Psychosocial factors associated with intention to pursue tertiary education among Malawian students: the moderating effect of mental health.

BACKGROUND: In Sub Saharan Africa (SSA), approximately 9 million students are enrolled in tertiary education (TE), which is 4% of the total TE enrolment globally. Barriers to higher education in SSA are numerous: poverty, food insecurity, gender, and disability, while the COVID-19 pandemic has worsened the situation. Little is known about the psychosocial factors and underlying mechanisms associated with students' intention to apply for TE. Using a psychological theory of behaviour change, our study investigated the psychosocial and context factors associated with the application to TE. METHODS: In a cross-sectional research study 821 interviews using researcher-administered questionnaires were conducted with secondary school students in rural and urban Blantyre, Malawi. A quantitative questionnaire based on the risks, attitudes, norms, abilities, and self-regulation (RANAS) model was used to assess psychosocial factors underlying application for TE. The Centre for Epidemiological Studies Depression Scale for Children (CES-DC) and household hunger scale were used to assess mental health and hunger respectively. RESULTS: More than half of the youth were at risk to develop depression (66.5%). Girls reported experiencing more depression symptoms than boys. Around 1 in every 5 interviewed youth lived in a home experiencing moderate or severe hunger. A higher intention to apply for TE was related to perceived vulnerability, affective beliefs (joy, happiness, excitement), injunctive (approval of others) and personal norms, self-efficacy, and commitment to apply. Factual knowledge about TE application was very limited. An intention to apply for TE and self-efficacy was positively associated with regular physical exercise, but negatively associated with mental health and hunger. However, mental health moderated the effects of physical exercise on the intention to apply for TE. We found significant differences between poor and good mental health groups on intention to apply for TE in perceived vulnerability, descriptive (behaviour of others) and personal norms, self-efficacy, maintenance self-efficacy and commitment factors. The results informed a behaviour change intervention strategy to increase students' intention to apply for TE. CONCLUSIONS: Our research findings are an important contribution to the long-term strategy of achieving the Sustainable Development Goals (SDGs) and contribute to the inclusion of vulnerable students with impaired mental health in higher education in Malawi and beyond.

"It is unbearable to breathe here": air quality, open incineration, and misinformation in Blantyre, Malawi.

Blantyre, Malawi's Queen Elizabeth Central Hospital (QECH), or Queen's, as it's known locally, is the country's largest public hospital. However, Queen's is not served by regular municipal waste collection. Rather, most hospital waste (infectious and non-infectious) is gathered by grounds staff and openly burned, in several constantly smouldering piles, sending up clouds of smoke. Speaking directly to an identified knowledge gap on air quality impacts linked to trash burning and the paucity of African urban dwellers' voices on air quality issues, this study employed a mixed-methods approach to both quantitatively measure the air quality around QECH, and to qualitatively investigate the perceived impacts amongst staff and caregivers. Low-cost sensors measuring particulate matter (PM) with particle sizes less than 10 µm (PM10) and less than 2.5 µm (PM2.5), expressed as the mass of PM per volume of air (µg PMx/m3 air) were recorded every 5 min at 8 locations across the QECH for 2 months. Qualitative data collection consisted of 56 interviews with patients, caregivers and hospital staff (including janitorial and maintenance staff, nurses, doctors, and administrators). Our results show that safe air quality thresholds are consistently exceeded across space and time and that the most problematic air quality surrounds the shelter for caregivers and those receiving treatment for HIV/AIDS. Moreover, staff and visitors are severely impacted by the poor air quality within the space, but feel powerless to make changes or address complaints. Waste management interventions are desperately needed lest the patients who arrive at Queen's leave with more health issues than the ones with which they arrived.

"The rich will always be able to dispose of their waste": a view from the frontlines of municipal failure in Makhanda, South Africa.

