Primary healthcare service delivery for older people with progressive multimorbidity in low- and middle-income countries: a systematic review.

Ensuring primary healthcare (PHC) accessibility to older people with multimorbidity is vital in preventing unnecessary health deterioration. However, older people ≥50 y of age in low- and middle-income countries (LMICs) face challenges in effectively accessing and utilizing PHC. A systematic review was conducted adopting the Andersen-Newman theoretical framework for health services utilization to assess evidence on factors that affect access to PHC by older people. This framework predicts that a series of factors (predisposing, enabling and need factors) influence the utilization of health services by people in general. Seven publications were identified and a narrative analytical method revealed limited research in this area. Facilitating factors included family support, closeness to the PHC facility, friendly service providers and improved functional status of the older people. Barriers included long distance and disjointed PHC services, fewer health professionals and a lack of person-centred care. The following needs were identified: increasing the number of health professionals, provision of PHC services under one roof and regular screening services. There is a need for more investment in infrastructure development, coordination of service delivery and capacity building of service providers in LMICs to improve access and utilization of PHC services for older people.

Maternal mental health research in Malawi: Community and healthcare provider perspectives on acceptability and ethicality.

Maternal mental health (MMH) is recognised as globally significant. The prevalence of depression and factors associated with its onset among perinatal women in Malawi has been previously reported, and the need for further research in this domain is underscored. Yet, there is little published scholarship regarding the acceptability and ethicality of MMH research to women and community representatives. The study reported here sought to address this in Malawi by engaging with communities and healthcare providers in the districts where MMH research was being planned. Qualitative data was collected in Lilongwe and Karonga districts through 20 focus group discussions and 40 in-depth interviews with community representatives and healthcare providers from January through April 2021. All focus groups and interviews were audio recorded, transcribed verbatim (in local languages Chichewa and Tumbuka), translated into English, and examined through thematic content analysis. Participants' accounts suggest that biopsychosocial MMH research could be broadly acceptable within the communities sampled, with acceptability framed in part through prior encounters with biomedical and public health research and care in these regions, alongside broader understandings of the import of MMH. Willingness and consent to participate do not depend on specifically biomedical understandings of MMH, but rather on familiarity with individuals regarded as living with mental ill-health. However, the data further suggest some 'therapeutic misconceptions' about MMH research, with implications for how investigations in this area are presented by researchers when recruiting and working with participants. Further studies are needed to explore whether accounts of the acceptability and ethicality of MMH research shift and change during and following research encounters. Such studies will enhance the production of granular recommendations for further augmenting the ethicality of biomedical and public health research and researchers' responsibilities to participants and communities.

'We stay silent and keep it in our hearts': a qualitative study of failure of complaints mechanisms in Malawi's health system.

A responsive health system must have mechanisms in place that ensure it is accountable to those it serves. Patients in Malawi have to overcome many barriers to obtain care. Many of these barriers reflect weak accountability. There are at least 30 mechanisms through which Malawian patients in the public sector can assert their rights, yet few function well and, as a consequence, they are underused. Our aim was to identify the various channels for complaints and why patients are reluctant to use them when they experience poor quality or inappropriate care, as well as the institutional, social and political factors that give rise to these problems. The study was set in the Blantyre district. We used qualitative methods, including ethnographic observations, focus group discussions, document analysis and interviews with stakeholders involved in complaint handling both in Blantyre and in the capital, Lilongwe. We found that complaints mechanisms and redress procedures are underutilized because of lack of trust, geographical inaccessibility and lack of visibility leading to limited awareness of their existence. Drawing on these results, we propose a series of recommendations for the way forward.

Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE) protocol.

Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and caregivers will be closely involved throughout to ensure that the interventions are shaped by the communities concerned. The effect of the interventions will be assessed with a quasi-experimental sequential implementation in three regions, in terms of DUP reduction, symptom remission, functional recovery and PWLE / caregiver impact, with quality of life as the primary outcome. As the study team is focused on long-term impact, we recognise the importance of having embedded, robust evaluation of the programme as a whole. We will therefore evaluate implementation processes and outcomes, and cost-effectiveness, to demonstrate the value of this approach to the Ministry of Health, and to encourage longer-term adoption across Malawi.

Perspectives of agriculture, nutrition and health researchers regarding research governance in Malawi. Using a leadership, ethics, governance and systems framework.

