Factors associated with malaria vaccine uptake in Nsanje district, Malawi.

BACKGROUND: Malaria remains a significant global health burden affecting millions of people, children under 5 years and pregnant women being most vulnerable. In 2019, the World Health Organization (WHO) endorsed the introduction of RTS,S/AS01 malaria vaccine as Phase IV implementation evaluation in three countries: Malawi, Kenya and Ghana. Acceptability and factors influencing vaccination coverage in implementing areas is relatively unknown. In Malawi, only 60% of children were fully immunized with malaria vaccine in Nsanje district in 2021, which is below 80% WHO target. This study aimed at exploring factors influencing uptake of malaria vaccine and identify approaches to increase vaccination. METHODS: In a cross-sectional study conducted in April-May, 2023, 410 mothers/caregivers with children aged 24-36 months were selected by stratified random sampling and interviewed using a structured questionnaire. Vaccination data was collected from health passports, for those without health passports, data was collected using recall history. Regression analyses were used to test association between independent variables and full uptake of malaria vaccine. RESULTS: Uptake of malaria vaccine was 90.5% for dose 1, but reduced to 87.6%, 69.5% and 41.2% for dose 2, 3, and 4 respectively. Children of caregivers with secondary or upper education and those who attended antenatal clinic four times or more had increased odds of full uptake of malaria vaccine [OR: 2.43, 95%CI 1.08-6.51 and OR: 1.89, 95%CI 1.18-3.02], respectively. Children who ever suffered side-effects following immunization and those who travelled long distances to reach the vaccination centre had reduced odds of full uptake of malaria vaccine [OR: 0.35, 95%CI 0.06-0.25 and OR: 0.30, 95%CI 0.03-0.39] respectively. Only 17% (n = 65) of mothers/caregivers knew the correct schedule for vaccination and 38.5% (n = 158) knew the correct number of doses a child was to receive. CONCLUSION: Only RTS,S dose 1 and 2 uptake met WHO coverage targets. Mothers/caregivers had low level of information regarding malaria vaccine, especially on numbers of doses to be received and dosing schedule. The primary modifiable factor influencing vaccine uptake was mother/caregiver knowledge about the vaccine. Thus, to increase the uptake Nsanje District Health Directorate should strengthen communities' education about malaria vaccine. Programmes to strengthen mother/caregiver knowledge should be included in scale-up of the vaccine in Malawi and across sub-Saharan Africa.

Challenges to the implementation of malaria policies in Malawi.

BACKGROUND: Despite malaria prevention initiatives, malaria remains a major health problem in Malawi, especially for pregnant mothers and children under the age of five. To reduce the malaria burden, Malawi established its first National Malaria Control Programme in 1984. Implementation of evidence-based policies contributed to malaria prevalence dropping from 43% in 2010 to 22% in 2017. In this study, we explored challenges to implementing malaria policies in Malawi from the perspective of key stakeholders in the country. METHODS: In this qualitative study, we conducted in-depth interviews with 27 key informants from April to July 2015. We stopped sampling new participants when themes became saturated. Purposive and snowballing sampling techniques were used to identify key informants including malaria researchers that were policy advisors, policy makers, programme managers, and other key stakeholders. Interviews were conducted in English, recorded and transcribed, and imported into QSR Nvivo 11 for coding and analysis. Data were analysed using the qualitative content analysis approach. RESULTS: Participants identified three main categories of challenges to the implementation of malaria policies. First structural challenges include inadequate resources, unavailability of trained staff, poor supervision and mentorship of staff, and personnel turnover in government. The second challenge is unilateral implementation of policies. The third category is the inadequately informed policy development and includes lack of platforms to engage with communities, top-down approach in policy formulation and lack of understanding of socio-cultural factors affecting policy uptake by communities. CONCLUSIONS: Policy makers should recognize that inadequate support of policy objectives leads to an implementation gap. Therefore, policy development and implementation should not be viewed as distinct, but rather as interactive processes shaping each other. Support for health policy and systems research should be mobilized to strengthen the health system. Detailed assessment of implementation challenges to specific malaria policies should also be conducted to address these challenges and support the shift from the paradigm of malaria prevention and control to elimination in Malawi.