A significant proportion of South African municipalities, who hold the mandate for providing solid waste management (SWM) services for millions of South Africans, appear to be on the brink of collapse. On the frontlines of municipal failure, the city of Makhanda, following two decades of poor governance and mismanagement, has found itself unable to fulfil its mandate, with the state retreating on SWM service provision, and disruptions to waste management services becoming a daily reality. Drawing on embedded, qualitative fieldwork, this article examines how differently placed residents have experienced disruptions to SWM services. This work explores how residents of Makhanda's two halves: the affluent and predominantly white neighbourhoods in the west, and the poor, non-white townships in the east, have (or have not) adapted to manage and dispose of their own waste during periods of disruption. Findings suggest that disruptions to waste management service provision have been broadly experienced by residents. However, the consequences of interruptions to municipal collection have not been evenly borne, as more resourced, western residents have been more successful at managing their own waste disposal, while the residents of Makhanda's townships are less capable of coping, with affected communities coming to resemble a dumping ground, and residents having to adopt unsafe or environmentally harmful disposal practices. These findings are important because they shed light on the challenges of creating cleaner, more equal communities without healthy municipal participation in waste management services, while raising important considerations for a South Africa facing the possibility of widespread municipal collapse.

Transitions for older people with intellectual disabilities and behaviours that challenge others: A rapid scoping review.

BACKGROUND: People with intellectual disabilities and behaviours that challenge others are living longer. This review aimed to explore what is known about the health and social care needs, experiences, service interventions and resources of and for this population as they transition to different care contexts in the UK. METHOD: A rapid scoping review of published and unpublished literature was conducted based on collaborative working with key stakeholders and using systematic methods of data searching, extraction and analysis. RESULTS: Consistent social work support, skilled staff, suitable accommodation, creative engagement with individuals and families to plan ahead, and timely access to quality healthcare are all required to promote successful transitions as people age, and to avoid unwanted/inappropriate transitions at points of crisis. CONCLUSIONS: More research is needed to assess the types of services that this population can and do access as they age, the quality of those services, and the extent to which local commissioners are planning ahead for people with intellectual disabilities and behaviours that challenge others.

Risk factors and predictors of violence: insights from the emergency department at a level 1 trauma center in the USA.

BACKGROUND: This study aimed to assess the risk factors and predictors of violence among patients admitted to a Level 1 trauma center in a single institution. METHODS: We conducted a retrospective analysis of patients who were admitted with a history of violence between 2012 and 2016. RESULTS: A total of 9855 trauma patients were admitted, of whom 746 (7.6%) had a history of violence prior to the index admission. Patients who had history of violence were younger and more likely to be males, Black, Hispanic and covered by low-income primary payer in comparison to non-assault trauma patients (P < 0.001 for all). Multivariate logistic regression analysis showed that covariate-adjusted predictors of violence were being Black, male having low-income primary payer, Asian, drug user, alcohol intoxicated and smoker. CONCLUSIONS: Violence is a major problem among young age subjects with certain demographic, social and ethnic characteristics. Trauma centers should establish violence injury prevention programs for youth and diverse communities.

Process Evaluation of "The Hygienic Family" Intervention: A Community-Based Water, Sanitation, and Hygiene Project in Rural Malawi.

Process evaluations of environmental health interventions are often under-reported and under-utilized in the development of future programs. The "Hygienic Family" intervention targeted improvements in hygiene behaviors of caregivers with under five-year-old children in rural Malawi. Delivered through a combination of open days, cluster meetings, household visits, and prompts, data were collected from two intervention areas for ten months. A process evaluation framework provided indicators that were measured through intervention implementation and expenditure reports, focus groups discussions, interviews, and household surveys. The collected data assessed the intervention fidelity, dose, reach, acceptability, impact, and cost. Results indicated that all planned hygiene promotion messages were delivered, and study participants were better reached primarily through household visits (78% attended over 75% of the intervention) than cluster meetings (57% attended over 75% of the intervention). However, regression found that the number of household visits or cluster meetings had no discernible effect on the presence of some household hygiene proxy indicators. Intervention implementation cost per household was USD 31.00. The intervention delivery model provided good fidelity, dose, and reach and could be used to strengthen the scope of child health and wellbeing content. The intensive face-to-face method has proven to be effective but would need to be adequately resourced through financial support for community coordinator remuneration.

"You need to dispose of them somewhere safe": Covid-19, masks, and the pit latrine in Malawi and South Africa.

