Exploring a framework for demandable services from antenatal to postnatal care: a deep-dive dialogue with mothers, health workers and psychologists.

BACKGROUND: One of the factors affecting quality of care is that clients do not demand care practises during antenatal, intrapartum and postnatal care. This study aimed to identify care practices that can be demanded by the mother in the continuum of care from antenatal to postnatal. METHODS: The study respondents included 122 mothers, 31 health workers and 4 psychologists. The researchers conducted 9 Key Informant Interviews with service providers and psychologists, 8 Focus Group Discussions with 8 mothers per group, and 26 vignettes with mothers and service providers. Data was analysed using Interpretative Phenomenological Analysis (IPA) where themes were identified and categorised. RESULTS: During antenatal and postnatal care, mothers demanded all recommended services presented to them. Some services seen as demandable during labour and delivery included 4-hourly assessments of vital signs and blood pressure, emptying of the bladder, swabbing, delivery counselling, administration of oxytocin, post-delivery palpation, and vaginal examination. For the child mothers demanded head to toe assessment, assessment of vital signs, weighing, cord stamp and eye antiseptics, and vaccines. Women observed that they could demand birth registration even though it was not among the recommended services. Respondents proposed empowerment of mothers with cognitive, behavioural and interpersonal skills to demand services e.g., knowledge of service standards and health benefits in addition to improved self-confidence and assertiveness. In addition, efforts have to be made to address perceived or real health worker attitudes, mental health for the client and the service provider, service provider workload, and availability of supplies. CONCLUSION: The study found that if a mother is informed in simple language about services that she is supposed to receive, she can demand numerous services in the continuum of care from antenatal to postnatal. However, demand cannot be a standalone solution for improving quality of care. What the mother can ask for is a step in the guidelines, but she cannot probe deeper to influence quality of the procedure. In addition, empowerment of mothers needs to be coupled with services and systems strengthening in support of health workers.

Mental health is just an Addendum: Assessing stakeholder's perceptions on COVID-19 and mental health services provision in Malawi.

INTRODUCTION: The World Health Organization declared COVID-19 as a pandemic in March 2020. COVID-19 has since caused a significant increase in mental health problems at national and global levels. This study assessed the views of key mental health stakeholders regarding the state of mental health service provision in Malawi and the pandemic's impact on the sector. METHODS: The study utilised a qualitative approach through key informant interviews (KIIs) conducted using a semi-structured interview guide. The interviews were audio recorded in English language and were manually transcribed for thematic analysis by generating codes re-classified into themes, sub-themes and quotes. RESULTS: The results are categorised into five themes. Firstly, the availability of mental health services. All experts confirmed the lack of availability of the mental health services especially at the lower levels of care. Currently, only 0.3% of facilities offer mental health services in Malawi. Moreover, although mental health services are part of the essential health care package and, therefore, are supposed to be provided for free in public facilities at all levels, the services are centralised and only functional at a tertiary level of care in public facilities. Secondly, funding sources for mental health in public and private facilities. We learnt that public facilities depend on donor sources and there is lack of prioritisation in budget allocation for mental health services. Whereas private facilities, their major source of funding is user fees. Thirdly, government's response in the provision of mental health services during COVID-19. Almost all experts echoed that government took a proactive approach to address the mental health needs of its population during the pandemic. There was increased collaboration between the government and the private sector to provide psychosocial and counselling services to health workers working directly with COVID-19 patients in isolation centres. Furthermore, to increase awareness of the general population on where to seek counselling services. Lastly, challenges in the provision of mental health services were highlighted and how the pandemic acerbated the challenges including shortage in human resources for health and inadequate funding. CONCLUSION: This study underscores the urgency of addressing mental health challenges in Malawi. Policymakers must prioritize the decentralization of mental health services, explore funding opportunities, and build on the successful collaboration with the private sector. These measures will not only enhance the accessibility and quality of mental health services but also ensure that mental well-being is a central component of public health efforts in Malawi.

The mental health toll among healthcare workers during the COVID-19 Pandemic in Malawi.