Experiences of capacity strengthening in sanitation and hygiene research in Africa and Asia: the SHARE Research Consortium.

The Sanitation and Hygiene Applied Research for Equity (SHARE) Research Programme consortium is a programme funded by the United Kingdom Department for International Development (DFID) that aims to contribute to achieving universal access to effective, sustainable, and equitable sanitation and hygiene worldwide. The capacity development component is an important pillar for this programme and different strategies were designed and implemented during the various phases of SHARE. This paper describes and reflects on the capacity-building strategies of this large multi-country research consortium, identifying lessons learnt and proposing recommendations for future global health research programmes. In the first phase, the strategy focused on increasing the capacity of individuals and institutions from low- and middle-income countries in conducting their own research. SHARE supported six PhD students and 25 MSc students, and organised a wide range of training events for different stakeholders. SHARE peer-reviewed all proposals that researchers submitted through several rounds of funding and offered external peer-review for all the reports produced under the partner's research platforms. In the second phase, the aim was to support capacity development of a smaller number of African research institutions to move towards their independent sustainability, with a stronger focus on early and mid-career scientists within these institutions. In each institution, a Research Fellow was supported and a specific capacity development plan was jointly developed.Strategies that yielded success were learning by doing (supporting institutions and postgraduate students on sanitation and hygiene research), providing fellowships to appoint mid-career scientists to support personal and institutional development, and supporting tailored capacity-building plans. The key lessons learnt were that research capacity-building programmes need to be driven by local initiatives tailored with support from partners. We recommend that future programmes seeking to strengthen research capacity should consider targeted strategies for individuals at early, middle and later career stages and should be sensitive to other institutional operations to support both the research and management capacities.

Using participatory methods to design an mHealth intervention for a low income country, a case study in Chikwawa, Malawi.

BACKGROUND: mHealth holds the potential to educate rural communities in developing countries such as Malawi, on issues which over-burdened and under staffed health centres do not have the facilities to address. Previous research provides support that mHealth could be used as a vehicle for health education campaigns at a community level; however the limited involvement of potential service users in the research process endangers both user engagement and intervention effectiveness. METHODS: This two stage qualitative study used participatory action research to inform the design and development of an mHealth education intervention. First, secondary analysis of 108 focus groups (representing men, women, leadership, elderly and male and female youth) identified four topics where there was a perceived health education need. Second, 10 subsequent focus groups explored details of this perceived need and the acceptability and feasibility of mHealth implementation in Chikwawa, Malawi. RESULTS: Stage 1 and Stage 2 informed the design of the intervention in terms of target population, intervention content, intervention delivery and the frequency and timing of the intervention. This has led to the design of an SMS intervention targeting adolescents with contraceptive education which they will receive three times per week at 4 pm and will be piloted in the next phase of this research. CONCLUSION: This study has used participatory methods to identify a need for contraception education in adolescents and inform intervention design. The focus group discussions informed practical considerations for intervention delivery, which has been significantly influenced by the high proportion of users who share mobile devices and the intervention has been designed to allow for message sharing as much as possible.

Water journeys: Household water insecurity, health risks, and embodiment in slums and informal settlements.

Water insecurity is a critical public-health challenge in Africa's urban informal settlements, where most of the population often lacks access to household taps. In these settings, water fetching is disproportionately performed by women. While water fetching is physically laborious and exposes women to multiple risks, the water-insecurity literature has predominantly focused on household experiences, ignoring women's water-collection journeys. This paper uses the water journey as a window into the embodied dimensions of water insecurity. Combining theoretical insights from embodiment, embodied political ecology of health, and time geographies, we use video-recorded walking interviews to analyze women's everyday water journeys in Ntopwa, an urban informal settlement in Blantyre, Malawi, from initial decision making through exposure to water-fetching risks and household practices regarding use and storage. We identify three principal sources of environmental risk- terrain, built environment, and human behavior-that present challenges for water collectors. Using the walking interview as a heuristic, we show how the seemingly simple practice of water fetching is compounded by complex decision making, constant spatiotemporal trade-offs, and exposure to diverse risks, all of which have embodied health consequences. Based on our findings, we conclude that interventions seeking to improve household water insecurity must consider the embodied effects of water-fetching journeys. This study also provides methodological insights into using walking interviews and videos for water and health research.

