May Measurement Month 2019: an analysis of blood pressure screening results from Malawi.

May Measurement Month (MMM) is a global initiative that aims at raising awareness and screening people for high blood pressure (BP). Malawi has participated in MMM since 2017. A 2017 STEPwise Survey conducted in Malawi among 4187 participants found that 65.2% had never had their BP measured before, 26.8% had their BPs measured but not diagnosed, 3.9% were diagnosed but not within the last 12 months, and 4.1% were diagnosed within the last 12 months. An opportunistic cross-sectional survey of volunteers aged 18 and above was carried out in May and June 2019. All BP measurements, definition of hypertension and statistical analysis followed the standard MMM protocol. The screening took place in Nkhatabay, Lilongwe, and Blantyre. A total number of 9723 participants were screened with a mean age of 42.0 (SD 16.6) years. Of these 8444 (86.8%) had never had their BP measured within the last 12 months, 2559 (26.3%) had raised BP, 2169 (23.2%) of those with raised BP were not on treatment whereas 390 (4.0%) were on treatment. The results showed that many of the participants had not had their BP checked in the past year. There is a significant need to expand BP screening opportunities within Malawi for early detection of hypertension.

May Measurement Month 2018: an analysis of blood pressure screening results from Malawi.

Raised blood pressure (BP) is a growing health care problem in the world leading to over 10 million deaths annually. May Measurement Month (MMM), which aims at raising awareness and screening people for raised BP, is assisting people to know their BP status. In 2018, an opportunistic cross-sectional survey was carried out during May and June in 10 791 volunteers aged 18 years and above following that done in 2017. The screening took place in Lilongwe, Blantyre, Dedza, Kasungu, and Nkhatabay districts mostly in hospitals/clinics, marketplaces, workplaces, and churches/mosques with Kasungu and Nkhatabay in rural areas. After multiple imputation, 2404 (22.3%) had hypertension. Of individuals not receiving antihypertensive treatment, 2101 (20.0%) were found to have raised BP. Only 303 (12.6%) of those with hypertension were receiving antihypertensive treatment, and of these 101 (33.3%) had uncontrolled BP. MMM was the largest BP screening campaign ever undertaken in Malawi. The results identified a large number of individuals with raised BP who were unaware and not on treatment and over one-third of those on treatment were uncontrolled, indicating the need for better management of cases. These results suggest that opportunistic screening can identify significant numbers with raised BP.

Is the Urban Child Health Advantage Declining in Malawi?: Evidence from Demographic and Health Surveys and Multiple Indicator Cluster Surveys.

In many developing countries including Malawi, health indicators are on average better in urban than in rural areas. This phenomenon has largely prompted Governments to prioritize rural areas in programs to improve access to health services. However, considerable evidence has emerged that some population groups in urban areas may be facing worse health than rural areas and that the urban advantage may be waning in some contexts. We used a descriptive study undertaking a comparative analysis of 13 child health indicators between urban and rural areas using seven data points provided by nationally representative population based surveys-the Malawi Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Rate differences between urban and rural values for selected child health indicators were calculated to denote whether urban-rural differentials showed a trend of declining urban advantage in Malawi. The results show that all forms of child mortality have significantly declined between 1992 and 2015/2016 reflecting successes in child health interventions. Rural-urban comparisons, using rate differences, largely indicate a picture of the narrowing gap between urban and rural areas albeit the extent and pattern vary among child health indicators. Of the 13 child health indicators, eight (neonatal mortality, infant mortality, under-five mortality rates, stunting rate, proportion of children treated for diarrhea and fever, proportion of children sleeping under insecticide-treated nets, and children fully immunized at 12 months) show clear patterns of a declining urban advantage particularly up to 2014. However, U-5MR shows reversal to a significant urban advantage in 2015/2016, and slight increases in urban advantage are noted for infant mortality rate, underweight, and stunting rate in 2015/2016. Our findings suggest the need to rethink the policy viewpoint of a disadvantaged rural and much better-off urban in child health programming. Efforts should be dedicated towards addressing determinants of child health in both urban and rural areas.

Correction to: Is the Urban Child Health Advantage Declining in Malawi?: Evidence from Demographic and Health Surveys and Multiple Indicator Cluster Surveys.

The third from last sentence of the abstract, which reads: "However, U-5MR shows reversal to a significant urban advantage in 2015/2016, and slight increases in urban advantage are noted for infant mortality rate, underweight, full childhood immunization, and stunting rate in 2015/2016".