The COVID-19 pandemic has affected the mental health of healthcare workers worldwide, with frontline personnel experiencing heightened rates of depression, anxiety, and posttraumatic stress. This mixed-methods study aimed to assess the mental health toll of COVID-19 on healthcare workers in Malawi. A cross-sectional survey utilising the Generalized Anxiety Disorder (GAD-7), Patient Health Questionnaire (PHQ-9), and Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) was conducted among 109 frontline healthcare workers. Additionally, in-depth interviews were conducted with 16 healthcare workers to explore their experiences and challenges during the pandemic. The results indicated a high prevalence of COVID-19-related depression (31%; CI [23, 41]), anxiety (30%; CI [22, 40]), and PTSD (25%; CI [17, 34]) among participants. Regression analysis revealed significantly higher rates of depression, anxiety, and PTSD among healthcare workers in city referral hospitals compared to district hospitals. Qualitative findings highlighted the emotional distress, impact on work and personal life, and experiences of stigma and discrimination faced by healthcare workers. The stress process model provided a valuable framework for understanding the relationship among pandemic-related stressors, coping resources, and mental health outcomes. The findings underscore the urgent need for interventions and support systems to mitigate the mental health impact of COVID-19 on frontline healthcare workers in Malawi. Policymakers should prioritise the assessment and treatment of mental health problems among this critical workforce to maintain an effective pandemic response and build resilience for future crises.

Effectiveness of a chatbot in improving the mental wellbeing of health workers in Malawi during the COVID-19 pandemic: A randomized, controlled trial.

We conducted a randomized, controlled trial (RCT) to investigate our hypothesis that the interactive chatbot, Vitalk, is more effective in improving mental wellbeing and resilience outcomes of health workers in Malawi than the passive use of Internet resources. For our 2-arm, 8-week, parallel RCT (ISRCTN Registry: trial ID ISRCTN16378480), we recruited participants from 8 professional cadres from public and private healthcare facilities. The treatment arm used Vitalk; the control arm received links to Internet resources. The research team was blinded to the assignment. Of 1,584 participants randomly assigned to the treatment and control arms, 215 participants in the treatment and 296 in the control group completed baseline and endline anxiety assessments. Six assessments provided outcome measures for: anxiety (GAD-7); depression (PHQ-9); burnout (OLBI); loneliness (ULCA); resilience (RS-14); and resilience-building activities. We analyzed effectiveness using mixed-effects linear models, effect size estimates, and reliable change in risk levels. Results support our hypothesis. Difference-in-differences estimators showed that Vitalk reduced: depression (-0.68 [95% CI -1.15 to -0.21]); anxiety (-0.44 [95% CI -0.88 to 0.01]); and burnout (-0.58 [95% CI -1.32 to 0.15]). Changes in resilience (1.47 [95% CI 0.05 to 2.88]) and resilience-building activities (1.22 [95% CI 0.56 to 1.87]) were significantly greater in the treatment group. Our RCT produced a medium effect size for the treatment and a small effect size for the control group. This is the first RCT of a mental health app for healthcare workers during the COVID-19 pandemic in Southern Africa combining multiple mental wellbeing outcomes and measuring resilience and resilience-building activities. A substantial number of participants could have benefited from mental health support (1 in 8 reported anxiety and depression; 3 in 4 suffered burnout; and 1 in 4 had low resilience). Such help is not readily available in Malawi. Vitalk has the potential to fill this gap.

Umunthu, Covid-19 and mental health in Malawi.

This paper investigates the centrality of Umunthu in mental health conception and treatment in Malawi. Umunthu is an African philosophical worldview which stresses that an individual is human as they relate to others, as in the saying I am because we are. Its communitarian approach contrasts with a predominantly western individualistic worldview; I think therefore I am. There are spelling variations of the word across Bantu languages, including bomoto (Congo), gimuntu (Angola); umunthu (Malawi); vumutu (Mozambique); vumuntu, vhutu (South Africa); humhunu/ubuthosi (Zimbabwe); bumuntu (Tanzania); and umuntu (Uganda). Literature shows that if embraced and advocated for, Umunthu plays a positive and influential role in mainstreaming and dealing with mental health issues in communitarian societies where the Umunthu ideals are part of the social fabric. However, in the case of Covid-19 and mental health in Malawi, the paper argues that Covid-19 preventive measures, particularly self-isolation when Covid-19 positive; maintaining social distance at all times; and reducing the number of people gathered at funerals, challenge Umunthu ideals, which have in the past been crucial in reducing stress, trauma and anxiety. This original paper bases its arguments on empirical data collected in a study conducted in Mangochi, Blantyre, Karonga and Lilongwe. Based on the study's findings, the paper highlights that although Covid-19 preventative measures have been globally embraced, it is also a limiting factor in the quest for mental health in societies with communitarian value systems.

The world is coming to an end! COVID-19, depression, and anxiety among adolescents in Malawi.