An application of mixed-effect models to analyse contraceptive use in Malawian women.

In Malawi, the current approach to family planning using contraceptive methods is individualised, yet studies have shown that variability in contraceptive-use still remains after accounting for it at individual and household levels. Therefore, this study assessed variability at higher levels such as enumeration areas, districts and regions. Biasness of the estimates was addressed by the use of Bayesian approach. The study used 2015-16 Malawi Demographic Health Survey women data. After ascertaining the significance of association of all explanatory variables with contraceptive use, the top-down (backward) stepwise model selection method was followed in the Bayesian framework using Markov Chain Monte Carlo and defuse priors. Models were compared on the basis of Deviance Information Criteria and significance of parameter estimates was checked via credible intervals while that of cross-cluster variances was checked by examining their diagnostic plots. All the selected socio-demographic factors were strongly associated with contraceptive-use (p-value< 0.001). These factors include; region, place-of-residence, age, parity, education, occupation, marital-status and religion. It was also found that about 15 and 2.3% of the variation in contraceptive-use was attributed to enumeration area and district clustering, respectively. The single-level model underestimated the parameter estimates by at least 4% for both models. And parity-enumeration area, age-enumeration area and age-district random effects were significant in their respective models. It was also noted that most young women aged between 15 and 24 years were not using any contraceptive methods. The study indicated that there exist significant enumeration area and district heterogeneity on contraceptive use in Malawian women and that random-effect models are the most appropriate models other than single-level models. Thus family planning programs focusing on contraceptive-use should switch to inclusive approach and statistical analyses should consider including enumeration area and district heterogeneity while controlling for the above significant factors. Stakeholders may also consider encouraging young women to use contraceptive methods, if Malawi is to minimize problems due to overpopulation.

Risk Factors Associated with Feeding Children under 2 Years in Rural Malawi-A Formative Study.

Diarrhoeal disease remains one of the leading causes of morbidity and mortality in the under-five population, particularly in low income settings such as sub-Saharan Africa. Despite significant progress in sanitation and water access, faecal-oral infections persist in these populations. Therefore, a better understanding of these transmission pathways, and how potential risk factors can be reduced within low income contexts is needed. This study, conducted in Southern Malawi from June to October 2017, used a mixed methods approach to collect data from household surveys (n = 323), checklists (n = 31), structured observations (n = 80), and microbiological food samples (n = 20). Results showed that food prepared for immediate consumption (primarily porridge for children) posed a low health risk. Poor hygiene practices increased the risk of contamination from shared family meals. Faecal and nosocomial bacteria were associated with poor hand hygiene and unhygienic eating conditions. Leftover food storage and inadequate pre-consumption heating increased the risk of contamination. Improvements in food hygiene and hand hygiene practices at critical points could reduce the risk of diarrhoeal disease for children under 2 years but must consider the contextual structural barriers to improved practice like access to handwashing facilities, soap, food and water storage.

Toward Complementary Food Hygiene Practices among Child Caregivers in Rural Malawi.