BACKGROUND: Research ethics is intertwined with and depends on building robust and responsive research governance systems alongside researchers. Globally there has been substantial investment in agriculture, nutrition, and health (ANH) research motivated by the need to improve health outcomes, such as micronutrient deficiencies in Sub-Saharan Africa. Although there has been a notable focus on ethical issues inherent in ANH studies, there has been scanty research examining researchers' attitudes related to ANH research. This study was conducted to explore the perspectives of researchers who conducted an agronomic biofortification study in Malawi. METHODOLOGY: In-depth interviews were conducted with a purposive sample of ten ANH researchers. Interviews were conducted online via Zoom, audio-recorded, transcribed verbatim, and thematically analysed using the Leadership, Ethics, Governance and Systems Framework. RESULTS: Four core aspects emerged: Leadership: The relevance of building ethics leadership and ethical competence among researchers. ETHICS: There is a need to develop a framework that operationalises core ethical values that can guide the implementation of ANH research. Governance: Research guidelines were perceived to be too generic to guide ANH research. Systems: Researchers' recommended the establishment of a specialised ANH research ethics committee. CONCLUSIONS: The findings highlight the significance of building ethics leadership and supporting ethical competency amongst researchers. Researchers recommended the development of tailored approaches rather than utilising generic governance systems and frameworks that are drawn from medical research and thus not fit for purpose in this field. In Malawi, specialised ethics review committees are needed to guide ANH research.

Correlates of Depression in ART Adherence among Youths in Lilongwe, Malawi.

Despite collaborative efforts to improve mental health services among youths living with HIV (YLHIVs) aged 15-24, evidence shows that many suffer from depression. We established the correlates of depression and how it affects ART adherence. Structured questionnaires, a Patient Health Questionnaire 9 depression scale assessment, in-depth interviews, and Electronic Medical Record reviews were conducted at the Lighthouse Trust Martin Preus Centre (MPC) ART clinic in Lilongwe from April 2021 to October 2022. A total of 303 YLHIVs aged 15-24 were on ART, and 7 key informants were recruited. Bivariate and multivariate logistic regression analyses were performed using STATA V14.1. A thematic content analysis was used for qualitative data. Forty-six per cent of recruits were male, and fifty-four per cent were female. Seventy-one per cent were aged 20-24, and twenty-nine per cent were aged 15-19. Twenty-three per cent of the YLHIVs had depression symptoms, of whom seventy-nine per cent were aged 20-24 years. Twenty-two per cent had an unsuppressed viral load (non-adherent). Sixty-seven per cent of non-adherent participants were aged 20-24. There was no factor associated with ART non-adherence. Source of income (p = 0.003), alcohol consumption (p = 0.010), and sexual behaviour (p = 0.014) were associated with depression. Sexual behaviour was statistically significantly associated with depression (p = 0.024. The themes were a lack of basic needs, a lack of privacy, psychological trauma, incomplete disclosure, a shortage of psychosocial providers, and a knowledge deficit of ART providers to screen for depression. This study shows that depression is considerably high among YLHIVs in Malawi and linked to ART non-adherence. Strengthening mental health training for providers and routinely screening YLHIVs for depression would help in the early identification and management of depression, thereby improving ART adherence.

Operationalising a real-time research ethics approach: supporting ethical mindfulness in agriculture-nutrition-health research in Malawi.

BACKGROUND: There have been notable investments in large multi-partner research programmes across the agriculture-nutrition-health (ANH) nexus. These studies often involve human participants and commonly require research ethics review. These ANH studies are complex and can raise ethical issues that need pre-field work, ethical oversight and also need an embedded process that can identify, characterise and manage ethical issues as the research work develops, as such more embedded and dynamic ethics processes are needed. This work builds on notions of 'ethics in practice' by developing an approach to facilitate ethical reflection within large research programmes. This study explores the application of a novel 'real-time research ethics approach' (RTREA) and how this can support ethical mindfulness. This involves embedding ethical analysis and decision-making within research implementation, with a continuous dialogue between participants and researchers. The aim is to improve ethical responsiveness and participant experience, which in turn may ethically support adherence and retention. In this case study, a bioethics team (BT) was embedded in a community-based randomised, controlled trial conducted in rural Malawi, titled the 'Addressing Hidden Hunger with Agronomy'. To identify ethical issues, the researchers conducted ten focus group discussions, fourteen in-depth interviews with key informants, two workshops, observed two sensitisation and three activity meetings conducted by the trial team, and analysed fifteen reports from pre-trial to trial implementation. RESULTS: The RTREA facilitated the identification of social and ethical concerns and made researchers aware of participants' 'lived research experience'. To address concerns and experiences, the BT worked with researchers to facilitate conversation spaces where social and ethical issues were discussed. Conversation spaces were designed to create partnerships and promote participatory methods to capture trial participants' (TPs) perspectives and experiences. CONCLUSIONS: The use of RTREA showed the value of real-time and continuous engagement between TPs and researchers. These real-time processes could be embedded to complement traditional ethical guidance and expert opinions. A deeper engagement appeared to support greater operationalising of principles of inclusion, empowerment, and participant autonomy and supported researchers 'ethical mindfulness' which in turn may support instrumental outcomes of high recruitment, retention, and adherence levels.

