP using these available measures of technical efficiency. METHODS: A burden of disease model was used to identify the priority diseases and their estimated incidence. Data from the health management information system (HMIS) were used to measure the coverage of these interventions. A review of the cost-effectiveness of the chosen and potential interventions was undertaken to assess the appropriateness of each intervention used in the EHP. Expenditure data were used to assess the level of funding of the EHP. RESULTS: 33 of the 55 EHP interventions were found to be potentially cost-effective (<$150/DALY), 12 were not so cost-effective (>$150/DALY) and cost-effective estimates were not available for ten. 15 potential interventions, which were cost-effective and tackling one of the top 20 ranked diseases, were identified.Provision had increased in nearly all EHP services over the period of the SWAp. The rates of out patient attendances and inpatient days per 1000 population had both increased from 929 attendances in 2002/3 to 1135 in 2007/08 and from 124 inpatient days in 2002/03 to 179 in 2007/08.However, by 2007/08 the mean gap between what was required and what was provided was 0.68 of the estimated need. Two services involving the treatment of malaria were overprovided, but the majority were underprovided, with some such as maternity care providing less than half of what was required.The EHP was under-funded throughout the period covering on average 57% of necessary costs. By 2007/08 the funding paid by SWAp partners including the government of Malawi to fund the EHP was at US$13.5 per capita per annum, which was almost half of the revised EHP estimated required expenditure per capita per annum. DISCUSSION: The SWAp had invested in some very cost-effective health interventions. In terms of numbers of patients treated, the EHP had delivered two thirds of the services required. This was despite serious under-funding of the EHP, an increase in the population and shortage of staff. CONCLUSIONS: The identification of interventions of proven effectiveness and good value for money and earmarked funding through a SWAp process can produce measurable improvement in health service delivery at extremely low cost.

Changing clinical needs of people living with AIDS and receiving home based care in Malawi--the Bangwe Home Based Care Project 2003-2008--a descriptive study.

BACKGROUND: Home based care (HBC) has been an important component of the response to the AIDS epidemic in Africa, and particularly so before antiretroviral therapy (ART) became available. Has HBC become unnecessary now that ART is available in many African countries? One way to investigate this is to assess the changing need for comprehensive HBC as an ART programme becomes available. The Bangwe HBC programme in Malawi has been collecting data since 2003 before ART became available in 2005/6. Has the introduction of ART changed the clinical needs for HBC? METHODS: Information obtained at initial assessment and follow up visits of patients receiving HBC were combined to assess case severity, survival and the response to treatment. This information was used to assess trends in mortality and the incidence, duration and severity of common symptoms over a six year period in a defined urban population in Malawi. RESULTS: 1266 patients, of whom 1190 were followed up and of whom 652 (55%) died, were studied. 282 (25%) patients died within two months of being first seen with an improvement between 2003-2005 and 2006-2008 of reduced mortality from 28% to 20%. 341 (27%) patients were unable to care for themselves on first assessment and 675 (53%) had stage 4 AIDS disease. Most patients had a mix of symptoms at presentation. Self care increased somewhat over the six years although case severity as measured by WHO staging and nutritional status did not.350 patients were on ART either started before or after initial assessment. There were significant barriers to accessing ART with 156 (51%) of 304 stage 3 or 4 patients first assessed in 2007 or 2008 not receiving ART.Over the six year period new HBC cases reduced by 8% and follow up visits increased by 9% a year. Between 4 and 5 people sought HBC for the first time each week from an urban health centre catchment of 100,000, which required 37.3 follow up visits each week. CONCLUSIONS: Since the availability of ART in the local health facilities and despite strenuous efforts to persuade people to seek HIV testing and ART, in practice barriers existed and half the eligible HBC patients did not have access to ART. This is one reason why the clinical need for HBC services had not changed much. In terms of quantity of care the number of new patients seeking HBC reduced by 8% a year. In terms of content of care, while there had been a marginal increase in self care the severity of illness had not changed and the survival of a significant proportion of patients generated the need for repeat visits, which increased by 9% a year. In conclusion, although the content has changed the need for HBC has not diminished despite the availability of ART.

Selecting HIV infection prevention interventions in the mature HIV epidemic in Malawi using the mode of transmission model.