May Measurement Month 2017: results of a blood pressure screening campaign in Malawi-Sub-Saharan Africa.

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programs worldwide. A World Health Organization and Ministry of Health STEPS Survey conducted in 2009 in Malawi found that 32.9% tested positive for age-standardized hypertension. The survey further showed that three-quarters (75%) of the participants never had their BP measured before and 94.9% with high BP were unaware of the hypertensive condition. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2017. BP measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. The screening took place in cities of Lilongwe and Blantyre mostly in hospitals, clinics, marketplaces, workplaces, and churches. About 4009 individuals were screened during MMM17. After multiple imputations, 849 (22.3%) had hypertension. Of individuals not receiving antihypertensive medication, 697 (19.1%) were found to have hypertension. Only 152 individuals were receiving antihypertensive medication, and of these 78 (51.4%) had uncontrolled BP. MMM17 was the largest BP screening campaign ever undertaken in Malawi. The results identified a large number with hypertension who were not on treatment and over half of those on antihypertensive treatment who were uncontrolled, indicating the need for better management of cases. These results suggest that opportunistic screening can identify significant numbers with raised BP.

Healthcare seeking practices and barriers to accessing under-five child health services in urban slums in Malawi: a qualitative study.

BACKGROUND: Access to child health services is an important determinant of child health. Whereas, child health indicators are generally better in urban than rural areas, some population groups in urban areas, such as children residing in urban slums do not enjoy this urban health advantage. In the context of increasing urbanisation and urban poverty manifesting with proliferation of urban slums, the health of under-five children in slum areas remains a public health imperative in Malawi. This paper explores healthcare-seeking practices for common childhood illnesses focusing on use of biomedical health services and perceived barriers to accessing under-five child health services in urban slums of Lilongwe, Malawi's capital city. METHODS: Qualitative data from 8 focus group discussions with caregivers and 11 in-depth interviews with key informants conducted from September 2012 to April 2013 were analysed using conventional content analysis. RESULTS: Whereas, caregivers sought care from biomedical health providers, late care-seeking also emerged as a major theme and phenomenon. Home management was actively undertaken for childhood illnesses. Various health system barriers: lack of medicines and supplies; long waiting times; late facility opening times; negative attitude of health workers; suboptimal examination of the sick child; long distance to health facility; and cost of healthcare were cited in this qualitative inquiry as critical health system factors affecting healthcare-seeking for child health services. CONCLUSIONS: Interventions to strengthen the health system's responsiveness to expectations are essential to promote utilisation of child health services among urban slum populations, and ultimately improve child health and survival.

Client satisfaction with cervical cancer screening in Malawi.

BACKGROUND: Assessing client and patient satisfaction towards a service is of programmatic importance. A study was conducted in Malawi between July and October 2013 to assess client satisfaction among women who had been screened for cervical cancer using Visual Inspection with Acetic acid test. METHODS: This was a cross sectional descriptive study which was conducted in 16 out of 43 cervical cancer screening centres. A semi structured questionnaire was used for data collection. Data were analyzed using STATA version 11 for windows. Descriptive statistics were computed to summarize participant characteristics. Logistic regression was also conducted to assess the relationship between client satisfaction with the service and the independent variables. RESULTS: One hundred and twenty women with a mean age of 33.7 (SD = 10.1) participated in the survey. All women reported being satisfied with the received service at the facility, with 68.33% reported to be very satisfied. All demographic characteristics such as age, marital status, level of education, with exception of distance to the nearest health facility had no statistically significant association with satisfaction at both univariate and multivariate analysis. However, previous knowledge about the cause of the disease itself, its prevention, knowledge that the disease can be cured, knowledge of clinic times, previous knowledge of the VIA screening test and the source from where they heard about cervical cancer had a statistical significant relationship with the outcome variable. Logistic regression revealed that satisfaction in this study was predicted by having an appointment before the screening with adjusted odd ratio of 5.71(95%CI: 1.75 - 18.63), having previous knowledge of the VIA test, AOR = 0.021(95% CI: 0.002-0.226) distance from the home to the health facility AOR = 0.11(95%CI: 0.02-0.65) and waiting time AOR = 0.09 with 95% CI: 0.09 - 0.83. Having an appointment had the only independent variable with a positive relationship with satisfaction. CONCLUSION: Women were satisfied with the screening service. The study also showed several challenges in cervical cancer screening services which can be considered as areas of potential improvement.