Is mpox an STI? The societal aspects and healthcare implications of a key question.

This letter explores the societal aspects and healthcare implications that underlie thinking about mpox (formerly known was monkeypox), in the 2022 outbreak, as a sexually transmitted infection (STI). The authors examine what underlies this question, exploring what is an STI, what is sex, and what is the role of stigma in sexual health promotion. The authors argue that, in this specific outbreak, mpox is an STI among men who have sex with men (MSM). The authors highlight the need of critically thinking about how to communicate effectively, the role of homophobia and other inequalities, and the importance of the social sciences.

Examining study participants' decision-making and ethics-related experiences in a dietary community randomized controlled trial in Malawi.

BACKGROUND: The participant recruitment process is a key ethical pivot point when conducting robust research. There is a need to continuously review and improve recruitment processes in research trials and to build fair and effective partnerships between researchers and participants as an important core element in ensuring the ethical delivery of high-quality research. When participants make a fair, informed, and voluntary decision to enroll in a study, they agree to fulfill their roles. However, supporting study participants to fulfill study requirements is an important ethical obligation for researchers, yet evidenced as challenging to achieve. This paper reports on participants' motivations to volunteer and remain part of a dietary study conducted in Kasungu District, Malawi. METHODS: We conducted twenty in-depth interviews (with chiefs, religious leaders, trial participants, and health surveillance assistants), five systematic ethnographic observations, and fourteen focus group discussions with trial participants and their partners. Interviews were audio-recorded and transcribed verbatim. We used a grounded theory methodology to analyse data that included coding, detailed memo writing, and data interpretation. FINDINGS: The findings reveal that many participants had concerns during the trial. Thematically, experiences included anxieties, mistrust of researchers, rumours, fears of exploitation, and misconceptions. Anonymous concerns collected from the participants were reported to the trial team which enabled the researchers to appropriately support participants. Despite initial concerns, participants described being supported and expressed motivation to take up their role. CONCLUSION: These findings highlight a diverse map of multiple notions of what is ethically relevant and what can impact participation and retention within a study. The study has revealed how embedding a responsive approach to address participants' concerns and ethical issues can support trust relationships. We argue for the need to employ embedded ethics strategies that enhance informed consent, focus on participants' needs and positive experiences, and support researchers to fulfill their roles. This work highlights the need for research ethics committees to focus on the risks of undue influence and prevent exploitation especially in settings with a high asymmetry in resources and power between researcher and participant groups. TRIAL REGISTRATION: The Addressing Hidden Hunger with Agronomy (Malawi) trial was registered on 5th March 2019 (ISCRTN85899451).

Developing Biopsychosocial Research on Maternal Mental Health in Malawi: Community Perspectives and Concerns.

Interest in maternal mental health research is growing around the world. Maternal mental health research studies in Malawi have, for instance, sought to determine and establish the incidence and prevalence of depression and anxiety in pregnant people and the factors that contribute to experiences of these states. This article reports stakeholder perspectives on potential community concerns with biopsychosocial mental health research (which might include collecting blood samples) in Malawi. These perspectives were generated through a town hall event that featured five focus group discussions with various participants. In this article, we reflect on key themes from these discussions, demonstrating the endurance of long-standing concerns and practices around autonomy, consent, and the drawing of blood. We conclude by arguing that, while maternal mental health research conducted in Malawi could benefit Malawian women and children, consultation with community stakeholders is necessary to inform whether and how such research should be conducted.

Using factor analyses to estimate the number of female sex workers across Malawi from multiple regional sources.