BACKGROUND: Malawi is reassessing its HIV prevention strategy in the light of a limited reduction in the epidemic. No community based incidence studies have been carried out in Malawi, so estimates of where new infections are occurring require the use of mathematical models and knowledge of the size and sexual behaviour of different groups. The results can help to choose where HIV prevention interventions are most needed. METHODS: The UNAIDS Mode of Transmission model was populated with Malawi data and estimates of incident cases calculated for each exposure group. Scenarios of single and multiple interventions of varying success were used to identify those interventions most likely to reduce incident cases. RESULTS: The groups accounting for most new infections were the low-risk heterosexual group - the discordant couples (37%) and those who had casual sex and their partners (a further 16% and 27% respectively) of new cases.Circumcision, condoms with casual sex and bar girls and improved STI treatment had limited effect in reducing incident cases, while condom use with discordant couples, abstinence and a zero-grazing campaign had major effects. The combination of a successful strategy to eliminate multiple concurrent partners and a successful strategy to eliminate all infections between discordant couples would reduce incident cases by 99%. CONCLUSIONS: A revitalised HIV prevention strategy will need to include interventions which tackle the two modes of transmission now found to be so important in Malawi - concurrency and discordancy.

Understanding job satisfaction amongst mid-level cadres in Malawi: the contribution of organisational justice.

The migration of doctors and nurses from low- to high-income countries has left many countries relying on mid-level cadres as the mainstay of their health delivery system, Malawi being an example. Although an extremely important resource, little attention has been paid to the management and further development of these cadres. In this paper we use the concept of organisational justice - fairness of treatment, procedures and communication on the part of managers - to explore through a questionnaire how mid-level cadres in jobs traditionally done by higher-level cadres self-assessed their level of job satisfaction. All mid-level health workers present on the day of data collection in 34 health facilities in three health districts of Malawi, one district each from the three geographical regions, were invited to participate; 126 agreed. Perceptions of justice correlated strongly with level of job satisfaction, and in particular perceptions of how well they were treated by their managers and the extent to which they were informed about decisions and changes. Pay was not the only important element in job satisfaction; promotion opportunities and satisfaction with current work assignments were also significant. These findings highlight the important role that managers can play in the motivation, career development and performance of mid-level health workers.

Retention of health workers in Malawi: perspectives of health workers and district management.

BACKGROUND: Shortage of human resources is a major problem facing Malawi, where more than 50% of the population lives in rural areas. Most of the district health services are provided by clinical health officers specially trained to provide services that would normally be provided by fully qualified doctors or specialists. As this cadre and the cadre of enrolled nurses are the mainstay of the Malawian health service at the district level, it is important that they are supported and motivated to deliver a good standard of service to the population. This study explores how these cadres are managed and motivated and the impact this has on their performance. METHODS: A quantitative survey measured health workers' job satisfaction, perceptions of the work environment and sense of justice in the workplace, and was reported elsewhere. It emerged that health workers were particularly dissatisfied with what they perceived as unfair access to continuous education and career advancement opportunities, as well as inadequate supervision. These issues and their contribution to demotivation, from the perspective of both management and health workers, were further explored by means of qualitative techniques.Focus group discussions were held with health workers, and key-informant interviews were conducted with members of district health management teams and human resource officers in the Ministry of Health. The focus groups used convenience sampling that included all the different cadres of health workers available and willing to participate on the day the research team visited the health facility. The interviews targeted district health management teams in three districts and the human resources personnel in the Ministry of Health, also sampling those who were available and agreed to participate. RESULTS: The results showed that health workers consider continuous education and career progression strategies to be inadequate. Standard human resource management practices such as performance appraisal and the provision of job descriptions were not present in many cases. Health workers felt that they were inadequately supervised, with no feedback on performance. In contrast to health workers, managers did not perceive these human resources management deficiencies in the system as having an impact on motivation. CONCLUSION: A strong human resource management function operating at the district level is likely to improve worker motivation and performance.

Measuring and managing the work environment of the mid-level provider--the neglected human resource.