Promoting universal financial protection: contracting faith-based health facilities to expand access--lessons learned from Malawi.

BACKGROUND: Public-private collaborations are increasingly being utilized to universalize health care. In Malawi, the Ministry of Health contracts selected health facilities owned by the main faith-based provider, the Christian Health Association of Malawi (CHAM), to deliver care at no fee to the most vulnerable and underserved populations in the country through Service Level Agreements (SLAs). This study examined the features of SLAs and their effectiveness in expanding universal coverage. The study involved a policy analysis focusing on key stakeholders around SLAs as well as a case study approach to analyse how design and implementation of SLAs affect efficiency, equity and sustainability of services delivered by SLAs. METHODS: The study employed both qualitative and quantitative research methods to address the research questions and was conducted in five CHAM health facilities: Mulanje Mission, Holy Family, and Mtengowanthenga Hospitals, and Mabiri and Nkope Health Centres. National and district level decision makers were interviewed while providers and clients associated with the health facilities were surveyed on their experiences. A total of 155 clients from an expected 175 were recruited in the study. RESULTS: The study findings revealed key aspects of how SLAs were operating, the extent to which their objectives were being attained and why. In general, the findings demonstrated that SLAs had the potential to improve health and universal health care coverage, particularly for the vulnerable and underserved populations. However, the findings show that the performance of SLAs in Malawi were affected by various factors including lack of clear guidelines, non-revised prices, late payment of bills, lack of transparency, poor communication, inadequate human and material resources, and lack of systems to monitor performance of SLAs, amongst others. CONCLUSIONS: There was strong consensus and shared interest between the government and CHAM regarding SLAs. It was clear that free services provided by SLAs had a great impact on the impoverished locals that used the facilities. However, lack of supporting systems, inadequate infrastructure and shortage of health care providers affected SLA performance. The paper provides recommendations to policy makers for the replication and strengthening of SLA implementation in the roll-out of universalization policy.

Lived experiences of people living with HIV-A qualitative exploration on the manifestation, drivers, and effects of internalized HIV stigma within the Malawian context.

INTRODUCTION: HIV-related internalized stigma remains a major contributor to challenges experienced when accessing and providing HIV diagnosis, care and treatment services. It is a key barrier to effective prevention, treatment and care programs. This study investigated experiences of internalized stigma among people living with HIV in Malawi. METHODOLOGY: A participatory cross-sectional study design of participants from eight districts across the three administrative regions of Malawi. Data were collected using Key Informant Interviews (n = 22), Focus Group Discussions (n = 4) and life-stories (n = 10). NVIVO 12 software was used for coding applying both deductive and inductive techniques. Health Stigma and Discrimination Framework was used as a theoretical and analytical framework during data analysis. RESULTS: Overt forms of stigma and discrimination were more recognizable to people living with HIV while latent forms, including internalized stigma, remained less identifiable and with limited approaches for mitigation. In this context, manifest forms of HIV-related stigma intersected with latent forms of stigma as people living with HIV often experienced both forms of stigma concurrently. The youths, HIV mixed-status couples and individuals newly initiated on ART were more susceptible to internalized stigma due to their lack of coping mechanism, unavailability of mitigation structures, and lack of information. Broadly, people living with HIV found it difficult to identify and describe internalized stigma and this affected their ability to recognize it and determine an appropriate course of action to deal with it. CONCLUSION: Understanding the experiences of internalized stigma is key to developing targeted and context specific innovative solutions to this health problem.

The impact of taking or not taking ARVs on HIV stigma as reported by persons living with HIV infection in five African countries.