PURPOSE: Human immunodeficiency virus (HIV) risks are heterogeneous in nature even in generalized epidemics. However, data are often missing for those at highest risk of HIV, including female sex workers. Statistical models may be used to address data gaps where direct, empiric estimates do not exist. METHODS: We proposed a new size estimation method that combines multiple data sources (the Malawi Biological and Behavioral Surveillance Survey, the Priorities for Local AIDS Control Efforts study, and the Malawi Demographic Household Survey). We used factor analysis to extract information from auxiliary variables and constructed a linear mixed effects model for predicting population size for all districts of Malawi. RESULTS: On average, the predicted proportion of female sex workers among women of reproductive age across all districts was about 0.58%. The estimated proportions seemed reasonable in comparing with a recent study Priorities for Local AIDS Control Efforts II (PLACE II). Compared with using a single data source, we observed increased precision and better geographic coverage. CONCLUSIONS: We illustrate how size estimates from different data sources may be combined for prediction. Applying this approach to other subpopulations in Malawi and to countries where size estimate data are lacking can ultimately inform national modeling processes and estimate the distribution of risks and priorities for HIV prevention and treatment programs.

Emergency and critical care services in Malawi: Findings from a nationwide survey of health facilities.

Background: Globally, critical illness causes up to 45 million deaths every year. The burden is highest in low-income countries such as Malawi. Critically ill patients require good quality, essential care in emergency departments and in hospital wards to avoid negative outcomes such as death. Little is known about the quality of care or the availability of necessary resources for emergency and critical care in Malawi. The aim of this study was to assess the availability of resources for emergency and critical care in Malawi using data from the Service Provision Assessment (SPA). Methods: We conducted a secondary data analysis of the SPA - a nationwide survey of all health facilities. We assessed the availability of resources for emergency and critical care using previously developed standards for hospitals in low-income countries. Each health facility received an availability score, calculated as the proportion of resources that were present. Resource availability was sub-divided into the seven a-priori defined categories of drugs, equipment, support services, emergency guidelines, infrastructure, training and routines. Results: Of the 254 indicators in the standards necessary for assessing the quality of emergency and critical care, SPA collected data for 102 (40.6%). Hospitals had a median resource availability score of 51.6% IQR (42.2-67.2) and smaller health facilities had a median of 37.5% (IQR 28.1-45.3). For the category of drugs, the hospitals' median score was 62.0% IQR (52.4-81.0), for equipment 51.9% IQR (40.7-66.7), support services 33.3% IQR (22.2-77.8) and emergency guidelines 33.3% IQR (0-66.7). SPA did not collect any data for resources in the categories of infrastructure, training or routines. Conclusion: Hospitals in Malawi lack resources for providing emergency and critical care. Increasing data about the availability of resources for emergency and critical care and improving the hospital systems for the care of critically ill patients in Malawi should be prioritized.

A structural equation model of factors associated with HIV risk behaviors and mental health among men who have sex with men in Malawi.

BACKGROUND: Men who have sex with men (MSM) bear a disproportionate burden of HIV in Malawi. Early prevention efforts in Malawi have been largely focused on preventing heterosexual and vertical transmission of HIV, and MSM have rarely been the specific benefactors of these efforts, despite facing both higher prevalence of HIV coupled with multiple barriers to prevention and care. To better facilitate the design of culturally relevant HIV prevention programs and prioritize resources among MSM in resource limited settings, the objective of this analysis was to estimate the relationship between social factors and HIV related risk behaviors and mental health. METHODS: 338 MSM were recruited using respondent-driven sampling in Blantyre, Malawi from April 2011 to March 2012. Structural equation models were built to test the association between six latent factors: participation in social activities, social support, stigma and human rights violations, depression symptomatology, condom use, and sexual risk behaviors, including concurrent sexual partnerships and total number of partners. RESULTS: The mean age of participants was 25 years old. Almost 50% (158/338) of the participants were unemployed and 11% (37/338) were married or cohabiting with women. More than 30% (120/338) of the participants reported sexual behavior stigma and 30% (102/338) reported depression symptomatology. Almost 50% (153/338) of the participants reported any kind of HIV-related risk behaviors and 30% (110/338) participated in one of the recorded social activities. Significant associations were identified between stigma and risk behaviors (ß = 0.14, p = 0.03); stigma and depression symptomatology (ß = 0.62, p = 0.01); participation in social activities and depression symptomatology (ß = 0.17, p = 0.01). CONCLUSION: Results suggest MSM reporting stigma are more likely to report sexual risk practices associated with HIV/STI transmission and depressive symptoms, while those reporting participation in social activities related to HIV education are less likely to be depressed. Furthermore, interventions at the community level to support group empowerment and engagement may further reduce risks of HIV transmission and improve mental health outcomes. Taken together, these results suggest the potential additive benefits of mental health services integrated within comprehensive HIV prevention packages to optimize both HIV-related outcomes and general quality of life among MSM in Malawi.