Introduction: This paper assessed the effects of Covid-19 on adolescent mental health in Malawi. There is minimal research on adolescent mental health in Africa, Malawi in particular. The study shows a link between the pandemic and mental health. Some factors that may have contributed to this link include; Covid-19 preventive measures, media exposure and the increase in unemployment. Methods: The study used a mixed methods approach, quantitative and qualitative methods. It was conducted in Malawi's four districts (Blantyre, Mangochi, Lilongwe and Karonga). Results: Overall 22%, 21%, and 23% of the respondents had depression, anxiety and post-traumatic stress disorder, respectively. The Chi-square test showed that significantly more adolescents with secondary education (28%) had anxiety than those with primary education (14%). Further, regression analysis revealed that adolescents with anxiety were 18 [95%CI: 9.34, 35.8] times more likely to have depression compared to those who did not have anxiety. The study found no significant differences in the proportions of adolescents with the three outcomes when comparing different groups within the explanatory variable. The ratio of female and male adolescents with depression and anxiety was the same. Discussion: The adolescents expressed that Covid-19 affected their social, academic, and financial status. These effects had a significant bearing on their mental health in that they led to depression, anxiety, fear of the unknown, and stress. During the Covid-19 pandemic, adolescents' mental health diminished and posed a considerable risk to productivity of adolescents. As a result, adolescents may not fully realize their potential, form and maintain good relationships, contribute to their community and become resilient. These effects have devastating consequences for this young generation without proper coping strategies.

Growth deficits in antiretroviral and HIV-exposed uninfected versus unexposed children in Malawi and Uganda persist through 60 months of age.

OBJECTIVE: To compare childhood physical growth among antiretroviral drug and maternal HIV-exposed uninfected (AHEU) compared with HIV-unexposed uninfected (HUU) children. DESIGN: Longitudinal follow-up of PROMISE trial (NCT01061151) AHEU and age-matched and sex-matched HUU children, enrolled (September 2013 to October 2014) in Malawi and Uganda. METHOD: We compared WHO population standardized z-scores [height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ), head-circumference-for-age (HCAZ) at 12, 24, 36, 48, and 60 months of age]. We evaluated HUU versus AHEU [in-utero combination antiretroviral treatment (cART) versus Zidovudine (ZDV) alone]; stratified by country, using longitudinal linear and generalized linear mixed models. RESULTS: Of 466 Malawian and 477 Ugandan children, median maternal age at enrollment was 24.5 years (Malawi) and 27.8 years (Uganda); more than 90% were breastfed through 12 months except Uganda AHEU (64.0%). HAZ scores (adjusted for maternal age, breastfed, and socioeconomic status) were lower among AHEU versus HUU children at every time point, significant (P < 0.05) among Ugandan but not Malawian children. Similar patterns were seen for WAZ but not for WHZ or HCAZ scores. High stunting was observed in both countries, significantly higher in Malawi; and higher among AHEU versus HUU children through 48 months of age, significantly (P < 0.05) among Ugandan but not Malawian children. We found no differences in childhood growth trajectories with in-utero exposures to ZDV compared with cART. CONCLUSION: AHEU versus HUU children had lower median LAZ and WAZ scores persisting through 60 months of age. However, proportions of children with stunting or underweight decreased after 24 months of age.

Neurodevelopmental outcomes of HIV/antiretroviral drug perinatally exposed uninfected children aged 3-6 years.

OBJECTIVE: Given the roll out of maternal antiretroviral therapy (ART) for prevention-of-perinatal-HIV-transmission, increasing numbers of children are perinatally HIV/antiretroviral exposed but uninfected (CAHEU). Some studies suggest CAHEU may be at increased risk for neurodevelopmental (ND) deficits. We aimed to assess ND performance among preschool CAHEU. DESIGN: This cross-sectional study assessed ND outcomes among 3-6-year-old CAHEU at entry into a multicountry cohort study. METHODS: We used the Mullen Scales of Early Learning (MSEL) and Kaufman Assessment Battery for Children (KABC-II) to assess ND status among 3-6-year-old CAHEU at entry into the PROMISE Ongoing Treatment Evaluation (PROMOTE) study conducted in Uganda, Malawi, Zimbabwe and South Africa. Statistical analyses (Stata 16.1) was used to generate group means for ND composite scores and subscale scores, compared to standardized test score means. We used multivariable analysis to adjust for known developmental risk factors including maternal clinical/socioeconomic variables, child sex, growth-for-age measurements, and country. RESULTS: 1647 children aged 3-6 years had baseline ND testing in PROMOTE; group-mean unadjusted Cognitive Composite scores on the MSEL were 85.8 (standard deviation [SD]: 18.2) and KABC-II were 79.5 (SD: 13.2). Composite score group-mean differences were noted by country, with South African and Zimbabwean children having higher scores. In KABC-II multivariable analyses, maternal age >40 years, lower education, male sex, and stunting were associated with lower composite scores. CONCLUSIONS: Among a large cohort of 3-6 year old CAHEU from eastern/southern Africa, group-mean composite ND scores averaged within the low-normal range; with differences noted by country, maternal clinical and socioeconomic factors.