AIM: This study examined the impact of taking or not taking antiretroviral (ARV) medications on stigma, as reported by people living with HIV infection in five African countries. DESIGN: A two group (taking or not taking ARVs) by three (time) repeated measures analysis of variance examined change in reported stigma in a cohort sample of 1454 persons living with HIV infection in Lesotho, Malawi, South Africa, Swaziland, and Tanzania. Participants self-reported taking ARV medications and completed a standardized stigma scale validated in the African context. Data were collected at three points in time, from January 2006 to March 2007. Participants taking ARV medications self-reported a mean CD4 count of 273 and those not taking ARVs self-reported a mean CD4 count of 418. RESULTS: Both groups reported significant decreases in total HIV stigma over time; however, people taking ARVs reported significantly higher stigma at Time 3 compared to those not taking ARVs. DISCUSSION: This study documents that this sample of 1454 HIV infected persons in five countries in Africa reported significantly less HIV stigma over time. In addition, those participants taking ARV medications experienced significantly higher HIV stigma over time compared to those not taking ARVs. This finding contradicts some authors' opinions that when clients enroll in ARV medication treatment it signifies that they are experiencing less stigma. This work provides caution to health care providers to alert clients new to ARV treatment that they may experience more stigma from their families and communities when they learn they are taking ARV medications.

The development and validation of the HIV/AIDS Stigma Instrument - Nurse (HASI-N).

Illness-related stigma remains a serious problem in the management of HIV disease in Africa. This article describes a series of study phases conducted to develop and validate an instrument to measure HIV/AIDS-related stigma as perpetrated and experienced by nurses. Data were collected in Lesotho, Malawi, South Africa, Swaziland and Tanzania, from 2004-2006. The first phase was a qualitative study with focus group participants (n=251) to gather emic and etic descriptions of HIV/AIDS-related stigma in the five countries. Based on the qualitative data, a 46-item instrument was developed and tested during a second phase in the same five countries (n=244). The result of this phase was a 33-item, three-factor instrument with an average Cronbach alpha of 0.85. A third phase tested the instrument in 1474 nurses. The result was a final 19-item instrument, the HIV/AIDS Stigma Instrument - Nurse (HASI-N), comprised of two factors (Nurses Stigmatizing Patients and Nurses Being Stigmatized) with a Cronbach alpha of 0.90. Concurrent validity was tested by comparing the level of stigma with job satisfaction and quality of life. A significant negative correlation was found between stigma and job satisfaction. The HASI-N is the first inductively derived instrument measuring stigma experienced and enacted by nurses. It has the potential to be used not only to measure stigma, but also to develop stigma-reduction interventions.

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.

Coping with HIV-related stigma in five African countries.

People living with HIV (PLWH) and their families are subjected to prejudice, discrimination, and hostility related to the stigmatization of AIDS. This report examines how PLWH cope with HIV-related stigma in the five southern African countries of Lesotho, Malawi, South Africa, Swaziland, and Tanzania. A descriptive qualitative research design was used to explore the experience of HIV-related stigma of PLWH and nurses in 2004. A total of 43 focus groups were conducted with 251 participants (114 nurses, 111 PLWH, and 26 volunteers). In describing incidents of stigma, respondents reported strategies used or observed to cope with those incidents. Nurse reports of coping strategies that they used as well as observed in HIV-infected patients were coded. Coping strategies used by PLWH in dealing with HIV-related stigma were coded. A total of 17 different self-care strategies were identified: restructuring, seeing oneself as OK, letting go, turning to God, hoping, changing behavior, keeping oneself active, using humor, joining a support or social group, disclosing one's HIV status, speaking to others with same problem, getting counseling, helping others to cope with the illness, educating others, learning from others, acquiring knowledge and understanding about the disease, and getting help from others. Coping appears to be self-taught and only modestly helpful in managing perceived stigma.

Disclosure of HIV status: experiences and perceptions of persons living with HIV/AIDS and nurses involved in their care in Africa.

Most people with HIV have disclosed their status to someone, often with mixed results. Most health literature seems to favor disclosure by persons living with acquired immunodeficiency syndrome (AIDS), but it could be that to disclose is not always a good thing. We used a descriptive, qualitative research design to explore the experience of human immunodeficiency virus (HIV) and AIDS stigma of people living with HIV or AIDS and nurses involved in their care in Africa. Focus group discussions were held with respondents. We asked them to relate incidents that they themselves observed, and those that they themselves experienced in the community and in families. Thirty-nine focus groups were conducted in five countries in both urban and rural settings. This article is limited to a discussion of data related to the theme of disclosure only. The sub-themes of disclosure were experiences before the disclosure, the process of disclosure, and responses during and after disclosure.

"Eating plastic," "winning the lotto," "joining the www"...descriptions of HIV/AIDS in Africa.