A qualitative exploration of the experiences of community health animation on malaria control in rural Malawi.

BACKGROUND: While great strides have been achieved in fighting malaria through the Roll Back Malaria (RBM) strategy, the recent world malaria report shows an increase in malaria-related deaths compared to previous years. Malaria control tools are efficacious and effective in preventing the disease; however, the human behaviour aspect of the intervention strategies is weak due to heavy reliance on positive human health behaviour. The challenge lies in adoption of control interventions by the target population which, to an extent, may include access to prevention and treatment tools. We present a qualitative assessment of the use of the Health Animator (HA) model for Information, Education and Communication (IEC) to improve adoption and use of malaria control by promoting positive health behaviours. RESULTS: We conducted 3 Focus Group Discussions (FGDs) and 23 individual in-depth interviews (IDIs) with HAs. Each FGD consisted of 8 participants. Data was analysed using QSR International NVivo 10 software. There are four main themes emerging regarding HA experiences. The perceptions include; collaborative work experience, personal motivation and growth, community participation with health animation and challenges with implementation. Results suggest that HAs were pleased with the training as they gained new information regarding malaria, which affected their use of malaria control interventions within their families. Knowledge was well assimilated from the trainings and influenced personal growth in becoming a community leader. Support from the leadership within the village and the health system was important in legitimising the main messages. The community responded positively to the workshops valued the information imparted. The voluntary nature of the work in a poverty-stricken community affected sustainability. CONCLUSIONS: There is need to empower communities with strategies within their reach. Functioning traditional social support structures are a crucial element in sustainability. Voluntarism is also key for sustainability, especially for rural and remote communities with limited sources of income.

Correlates of Water-Based Lubricant Use Among Men Who Have Sex with Men in Blantyre, Malawi.

Condom compatible lubricants (CCLs), including water-based lubricants (WBL) represent one strategy to prevent the breakage of latex condoms and thus decrease the risk of HIV transmission during anal intercourse. The analyses presented here characterize the correlates of WBL use during anal sex among men who have sex with men (MSM) in Blantyre, Malawi enrolled from April 2011 to March 2012 using respondent-driven sampling (RDS). Bivariate and multivariable logistic regression analyses with RDS-weighting were conducted on a total sample of 338 MSM. With RDS-weighting, 25.4% [95% confidence interval (CI): 20.3-31.4] of MSM (106/329) reported primarily using WBL during anal sex. In multivariable analysis, higher income [adjusted odds ratio (aOR): 5.9; 95% CI: 2.48-14.19], family being aware of their sexual practices (aOR: 2.52; 95% CI: 1.29-4.92), and reporting consistent condom use in the last 6 months (aOR: 1.27; 95% CI: 1.06-1.52) were positively associated with WBL use. Increasing age (per 1 year increase in age; aOR: 0.89; 95% CI: 0.83-0.95) was negatively associated with WBL. Taken together, these data highlight the limited uptake of WBL among MSM in Blantyre, Malawi, especially among older men and those belonging with lower income. Older MSM in Malawi are known to have a higher prevalence of HIV and lower reported use of WBL, suggesting significant risks of onward HIV transmission. Separately, the limited use among those with lower incomes suggests the need for free or subsidized distribution of CCL together with condoms and counseling about their use specifically for MSM in Malawi.

Virological Non-suppression and Its Correlates Among Adolescents and Young People Living with HIV in Southern Malawi.

We examined virological non-suppression (VLN) among youth ages 13-24 years receiving HIV treatment in public health facilities in six southern Malawi districts. We also tested three ART adherence measures to determine how well each identified VLN: pill counts, a Likert scale item, and a visual analogue scale. VLN was defined as HIV RNA > 1000 copies/ml. Of the 209 youth, 81 (39%) were virally non-suppressed. Male gender and stigma were independently associated with VLN; social support and self-efficacy were independently protective. Pill count had the highest positive predictive value (66.3%). Using a pill count cut-off of < 80% nonadherence, 36 (17%) of the youth were non-adherent. Of the adherent, 120 (69%) were viral suppressed. Results indicate the need to address HIV-related stigma and to bolster social support and selfefficacy in order to enhance viral suppression. In the absence of viral load testing, pill count appears the most accurate means to assess VLN.