Validation of the Infant and Young Child Development (IYCD) Indicators in Three Countries: Brazil, Malawi and Pakistan.

BACKGROUND: The early childhood years provide an important window of opportunity to build strong foundations for future development. One impediment to global progress is a lack of population-based measurement tools to provide reliable estimates of developmental status. We aimed to field test and validate a newly created tool for this purpose. METHODS: We assessed attainment of 121 Infant and Young Child Development (IYCD) items in 269 children aged 0-3 from Pakistan, Malawi and Brazil alongside socioeconomic status (SES), maternal educational, Family Care Indicators and anthropometry. Children born premature, malnourished or with neurodevelopmental problems were excluded. We assessed inter-rater and test-retest reliability as well as understandability of items. Each item was analyzed using logistic regression taking SES, anthropometry, gender and FCI as covariates. Consensus choice of final items depended on developmental trajectory, age of attainment, invariance, reliability and acceptability between countries. RESULTS: The IYCD has 100 developmental items (40 gross/fine motor, 30 expressive/receptive language/cognitive, 20 socio-emotional and 10 behavior). Items were acceptable, performed well in cognitive testing, had good developmental trajectories and high reliability across countries. Development for Age (DAZ) scores showed very good known-groups validity. CONCLUSIONS: The IYCD is a simple-to-use caregiver report tool enabling population level assessment of child development for children aged 0-3 years which performs well across three countries on three continents to provide reliable estimates of young children's developmental status.

IMPAACT 2016: Operationalizing HIV Intervention Adaptations to Inform the Science and Outcomes of Implementation.

Introduction: Uptake of evidence-based interventions for adolescents and young adults living with HIV (AYA-LWH) in sub-Saharan Africa (SSA) is complex, and cultural differences necessitate local adaptations to enhance effective implementation. Few models exist to guide intervention tailoring, yet operationalizing strategies is critical to inform science and implementation outcomes, namely acceptability, appropriateness, feasibility, fidelity, and sustainability. This paper describes operationalizing the ADAPT-ITT framework applied to a manualized trauma-informed cognitive behavioral therapy (TI-CBT) intervention addressing mental and sexual health for AYA-LWH in SSA in preparation for a randomized controlled trial (RCT). Methods: Phase 1 of the RCT focused on operationalizing ADAPT-ITT steps 3-7 to tailor the intervention for use in eight sites across Botswana, Malawi, South Africa, and Zimbabwe. Well-defined processes were developed to supplement the general guidelines for each step to provide clear, consistent direction on how to prepare and conduct each step, including documenting, assessing, and determining adaptations, while maintaining intervention fidelity. The processes provided efficient standardized step-by-step progression designed for future replication. All sites participated in Phase 1 using the created tools and strategies to translate and present the TI-CBT to community stakeholders for feedback informing local adaptations. Results: The research team developed and operationalized materials guiding adaptation. A translation review process verified local adaptability, maintained core concepts, and revealed differing interpretations of words, idioms, and culturally acceptable activities. Strategically designed tools comprised of feedback and translation verification forms resulted in meticulous management of adaptations. Robust collaborations between investigators, research managers, site personnel, and topical experts maximized multidisciplinary expertise, resulting in ~10-15 personnel per site facilitating, collecting, assessing, and integrating local feedback. Processes and tools operationalized in steps 3-7 effectively addressed implementation outcomes during community engagements (n = 108), focus groups (n = 5-8 AYA-LWH and caregivers per group), and strategic training of youth leaders. Discussion: This paper offers a novel generalizable approach using well-defined processes to guide intervention adaptation building on the ADAPT-ITT framework. The processes strengthen the science of implementation and provide much-needed specificity in adaptation steps to optimize and sustain real-world impact and help researchers and community stakeholders maximize existing infrastructure, culture, and resources to inform implementation strategies.