This report is based on qualitative data gathered through a series of focus group discussions with people living with HIV or AIDS and nurses in five African countries. Participants were asked which words or phrases people use to refer to the illness and to people living with the illness. A total of 261 respondents were involved in the 40 focus group discussions, and an analysis of the data identified 290 descriptions. The descriptions were classified into 7 categories, which were (from most to least common): attributional, neutral, death-related, physical feature-related, factual statements, lingering illness-related, and common illness-related. Whereas some terms were used in more than one country, others were unique to a specific country. The descriptions show many negative labels and beliefs, but also an awareness of the devastating effects of the illness on individuals.

Cervical cancer control and prevention in Malawi: need for policy improvement.

INTRODUCTION: Malawi has the highest incidents of cervical cancer followed by Mozambique and Comoros thus according to the 2014 Africa cervical cancer multi indicator incidence and mortality score card. Despite having an established cervical cancer prevention program, there is low screening coverage. Studies have been carried out to determine socio-cultural and economical barriers to cervical cancer prevention services utilization and very few have concentrated on health system and policy related barriers to cervical cancer prevention and control. The paper presents finding on a qualitative study which carried out to determine the suitability of the national sexual and reproductive health and rights [SRHR] in mitigating challenges in cervical cancer control and prevention. METHODS: a desk review of the Malawi National Sexual and Reproductive Health and Rights [SRHR] policy 2009 was done with an aim of understanding its context, goal and objectives. Analysis of the policy history provided insight into the conditions that led to the policy. Policies from countries within the region were referred in the review. Government officials were interviewed to solicit information on the policy. RESULTS: Malawi does not have a standalone policy on cervical cancer; however, cervical cancer is covered under reproductive cancer theme in the SRHR. Unlike some policies within the region, the Malawian SRHR policy does not mention the age at which the women should be screened, the frequency and who is to do the screening. The policy does not stipulate policy implications on the ministry of health, the SRH programs and health service providers on cervical cancer. Furthermore the policy does not include HPV vaccination as a key component of cervical cancer control and prevention. CONCLUSION: the policy does not reflect fairly the best attempt to reduce the incidence and mortality of cervical cancer as such we recommend that the Reproductive Health Directorate to consider developing a standalone policy on cervical cancer control and prevention.

Underutilization of cervical cancer prevention services in low and middle income countries: a review of contributing factors.

This review aims at identifying barriers to utilization of cervical cancer prevention services in low- and middle-income countries. An electronic search was conducted using the following key words, HPV vaccination, screening, barriers, utilization and low and middle income/developed countries. Using the Garrard (1999) Matrix method approach, a modified matrix was designed and used as a data collection tool and data related to each category listed on the tool were entered into a matrix containing columns reflecting the categories. Constant comparative analysis was used to identify thematic categories. 31 articles published between 2001 and 2014 were yielded from the search. Analysis of the contents of the articles showed that the underutilization of cervical cancer screening services in low and middle-income countries is the result of barriers in accessing and utilizing of the prevention services. Though not mutually exclusive, the barriers were categorized in three categories; individual, community and health system related. Individual barriers include lack of awareness and knowledge about risk factors and prevention of cervical cancer. Age, marital status, diffidence, social economic status, cultural and religious belief of the women also determine the women's' willingness to utilize the services. In some communities there is stigma attached to discussing reproductive health issues and this limits the young women's awareness of cervical cancer and its prevention. Understanding individual, community and health system barriers that hinder women's utilization of cervical cancer prevention services is very crucial in designing effective cervical cancer control programs in low- and middle-income countries.

Health systems challenges in cervical cancer prevention program in Malawi.

BACKGROUND: Cervical cancer remains the leading cause of cancer death among women in sub-Saharan Africa. In Malawi, very few women have undergone screening and the incidence of cervical cancer is on the increase as is the case in most developing countries. We aimed at exploring and documenting health system gaps responsible for the poor performance of the cervical cancer prevention program in Malawi. DESIGN: The study was carried out in 14 randomly selected districts of the 29 districts of Malawi. All cervical cancer service providers in these districts were invited to participate. Two semi-structured questionnaires were used, one for the district cervical cancer coordinators and the other for the service providers. The themes of both questionnaires were based on World Health Organization (WHO) health system frameworks. A checklist was also developed to audit medical supplies and equipment in the cervical cancer screening facilities. The two questionnaires together with the medical supplies and equipment checklist were piloted in Chikwawa district before being used as data collection tools in the study. Quantitative data were analyzed using STATA and qualitative in NVIVO. RESULTS: Forty-one service providers from 21 health facilities and 9 district coordinators participated in the study. Our findings show numerous health system challenges mainly in areas of health workforce and essential medical products and technologies. Seven out of the 21 health facilities provided both screening and treatment. RESULTS showed challenges in the management of the cervical cancer program at district level; inadequate service providers who are poorly supervised; lack of basic equipment and stock-outs of basic medical supplies in some health facilities; and inadequate funding of the program. In most of the health facilities, services providers were not aware of the policy which govern their work and that they did not have standards and guidelines for cervical cancer screening and treatment. CONCLUSION: Numerous health system challenges are prevailing in the cervical cancer prevention program in Malawi. These challenges need to be addressed if the health system is to improve on the coverage of cervical cancer screening and treatment.