BACKGROUND: Much has been written in the past decade about the health workforce crisis that is crippling health service delivery in many middle-income and low-income countries. Countries having lost most of their highly qualified health care professionals to migration increasingly rely on mid-level providers as the mainstay for health services delivery. Mid-level providers are health workers who perform tasks conventionally associated with more highly trained and internationally mobile workers. Their training usually has lower entry requirements and is for shorter periods (usually two to four years). Our study aimed to explore a neglected but crucial aspect of human resources for health in Africa: the provision of a work environment that will promote motivation and performance of mid-level providers. This paper explores the work environment of mid-level providers in Malawi, and contributes to the validation of an instrument to measure the work environment of mid-level providers in low-income countries. METHODS: Three districts were purposely sampled from each of the three geographical regions in Malawi. A total of 34 health facilities from the three districts were included in the study. All staff in each of the facilities were included in the sampling frame. A total of 153 staff members consented to be interviewed. Participants completed measures of perceptions of work environment, burnout and job satisfaction. FINDINGS: The Healthcare Provider Work Index, derived through Principal Components Analysis and Rasch Analysis of our modification of an existing questionnaire, constituted four subscales, measuring: (1) levels of staffing and resources; (2) management support; (3) workplace relationships; and (4) control over practice. Multivariate analysis indicated that scores on the Work Index significantly predicted key variables concerning motivation and attrition such as emotional exhaustion, job satisfaction, satisfaction with the profession and plans to leave the current post within 12 months. Additionally, the findings show that mid-level medical staff (i.e. clinical officers and medical assistants) are significantly less satisfied than mid-level nurses (i.e. enrolled nurses) with their work environments, particularly their workplace relationships. They also experience significantly greater levels of dissatisfaction with their jobs and with their profession. CONCLUSION: The Healthcare Provider Work Index identifies factors salient to improving job satisfaction and work performance among mid-level cadres in resource-poor settings. The extent to which these results can be generalized beyond the current sample must be established. The poor motivational environment in which clinical officers and medical assistants work in comparison to that of nurses is of concern, as these staff members are increasingly being asked to take on leadership roles and greater levels of clinical responsibility. More research on mid-level providers is needed, as they are the mainstay of health service delivery in many low-income countries. This paper contributes to a methodology for exploring the work environment of mid-level providers in low-income countries and identifies several areas needing further research.

The geographical distribution of lymphatic filariasis infection in Malawi.

Mapping distribution of lymphatic filariasis (LF) is a prerequisite for planning national elimination programmes. Results from a nation wide mapping survey for lymphatic filariasis (LF) in Malawi are presented. Thirty-five villages were sampled from 23 districts excluding three districts (Karonga, Chikwawa and Nsanje) that had already been mapped and Likoma, an Island, where access was not possible in the time frame of the survey. Antigenaemia prevalence [based on immunochromatographic card tests (ICT)] ranged from 0% to 35.9%. Villages from the western side of the country and distant from the lake tended to be of lower prevalence. The exception was a village in Mchinji district on the Malawi-Zambia border where a prevalence of 18.2% was found. In contrast villages from lake shore districts [Salima, Mangochi, Balaka and Ntcheu (Bwanje valley)] and Phalombe had prevalences of over 20%.A national map is developed which incorporates data from surveys in Karonga, Chikwawa and Nsanje districts, carried out in 2000. There is a marked decline in prevalence with increasing altitude. Further analysis revealed a strong negative correlation (R2 = 0.7 p < 0.001) between altitude and prevalence. These results suggest that the lake shore, Phalombe plain and the lower Shire valley will be priority areas for the Malawi LF elimination programme. Implications of these findings as regards implementing a national LF elimination programme in Malawi are discussed.

Malaria control in Malawi: are the poor being served?

BACKGROUND: In Africa, national governments and international organizations are focusing on rapidly "scaling up" malaria control interventions to at least 60 percent of vulnerable populations. The potential health and economic benefits of "scaling up" will depend on the equitable access to malaria control measures by the poor. This paper analyses the present inequalities in access to malaria interventions in Malawi. METHODS: Equity in access to malaria control measures was assessed using the Malawi Demographic Health Survey (DHS) 2000 and the 2004 national survey on malaria control. Utilisation of malaria control methods was compared across the wealth quintiles, to determine whether the poor were being reached with malaria control measures. RESULTS: Overall ITN coverage increased from 5% in 2000 to 35% in 2004. However, there was a disproportionate concentration of ITNs amongst the least poor compared to the poorest group. Effective treatment of fever remains unacceptably low with only 17% of the under-five children being promptly treated with an effective antimalarial drug. And only 29 percent of pregnant women received the recommended dose of at least two doses during the pregnancy. No income related inequalities were associated with prompt treatment and IPT use. CONCLUSION: The present distribution strategies for ITNs are not addressing the needs of the vulnerable groups, especially the poor. Increasing access to ITNs by the poor will require innovative distribution models which deliberately target the poorest of the poor.