Despite being preventable, foodborne diseases remain a global health challenge. Poor food hygiene practices such as improper handling of kitchen utensils are among the major causes of diarrhea transmission. A formative study was conducted in Malawi to inform an intervention design to promote complementary food hygiene practices. An assessment of contextual and psychosocial factors for behavior change was conducted using Risk, Attitude, Norms, Ability, and Self-regulation model. We conducted 323 household surveys with caregivers of children aged 6 to 24 months. Analysis of variance was used to estimate difference between doers and non-doers of three targeted behaviors: washing utensils with soap, keeping utensils on a raised place, and handwashing with soap. Analysis of variance analyses revealed that literacy level, ownership of animals, and presence of handwashing facility and dish racks were contextual factors predicting storage of utensils on an elevated place and handwashing frequencies. Psychosocial factors, such as time spent to wash utensils with soap, distance to the handwashing facility, and cost for soap, had an influence on washing utensils and handwashing practices. Perceived vulnerability determined effective handwashing and storage of utensils. Perceived social norms and ability estimates were favorable for the three targeted behaviors. Promotion of already existing targeted beneficial behaviors should be encouraged among caregivers. Risk perceptions on storage of utensils and handwashing practices should be increased with motivational exercises such as paint games. Caregivers' technical know-how of local dish rack and tippy tap construction is essential.

Inactivation of pathogens in ecological sanitation latrines in Malawi: An observational follow up study.

Introduction: In Malawi, EcoSan sludge from ecological sanitation (EcoSan) latrines has been found to contain helminths, Salmonella and E. coli above WHO recommended levels making sludge unsuitable for direct handling and use on food crops. This research investigated survival of pathogens in EcoSan sludge with time after sealing the pit. Method: An observational longitudinal follow-up study was conducted where EcoSan latrines were followed from August 2015 to July 2016 in Blantyre and Chikwawa in Southern Malawi. The study enrolled 51 latrines in total with 35 latrines [13 fossa alterna (FAs) and 22 urine diverting dry latrines (UDDLs)] remaining at the end of study. Samples were collected five times from each latrine and examined for helminths, Salmonella and E. coli in the laboratory. Poisson regression was employed to assess factors that significantly contribute to pathogen die off at p<0.05. Results: Average concentrations of all pathogens investigated reduced over 12-month follow-up period except for Salmonella which increased. A. lumbricoides, increased to 2.3 viable eggs during the second sampling and decreased to 0.4 viable eggs per gram after 12 months of follow-up. Time was the only consistent predictor for concentration of helminths. Type of latrine and location were not significant predictors of helminths concentration (p>0.05). However, Salmonella and E. coli colonies were significantly higher in UDDLs (Blantyre) than FAs (Chikwawa) (p<0.05). Conclusion: Pathogen concentration was highest after recommended six months of storage posing a public health risk to those handling and using it for agriculture purposes. It is therefore recommended that the current guidelines be reviewed to suit Malawi context. A storage period of one year or more is recommended.

Social capital insights from Healthy Settings needs assessment in Malawi.

Despite global health improvements, substantial challenges in social determinants of health and poverty remain in rural communities in low-income countries. Public health theorists suggest that communities with high social capital are less vulnerable to such challenges and more likely to participate in community development. This research examines levels of social capital amongst rural communities in southern Malawi through data gathered as part of a participatory needs assessment for a Healthy Settings project, and discusses the potential benefits of having access to such data before project implementation. Social capital data was collected during 108 focus group discussions in 18 communities (split by gender, age, status) by adapting an existing mixed methods measurement tool, the Schutte tool. Five indicators were measured: sense of belonging, friendship, reliance, ability to work together and influence. Mean results showed all 18 communities had medium-high levels of social capital. Means from each group in the 18 communities highlighted the lowest social capital among the youth groups and the highest with the leaders. A more detailed breakdown highlighted that all groups had a strong sense of belonging to the community, while youth and women had lower social capital levels in terms of influence over local decisions and ability to rely on other community members. Incorporating social capital tools into community health needs assessments in low-income settings provides a valuable overview of community dynamics before project implementation, and Monitoring & Evaluation indicators which allow changes in social capital to be measured at different stages of the project.

Estimating the Health Risk Associated with the Use of Ecological Sanitation Toilets in Malawi.

