Barriers to accessing malaria treatment amongst school-age children in rural Malawi.

BACKGROUND: Over the last two decades, many countries have moved from malaria control toward malaria elimination. However, some sub-Saharan African countries, like Malawi, have recently seen a reversal in malaria control progress with reported increases in confirmed malaria cases. This may be the result of inadequate access to effective malaria control interventions by key population groups that perpetuate transmission. This study aimed to assess the barriers to accessing malaria treatment among school-aged children (SAC) in Malawi. METHODS: A qualitative study was conducted between September and October 2020, where data were gathered in rural Malawi using free-listing interviews, key-informant interviews, semi-structured interviews and focus group discussions. Purposively sampled participants included SAC, parents of SAC, health workers and key stakeholders at community and district levels. Interviews were digitally recorded and transcribed verbatim. Data were organized using NVivo 12 software and analysed using the thematic method. RESULTS: The study recruited 252 participants, with 156 being SAC, equally divided between boys and girls. Health system barriers to malaria treatment included long waiting hours and queues at clinics, frequent stock-outs of medical supplies, and travel time to the facility. Provider barriers included negative attitude and limited service hours. Individual and cultural barriers included fear of malaria tests and beliefs associating witchcraft as the best treatment for malaria. In addition, COVID-19-related barriers included the inability to follow preventive measures, a shift in focus from malaria to COVID-19, and fear of contracting COVID-19 and/or being tested for COVID-19 at the facility. CONCLUSIONS: This study shows most of the barriers to accessing malaria treatment among SAC are similar to those experienced by other population groups. Furthermore, COVID-19 adversely affected SAC's access to treatment. Interventions that support SAC access to prompt diagnosis and treatment are urgently needed to improve the effective control of malaria.

Protocol for a multi-country implementation research study to assess the feasibility, acceptability, and effectiveness of context-specific actions to train and support facilitators to deliver sexuality education to young people in out-of-school settings.

Comprehensive sexuality education (CSE) is a well-established component of the package of interventions required to improve adolescent sexual and reproductive health and rights. As the international community has increased its emphasis on equity and leaving no-one behind with the Agenda for Sustainable Development, attention has been drawn to the need for complementary CSE programmes to reach young people who are not in school, or whose needs are not met by in-school CSE programmes. CSE in out-of-school contexts presents unique considerations, especially those related to facilitation. In this manuscript, we present the protocol for a multi-country implementation research study in Colombia, Ethiopia, Ghana, and Malawi to assess the feasibility, acceptability, and effectiveness of context-specific actions to prepare and support facilitators to deliver CSE in out-of-school settings to defined groups of young people with varying needs and circumstances. This study will be led by the World Health Organization and the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, in partnership with local research institutions. It will be nested within a multi-country programme led by UNFPA, in partnership with local implementing partners and with financial support from the Government of Norway. This study will shed new insight into what it takes to effectively deliver CSE in out-of-school contexts, to enhance progress towards the achievement of SDG 3 "Ensure healthy lives and promote wellbeing for all at all ages" and SDG 5 "Achieve gender equality and empower all women and girls".

Comprehensive sexuality education for out-of-school young people living with HIV and young people with disabilities: findings from a formative research study in Malawi.

This formative study was undertaken between June 2020 and April 2021 to provide evidence to inform the design and delivery of comprehensive sexuality education (CSE) in Malawi for young people living with HIV (YPLHIV) and young people with disabilities (YPWD). The study included a desk review of the situation of these two groups and a mapping of CSE programmes and delivery approaches in Malawi. The study findings show that YPWD and YPLHIV in Malawi are marginalised groups, face stigma and discrimination, and are more vulnerable to abuse, warranting CSE that addresses their needs. Yet, they are often left out of sexuality education such as school-based programmes (due to early school drop-outs) and out-of-school programmes, as well as traditional modes. Furthermore, in instances where they have access to sexuality education, there is little evidence to suggest that the sexuality education that they receive is designed to address their needs, thus raising questions about its relevance. There is need for tailored CSE that addresses the needs of these groups and that is delivered using an approach that is easily accessible to them.

Implementation of a novel ultrasound training programme for midwives in Malawi: A mixed methods evaluation using the RE-AIM framework.