The pattern of symptoms in patients receiving home based care in Bangwe, Malawi : a descriptive study.

BACKGROUND: Home based care of HIV/AIDS patients is a health need recommended but not often available in Africa. Population based assessment helps to identify unmet health needs to plan services. Careful assessment and follow up of patients receiving home based care in a defined population of Bangwe, Malawi provides details of the frequency and severity of common symptoms. METHODS: Mortality and the incidence, duration and severity of common symptoms of patients in a defined population receiving home based care were measured over an eighteen month period. RESULTS: 358 patients, of whom 199 died, were studied. A third of patients died within 4 months of being first seen. About half the patients were unable to care for themselves on first assessment. Half were malnourished with a Body Mass Index (BMI) < 18.5 kg/m2. Most patients had a mixture of symptoms at presentation. These symptoms responded to treatment usually within a fortnight. However a small proportion (5%) of patients suffered repeated episodes often as many as 6-9 times a year. Incidence rates are estimated. CONCLUSION: Symptoms which are alleviated by simple treatments are common. The patients in whom symptoms recur need a responsive home based care service. Population based estimates of incidence and duration of disease and the visit work load allow an assessment of home based care needs in an urban setting in Africa.

An assessment of food supplementation to chronically sick patients receiving home based care in Bangwe, Malawi: a descriptive study.

BACKGROUND: The effect of food supplementation provided by the World Food Programme to patients and their families enrolled in a predominantly HIV/AIDS home based care programme in Bangwe Malawi is assessed. METHODS: The survival and nutritional status of patients and the nutritional status of their families recruited up to six months before a food supplementation programme started are compared to subsequent patients and their families over a further 12 months. RESULTS: 360 patients, of whom 199 died, were studied. Food supplementation did not improve survival but had an effect (not statistically significant) on nutritional status. Additional oil was given to some families; it may have improved survival but not nutritional status. CONCLUSION: Food supplementation to HIV/AIDS home based care patients and their families does not work well. This may be because the intervention is too late to affect the course of disease or insufficiently targeted perhaps due to problems of distribution in an urban setting. The World Food Programme's emphasis on supplementary feeding for these families needs to be reviewed.

A national survey of the prevalence of schistosomiasis and soil transmitted helminths in Malawi.

BACKGROUND: Past estimates have put the prevalence of schistosomiasis between 40% and 50% in the Malawi population overall based on studies undertaken ten years or more ago. More recent surveys in known high risk areas find similar levels. However control measures, changing ecology and migration may have led to changes in the prevalence of schistosomiasis in different parts of Malawi. A national schistosomiasis and soil-transmitted helminth (STH) survey was undertaken to measure the distribution, prevalence and intensity of infection in November 2002. METHODS: A school was selected randomly from a random sample of 30 Traditional Authorities stratified by six distinct ecological zones, and 1,664 year 3 pupils (9-10 year olds) were questioned about recent illnesses and "red urine". Samples of urine and faeces were examined for the presence of eggs using the standard Kato-Katz technique for soil-transmitted helminths and intestinal schistosomiasis and urine samples using the filtration technique for Schistosoma haematobium. RESULTS: The prevalence of Schistosoma mansoni is 0.4% (95% CI 0-1.3%), S. haematobium 6.9% (95% CI 1.9 - 11.9%), hookworm 1.3% (95% CI 0.4-2.3%), Ascariasis 0.5% (95% CI 0.1-1.0%) and trichuriasis 0% in year 3 pupils (modal age 10 years of age). Intensity of infection is low for all infections except for 2.5% who have high intensity S. haematobium infection. The "red urine" question is 67% sensitive and 80% specific for positive S. haematobium microscopy. CONCLUSIONS: The reduction in prevalences may be real as a result of recent control measures, or false if historical results were based on surveys of high risk populations. Another explanation is that this survey used an unrepresentative sample of schools. Detailed analysis suggests this is unlikely. Recommendations include the use of a 30% positive threshold for the "red urine" screening question to be used in schoolchildren in high prevalence areas. This survey, based on a national probability sample excluding the northern region lakeside area, finds much lower overall prevalence and intensity of schistosomiasis and STHs than previous estimates based on selected surveys. Disease control featuring chemotherapy may be having a profound effect. The localised nature of the distribution of the infections means that control programmes may work best if undertaken at district level or below. "Red urine" questionnaire surveys may help identify hot spots.