Comparing the job satisfaction and intention to leave of different categories of health workers in Tanzania, Malawi, and South Africa.

BACKGROUND: Job satisfaction is an important determinant of health worker motivation, retention, and performance, all of which are critical to improving the functioning of health systems in low- and middle-income countries. A number of small-scale surveys have measured the job satisfaction and intention to leave of individual health worker cadres in different settings, but there are few multi-country and multi-cadre comparative studies. OBJECTIVE: The objective of this study was to compare the job satisfaction and intention to leave of different categories of health workers in Tanzania, Malawi, and South Africa. METHODS: We undertook a cross-sectional survey of a stratified cluster sample of 2,220 health workers, 564 from Tanzania, 939 from Malawi, and 717 from South Africa. Participants completed a self-administered questionnaire, which included demographic information, a 10-item job satisfaction scale, and one question on intention to leave. Multiple regression was used to identify significant predictors of job satisfaction and intention to leave. RESULTS: There were statistically significant differences in job satisfaction and intention to leave between the three countries. Approximately 52.1% of health workers in South Africa were satisfied with their jobs compared to 71% from Malawi and 82.6% from Tanzania (χ2=140.3, p<0.001). 18.8% of health workers in Tanzania and 26.5% in Malawi indicated that they were actively seeking employment elsewhere, compared to 41.4% in South Africa (χ2=83.5, p<0.001). The country differences were confirmed by multiple regression. The study also confirmed that job satisfaction is statistically related to intention to leave. CONCLUSIONS: We have shown differences in the levels of job satisfaction and intention to leave between different groups of health workers from Tanzania, Malawi, and South Africa. Our results caution against generalising about the effectiveness of interventions in different contexts and highlight the need for less standardised and more targeted HRH strategies than has been practised to date.

Perceived HIV stigma and life satisfaction among persons living with HIV infection in five African countries: a longitudinal study.

BACKGROUND: Descriptive literature exists on the effects of HIV-related stigma on the lives of people living with HIV infection but few empirical studies have measured perceived HIV stigma nor explored its potential relationship to quality of life (QoL) over time in people living with HIV infection. AIM: A cohort study of a purposive convenient sample of 1457 HIV-positive persons was followed for one year in a longitudinal design that examined the effects of stigma and the life satisfaction dimension of the HIV/AIDS Targeted Quality of Life Instrument (HAT-QOL) over time, as well as the influence of other demographic and assessed social variables. Data were collected three times about six months apart from December 2005 to March 2007. RESULTS: The average age in this sample was 36.8 years (SD=8.78, n=1454) and 72.7% (n=1056) were female. The initial sample of participants was balanced among the five countries: Lesotho, Malawi, South Africa, Swaziland, and Tanzania. An attrition analysis demonstrated few demographic differences between those who remained in the study 12 months later compared with those at baseline. However, those who completed the study and who answered the QoL questions had significantly higher life satisfaction scores at baseline than those who left the study. There was a general increase in the report of life satisfaction QoL in all countries over the one-year period. However, as stigma scores increased over time there was a significant decrease in life satisfaction with differing rates of change by country. Certain factors had a positive influence on life satisfaction QoL: positive HIV media reports, taking antiretrovirals, reduced symptom intensity, and disclosure to a friend. CONCLUSION: This cohort study is the first to document empirically in a longitudinal sample, that perceived HIV stigma has a significantly negative and constant impact upon life satisfaction QoL for people with HIV infection. In the absence of any intervention to address and reduce stigmatization, individuals will continue to report poorer life satisfaction evidenced by reduced living enjoyment, loss of control in life, decreased social interactivity, and decreased perceived health status.