Introduction: Despite recommendation that all women receive an ultrasound in pregnancy prior to 24 weeks', this remains unavailable to many women in low-income countries where trained practitioners are scarce. Although many programmes have demonstrated efficacy, few have achieved longterm sustainability, with a lack of information about how best to implement such programmes. This mixed-methods study aimed to evaluate the implementation of a novel education package to teach ultrasound-naive midwives in Malawi basic obstetric ultrasound, assessing its impact in the context of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. Methods: The study ran across six sites in Malawi between October 2020 and June 2021, encompassing three phases; pre-implementation, implementation and post-implementation. Twenty nine midwives underwent a bespoke education package with matched pre and post course surveys assessed their knowledge, attitudes and confidence and "hands on" assessments evaluating practical skills. Training evaluation forms and in-depth interviews explored their satisfaction with the package, with repeat assessment and remote image review evaluating maintenance of skills. Results: 28/29 midwives completed the training, with significant increases in knowledge, confidence and practical skills. Adherence to the education package varied, however many changes to the proposed methodology were adaptive and appeared to facilitate the efficacy of the programme. Unfortunately, despite reporting approval regarding the training itself, satisfaction regarding supervision and follow up was mixed, reflecting the difficulties encountered with providing ongoing in-person and remote support. Conclusion: This programme was successful in improving trainees' knowledge, confidence and skill in performing basic obstetric ultrasound, largely on account of an adaptive approach to implementation. The maintenance of ongoing support was challenging, reflected by trainee dissatisfaction. By evaluating the success of this education package based on its implementation and not just its efficacy, we have generated new insights into the barriers to sustainable upscale, specifically those surrounding maintenance.

Wealth-related inequalities in demand for family planning satisfied among married and unmarried adolescent girls and young women in sub-Saharan Africa.

BACKGROUND: The use of modern contraception has increased in much of sub-Saharan Africa (SSA). However, the extent to which changes have occurred across the wealth spectrum among adolescents is not well known. We examine poor-rich gaps in demand for family planning satisfied by modern methods (DFPSm) among sexually active adolescent girls and young women (AGYW) using data from national household surveys. METHODS: We used recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys to describe levels of wealth-related inequalities in DFPSm among sexually active AGYW using an asset index as an indicator of wealth. Further, we used data from countries with more than one survey conducted from 2000 to assess DFPSm trends. We fitted linear models to estimate annual average rate of change (AARC) by country. We fitted random effects regression models to estimate regional AARC in DFPSm. All analysis were stratified by marital status. RESULTS: Overall, there was significant wealth-related disparities in DFPSm in West Africa only (17.8 percentage points (pp)) among married AGYW. The disparities were significant in 5 out of 10 countries in Eastern, 2 out of 6 in Central, and 7 out of 12 in West among married AGYW and in 2 out of 6 in Central and 2 out of 9 in West Africa among unmarried AGYW. Overall, DFPSm among married AGYW increased over time in both poorest (AARC = 1.6%, p < 0.001) and richest (AARC = 1.4%, p < 0.001) households and among unmarried AGYW from poorest households (AARC = 0.8%, p = 0.045). DPFSm increased over time among married and unmarried AGYW from poorest households in Eastern (AARC = 2.4%, p < 0.001) and Southern sub-regions (AARC = 2.1%, p = 0.030) respectively. Rwanda and Liberia had the largest increases in DPFSm among married AGYW from poorest (AARC = 5.2%, p < 0.001) and richest (AARC = 5.3%, p < 0.001) households respectively. There were decreasing DFPSm trends among both married (AARC = - 1.7%, p < 0.001) and unmarried (AARC = - 4.7%, p < 0.001) AGYW from poorest households in Mozambique. CONCLUSION: Despite rapid improvements in DFPSm among married AGYW from the poorest households in many SSA countries there have been only modest reductions in wealth-related inequalities. Significant inequalities remain, especially among married AGYW. DFPSm stalled in most sub-regions among unmarried AGYW.

Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review.

BACKGROUND: Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required. METHODS: A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted. RESULTS: 179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions. CONCLUSIONS: Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.