Long-term planning to meet UK government coronary heart disease revascularization targets.

The National Service Framework (NSF) for Coronary Heart Disease, published in the UK in 2000, gave target intervention rates of 750 procedures per million population (pmp) for both percutaneous transluminal angioplasty (PTCA) and coronary artery bypass graft (CABG). This paper describes how one Regional Office of the Department of Health, with CABG and PTCA rates of around half the NSF target levels, designed a strategy to plan rationally to meet the derived population need for these procedures. A bottom-up needs assessment model was used to predict the population need for these procedures for the Eastern Region of the UK. The Excel-based model took account of the effects of demographic change, anticipated reduction in incidence of heart disease due to primary prevention programmes and the expected improvement in cardiology and cardiac surgery technologies. The model predicted that excess procedures would be required across the region over the next 20 years. Further access study modelling was used to determine the best location for additional tertiary cardiac centres. Further, a commissioning tool was produced that could compare the predicted need, including additional procedures needed to meet waiting list targets, with capacity available from a range of providers. These tools have been used successfully in the Eastern Region to increase the regional revascularization rates from 371 pmp CABG and 322 pmp PTCA in 2000 to planned rates of 453 pmp CABG and 447 pmp PTCA in 2002/2003, to recommend the building of a new tertiary cardiac centre in Essex in the next decade and to inform the commissioning of revascularization rates in three coronary heart disease networks.

The burden of hypertension and its risk factors in Malawi: nationwide population-based STEPS survey.

Hypertension is the most common cause of cardiovascular diseases, accounting for at least half of haemorrhagic and ischaemic strokes, heart failure and renal failure in sub-Saharan Africa. However, population-based data to inform policies are scarce. Using the WHO STEPwise approach to chronic disease risk factor surveillance, a population-based nationwide survey was conducted on participants aged 25-64 years in Malawi. Detailed findings on the burden of hypertension are presented in this paper. Blood pressure (BP) was measured in 3727 participants. The age-standardised prevalence of hypertension (BP ≥140/90 mmHg) was 33.2% (95% CI 30.9-35.6%). Hypertension was more frequent in males than females (36.9% vs 29.9%), alcohol drinkers than non-drinkers (40.9% vs 31.6%), overweight than non-overweight (41.5% vs 30.7%) and increased with increasing age (21.4% in 25-34 years old vs 59.2% in 55-64 years old). Three-quarters of the participants said they never had their BP measured before and 94.9% of those with hypertension said they were not aware that they had such a medical problem. High prevalence of hypertension and its risk factors calls for the implementation of primary healthcare approaches such as the WHO package for essential non-communicable diseases to promote healthy lifestyles, early detection, treatment and control.

The burden of selected chronic non-communicable diseases and their risk factors in Malawi: nationwide STEPS survey.