Use of Ecological Sanitation (EcoSan) sludge is becoming popular due to increasing price of organic fertilizers in Malawi; however, there is little evidence on the associated risks. Quantitative microbiological risk assessment (QMRA) was done to determine health risks associated with use of EcoSan. Pathogens considered included Escherichia coli (E. coli), Salmonella, and soil transmitted helminths (STHs). Exponential and Beta Poisson models were used to estimate the risk from helminthic and bacterial pathogens, respectively. Main exposure pathways were through poor storage of sludge, contamination of foods during drying, walking barefoot on the ground contaminated with sludge, pit emptying without protection, and application of sludge in the fields. Estimated annual risk for Ascaris lumbricoides, Taenia, and hookworms was approximately over 5.6 × 10-1 for both Fossa Alternas (FAs) and Urine Diverting Dry Toilet (UDDTs). Risk from E. coli and Salmonella was 8.9 × 10-2 and above. The risks were higher than WHO acceptable risk for use of faecal sludge in crops of 10-4 infections per year. Promoters and users of EcoSan latrines need to consider advocating for strict guidelines to reduce the risk.

Assessment of implementation of the health management information system at the district level in southern Malawi.

Background: Despite Malawi's introduction of a health management information system (HMIS) in 1999, the country's health sector still lacks accurate, reliable, complete, consistent and timely health data to inform effective planning and resource management. Methods: A cross-sectional survey was conducted wherein qualitative and quantitative data were collected through in-depth interviews, document review, and focus group discussions. Study participants comprised 10 HMIS officers and 10 district health managers from 10 districts in the Southern Region of Malawi. The study was conducted from March to April 2012. Quantitative data were analysed using Microsoft Excel and qualitative data were summarised and analysed using thematic analysis. Results: The study established that, based on the Ministry of Health's minimum requirements, 1 out of 10 HMIS officers was qualified for the post. The HMIS officers stated that HMIS data collectors from the district hospital, health facilities, and the community included medical assistants, nurse-midwives, statistical clerks, and health surveillance assistants. Challenges with the system included inadequate resources, knowledge gaps, inadequacy of staff, and lack of training and refresher courses, which collectively contribute to unreliable information and therefore poorly informed decision-making, according to the respondents. The HMIS officers further commented that missing values arose from incomplete registers and data gaps. Furthermore, improper comprehension of some terms by health surveillance assistants (HSAs) and statistical clerks led to incorrectly recorded data. Conclusions: The inadequate qualifications among the diverse group of data collectors, along with the varying availability and utilisation different data collection tools, contributed to data inaccuracies. Nevertheless, HMIS was useful for the development of District Implementation Plans (DIPs) and planning for other projects. To reduce data inconsistencies, HMIS indicators should be revised and data collection tools should be harmonised.

Is there a difference in prevalence of helminths between households using ecological sanitation and those using traditional pit latrines? A latrine based cross sectional comparative study in Malawi.

BACKGROUND: Studies have shown that households using sludge from human excreta for agriculture are at an increased risk of soil transmitted helminths. However, while use of ecological sanitation (EcoSan) latrines is increasing in most African countries including Malawi, few studies have been done to check whether use of such sludge could potentially increase the prevalence of helminthic infections among household members as a results of exposure to faecal sludge/compared to use of traditional latrines. METHODS: A cross sectional study was done targeting households using EcoSan and traditional pit latrines. Samples were collected from both types of latrines in Chikwawa (rural) and Blantyre (urban) districts. These two districts have a high number of EcoSan latrines in southern region of Malawi. 156 latrines were sampled (n = 95 traditional; n = 61 EcoSan), and processed following standard guidelines using modified triple floatation method. Identification of helminth ova (Ascaris lumbricoides, hookworms, Trichuris trichiura, Taenia spp. and Diphyllobothrium latum) was done using standard microscopy methods. The difference between the prevalence and mean concentration of helminths between the two types of latrines was tested using Chi Square and t test respectively. RESULTS: Of the total latrines tested, 85.9% (n = 134) had at least one species of helminth while 84.6% (n = 132) had at least a STH, with 82.0% (n = 50) in EcoSan and 86.3% (n = 82) in traditional pit latrines. There was no significant difference between the prevalence of helminths in EcoSan and traditional pit latrines [χ2 = 0.43 (1), P = 0.5]. The prevalence of Ascaris lumbricoides was significantly higher in EcoSan than in traditional pit latrines [χ2 = 5.44 (1) p = 0.02] while prevalence of hookworms was significantly higher in traditional pit latrines than in EcoSan latrines [χ2 = 13.98 (1) p < 0.001]. The highest concentration of helminths per gram of faecal sludge was in traditional pit latrines [31.2 (95% CI 19.1-43.2)] than in EcoSan latrines [26.4 (95% CI 16.5-36.3)]. CONCLUSION: There was no significant difference between overall prevalence of helminths between households using EcoSan and those using traditional pit latrines. However, Ascaris lumbricoides was significantly higher in households using EcoSan latrines. EcoSan users need awareness on safe ways of handling faecal sludge in order to reduce chances of reinfection from Ascaris lumbricoides. Further research should be undertaken on household members to identify those infected and potential routes of infection to enable preventive targeting.