Associations between antenatal depression and neonatal outcomes in Malawi.

Studies from several low- and middle-income countries have shown that antenatal depression may be a risk factor for poor neonatal outcomes. However, those studies conducted in sub-Saharan Africa have not consistently demonstrated this association. We set out to investigate whether antenatal depression is associated with shorter duration of pregnancy and reduced newborn size in rural Malawi. Pregnant women recruited from four antenatal clinics to the International Lipid-Based Nutrient Supplements Project-DYAD-Malawi (iLiNS-DYAD-M) randomised controlled trial of nutrient supplementation were screened for antenatal depression in the second or third trimester using a locally validated version of the Self Reporting Questionnaire (SRQ). Outcomes were duration of pregnancy, birthweight, newborn length for age z-score (LAZ), head circumference z-score, and mid-upper arm circumference (MUAC). Other potential confounding factors and predictors of birth outcome were measured and adjusted for in the analysis. 1,391 women were enrolled to the trial. 1,006/1,391 (72.3%) of these women completed an SRQ and gave birth to a singleton infant whose weight was measured within 2 weeks of birth. 143/1,006 (14.2%) scored SRQ ≥ 8, indicating likely depression. Antenatal depression was not associated with birth weight, duration of pregnancy, newborn LAZ, or head-circumference Z-score. There was an inverse association with newborn MUAC (adjusted mean difference - 0.2 cm (95% CI -0.4 to 0, p = 0.021) the significance of which is unclear. The study was conducted within a randomised controlled trial of nutritional supplementation and there was a high proportion of missing data in some enrolment sites; this may have affected the validity of our findings.

The impact of maternal diet fortification with lipid-based nutrient supplements on postpartum depression in rural Malawi: a randomised-controlled trial.

Perinatal depression is highly prevalent in low-and-middle-income countries and has been linked to poor child health. Suboptimal maternal nutrition may be a risk factor for perinatal depression. In this randomised-controlled trial conducted in rural Malawi, we set out to test the hypothesis that women taking a fatty acid-rich lipid-based nutrient supplement (LNS) would have fewer depressive symptoms postpartum than those taking iron-folate (IFA) or multiple-micronutrient (MMN) capsules. Women were recruited from antenatal clinics and randomised to receive LNS or MMN during pregnancy and for 6 months postpartum, or IFA during pregnancy only. Maternal depressive symptoms were measured using validated translations of the Self Reporting Questionnaire (SRQ) and Edinburgh Postnatal Depression Scale (EPDS), antenatally (SRQ only) and at 6 months postpartum (SRQ and EPDS). Analysis was by modified intention to treat. One thousand three hundred and ninety one women were randomised (LNS = 462, MMN = 466, IFA = 463). The groups were similar across a range of baseline variables. At 6 months postpartum, 1078 (77.5%) had SRQ completed; mean (SD) scores were LNS 1.76(2.73), MMN 1.92(2.75), IFA 1.71(2.66), P = 0.541. One thousand and fifty seven (76.0%) had EPDS completed; mean (SD) scores were LNS 5.77(5.53), MMN 5.43(4.97), IFA 5.52(5.18), P = 0.676. There were no statistically significant differences between the groups on SRQ or EPDS scores (continuous or dichotomised) in unadjusted or adjusted models. In conclusion, fortification of maternal diet with LNS compared with MMN or IFA did not reduce postnatal depressive symptoms in this study.

Living with disabled children in Malawi: Challenges and rewards.

BACKGROUND: Rehabilitation personnel need to be sensitive to the cultural aspects that constitute the environment of a disabled child's family life. OBJECTIVES: The aim of this study was to gain insight on how families experience parenting of disabled children and how the families experience the support provided by the rehabilitation system in Malawi. METHOD: An anthropological field study combining interviews and observations was conducted in a rural district of Malawi in 2011. Permission was granted to follow four families, and this study presents the stories of two families, whose children have severe disabilities. We used phenomenological and narrative analyses to make sense of the stories. RESULTS: The findings indicate that families with disabled children invest time and emphasise care for their disabled children. They feel enriched by their experience despite challenging situations with little support from the rehabilitation services. High standards of care demonstrating positive and moral attitudes have earned these families respect in their communities. Storytelling has created an opportunity for the families to understand and interpret their challenging situation with inherent contextual meaning. CONCLUSION: This study shows that families with disabled children draw on cultural and structural strengths that rehabilitation professionals should be aware of in their support to mothers and other caregivers of children with disabilities.