BACKGROUND: Chronic non-communicable diseases (NCDs) are becoming significant causes of morbidity and mortality, particularly in sub-Saharan African countries, although local, high-quality data to inform evidence-based policies are lacking. OBJECTIVES: To determine the magnitude of NCDs and their risk factors in Malawi. METHODS: Using the WHO STEPwise approach to chronic disease risk factor surveillance, a population-based, nationwide cross-sectional survey was conducted between July and September 2009 on participants aged 25-64 years. Socio-demographic and behaviour risk factors were collected in Step 1. Physical anthropometric measurements and blood pressure were documented in Step 2. Blood cholesterol and fasting blood glucose were measured in Step 3. RESULTS AND CONCLUSION: A total of 5,206 adults (67% females) were surveyed. Tobacco smoking, alcohol drinking and raised blood pressure (BP) were more frequent in males than females, 25% vs 3%, 30% vs 4% and 37% vs 29%. Overweight, physical inactivity and raised cholesterol were more common in females than males, 28% vs 16%, 13% vs 6% and 11% vs 6%. Tobacco smoking was more common in rural than urban areas 11% vs 7%, and overweight and physical inactivity more common in urban than rural areas 39% vs 22% and 24% vs 9%, all with p<0.05. Overall (both sexes) prevalence of tobacco smoking, alcohol consumption, overweight and physical inactivity was 14%, 17%, 22%, 10% and prevalence of raised BP, fasting blood sugar and cholesterol was 33%, 6% and 9% respectively. These data could be useful in the formulation and advocacy of NCD policy and action plan in Malawi.

Prevalence distribution and risk factors for Schistosoma hematobium infection among school children in Blantyre, Malawi.

BACKGROUND: Schistosomiasis is a public health problem in Malawi but estimates of its prevalence vary widely. There is need for updated information on the extent of disease burden, communities at risk and factors associated with infection at the district and sub-district level to facilitate effective prioritization and monitoring while ensuring ownership and sustainability of prevention and control programs at the local level. METHODS AND FINDINGS: We conducted a cross-sectional study between May and July 2006 among pupils in Blantyre district from a stratified random sample of 23 primary schools. Information on socio-demographic factors, schistosomiasis symptoms and other risk factors was obtained using questionnaires. Urine samples were examined for Schistosoma hematobium ova using filtration method. Bivariate and multiple logistic regressions with robust estimates were used to assess risk factors for S. hematobium. One thousand one hundred and fifty (1,150) pupils were enrolled with a mean age of 10.5 years and 51.5% of them were boys. One thousand one hundred and thirty-nine (1,139) pupils submitted urine and S. hematobium ova were detected in 10.4% (95%CI 5.43-15.41%). Male gender (OR 1.81; 95% CI 1.06-3.07), child's knowledge of an existing open water source (includes river, dam, springs, lake, etc.) in the area (OR 1.90; 95% CI 1.14-3.46), history of urinary schistosomiasis in the past month (OR 3.65; 95% CI 2.22-6.00), distance of less than 1 km from school to the nearest open water source (OR 5.39; 95% CI 1.67-17.42) and age 8-10 years (OR 4.55; 95% CI 1.53-13.50) compared to those 14 years or older were associated with infection. Using urine microscopy as a gold standard, the sensitivity and specificity of self-reported hematuria was 68.3% and 73.6%, respectively. However, the positive predictive value was low at 23.9% and was associated with age. CONCLUSION: The study provides an important update on the status of infection in this part of sub-Saharan Africa and exemplifies the success of deliberate national efforts to advance active participation in schistosomiasis prevention and control activities at the sub-national or sub-district levels. In this population, children who attend schools close to open water sources are at an increased risk of infection and self-reported hematuria may still be useful in older children in this region.

Point-of-use water treatment and use among mothers in Malawi.

A national household survey was conducted in Malawi to determine awareness and use of a socially marketed water treatment product. In all, 64% of mothers were aware of the product, and 7% were using it. Both poor and rural mothers had lower awareness and use rates. Targeting promotion to rural populations could enhance program effectiveness.

Mental health of Kosovan Albanian refugees in the UK.

BACKGROUND: In 1999 the UK received 4346 refugees from Kosovo. AIMS: To determine the prevalence of mental health problems in this group. METHOD: A sample of 842 adults was surveyed. All were asked to complete self-report questionnaires (translated into Kosovan Albanian). A subset of 120 participants were later interviewed in Albanian using the Clinician Administered PTSD (post-traumatic stress disorder) Scale and a depression interview. RESULTS: The study yielded estimates of prevalence of PTSD and depression. Self-report measures appear to overestimate the prevalence of these disorders. Just under half of the group surveyed had a diagnosis of PTSD and less than one-fifth had a major depressive disorder. CONCLUSIONS: These results may be taken as a sign of the resilience of many who survived this conflict but they also imply that there is still a substantial need for good health and social care in a significant proportion. Psychosocial interventions are likely to be an important part of the treatment programme.