Challenges facing young African scientists in their research careers: A qualitative exploratory study.

BACKGROUND: Africa accounts for 14% of world's population, and the economies of most African countries are considered to be growing, but this is not reflected in the amount of research published by Africans. This study aimed at identifying the challenges that young African scientists face in their career development. METHODS: This was a qualitative exploratory study involving young researchers who attended the Teaching and Research in Natural Sciences for Development (TReND) in Africa scientific writing and communication workshop, which was held in Malawi in September 2015. A semi-structured questionnaire was sent to all workshop participants who consented to taking part in the survey. In total, 28 questionnaires were sent via email and 15 were returned, representing a response rate of 53.6%. Data were analysed using thematic analysis. RESULTS: Young Africans develop their research interests various ways. The most common career-promoting factors identified by the study participants included formal classroom learning, aspirations to attain academic qualifications, work satisfaction, and the desire to fulfill parents' dreams. Challenges cited by survey respondents included a lack of mentorship, funds, and research and writing skills. Lack of interest in research by policymakers, lack of motivation by peers, and heavy workload (leaving little time for research) were also reported as challenges. Respondents suggested that grants specifically targeting young scientists would be beneficial. Participants also urged for the establishment of mentorship programmes, increasing motivation for research, and more frequent training opportunities. CONCLUSIONS: There is need for improved funding for institutional and research network strengthening in Africa, with particular attention given to expanding opportunities for young researchers.

Rapid emergence of multidrug resistant, H58-lineage Salmonella typhi in Blantyre, Malawi.

INTRODUCTION: Between 1998 and 2010, S. Typhi was an uncommon cause of bloodstream infection (BSI) in Blantyre, Malawi and it was usually susceptible to first-line antimicrobial therapy. In 2011 an increase in a multidrug resistant (MDR) strain was detected through routine bacteriological surveillance conducted at Queen Elizabeth Central Hospital (QECH). METHODS: Longitudinal trends in culture-confirmed Typhoid admissions at QECH were described between 1998-2014. A retrospective review of patient cases notes was conducted, focusing on clinical presentation, prevalence of HIV and case-fatality. Isolates of S. Typhi were sequenced and the phylogeny of Typhoid in Blantyre was reconstructed and placed in a global context. RESULTS: Between 1998-2010, there were a mean of 14 microbiological diagnoses of Typhoid/year at QECH, of which 6.8% were MDR. This increased to 67 in 2011 and 782 in 2014 at which time 97% were MDR. The disease predominantly affected children and young adults (median age 11 [IQR 6-21] in 2014). The prevalence of HIV in adult patients was 16.7% [8/48], similar to that of the general population (17.8%). Overall, the case fatality rate was 2.5% (3/94). Complications included anaemia, myocarditis, pneumonia and intestinal perforation. 112 isolates were sequenced and the phylogeny demonstrated the introduction and clonal expansion of the H58 lineage of S. Typhi. CONCLUSIONS: Since 2011, there has been a rapid increase in the incidence of multidrug resistant, H58-lineage Typhoid in Blantyre. This is one of a number of reports of the re-emergence of Typhoid in Southern and Eastern Africa. There is an urgent need to understand the reservoirs and transmission of disease and how to arrest this regional increase.