The ongoing Covid-19 pandemic has generated an immense amount of potentially infectious waste, primarily face masks, which require rapid and sanitary disposal in order to mitigate the spread of the disease. Yet, within Africa, large segments of the population lack access to reliable municipal solid waste management (SWM) services, both complicating the disposal of hazardous waste, and public health efforts. Drawing on extensive qualitative fieldwork, including 96 semi-structured interviews, across four different low-income communities in Blantyre, Malawi and Durban, South Africa, the purpose of this article is to respond to a qualitative gap on mask disposal behaviours, particularly from within low-income and African contexts. Specifically, our purpose was to understand what behaviours have arisen over the past year, across the two disparate national contexts, and how they have been influenced by individual risk perceptions, established traditional practice, state communication, and other media sources. Findings suggest that the wearing of cloth masks simplifies disposal, as cloth masks can (with washing) be reused continuously. However, in communities where disposable masks are more prevalent, primarily within Blantyre, the pit latrine had been adopted as the most common space for 'safe' disposal for a used mask. We argue that this is not a new behaviour, however, and that the pit latrine was already an essential part of many low-income households SWM systems, and that within the Global South, the pit latrine fulfils a valuable and uncounted solid waste management function, in addition to its sanitation role.

Development and implementation of a pharmacist-led telehealth medication management program for veterans receiving oral antineoplastic therapies through the MISSION Act.

PURPOSE: Veterans prescribed oral antineoplastic therapies (OATs) by community providers outside the Veterans Health Administration (VA) may lack access to comprehensive medication management. To address this, our multidisciplinary team developed and implemented a pharmacist-led telehealth medication management program for veterans prescribed OATs by community providers. SUMMARY: The program exclusively uses telehealth to connect veterans with a dedicated board-certified clinical oncology pharmacist who provides comprehensive medication management. The program is based on established pharmacy models found in the research literature. We developed a standard operating procedure, communication templates, patient education materials, and a suite of health information technology tools to help streamline pharmacy processes. The Consolidated Framework for Implementation Research was used to design implementation strategies to promote the adoption of the program. In the first year, 64 veterans from 3 VA medical centers were enrolled in the program. The oncology clinical pharmacist performed 342 encounters and 101 interventions. The program saved an estimated $200,724 in medication-related costs. The veterans we surveyed reported high levels of satisfaction with the pharmacy services provided by the program. CONCLUSION: The delivery of comprehensive medication management through telehealth is feasible from a healthcare system perspective and beneficial for patients. The board-certified oncology clinical pharmacist provided remote pharmacy services to Veterans across three sites in a large and rural service area for the VA. The program realized several benefits, including positive clinical outcomes, high levels of patient satisfaction, and cost savings on medication-related costs.

Assessment of Decontamination and Reuse of Disposable Filter Funnels Used in Microbiological Water Quality Tests.

To monitor safely managed drinking water services, an increasing number of countries have integrated water quality testing for Escherichia coli into nationally-representative household surveys such as the Multiple Indicator Cluster Surveys (MICS). However, plastic waste generated during such water quality testing programs, mostly through the use of pre-sterilized disposable materials, is non-negligible. The objective of this study was to evaluate several re-use protocols for disposable filter funnels used by the MICS water quality test kits. Decontamination and re-use protocols were assessed in centralized laboratory and decentralized field settings and neither yielded positive results. Re-use of 100 mL sterile funnels decontaminated with an alcohol wipe resulted in a higher incidence of false positive results (i.e., positive contamination when processing sterile water), both in the laboratory and field; therefore, a higher proportion of positives tests can be expected if these components are re-used. Further improvements to the decontamination technique and training are needed before material re-use can be reliably adopted. Autoclaving the funnels for re-use is feasible, provided that there is capacity to re-package and distribute funnels in a sterile manner.

Impact of sampling depth on pathogen detection in pit latrines.

Wastewater based epidemiology (WBE) is increasingly used to provide decision makers with actionable data about community health. WBE efforts to date have primarily focused on sewer-transported wastewater in high-income countries, but at least 1.8 billion people in low- and middle-income countries (LMIC) use onsite sanitation systems such as pit latrines and septic tanks. Like wastewater, fecal sludges from such systems offer similar advantages in community pathogen monitoring and other epidemiological applications. To evaluate the distribution of enteric pathogens inside pit latrines-which could inform sampling methods for WBE in LMIC settings unserved by sewers-we collected fecal sludges from the surface, mid-point, and maximum-depth of 33 pit latrines in urban and peri-urban Malawi and analyzed the 99 samples for 20 common enteric pathogens via multiplex quantitative reverse transcription PCR. Using logistic regression adjusted for household population, latrine sharing, the presence of a concrete floor or slab, water source, and anal cleansing materials, we found no significant difference in the odds of detecting the 20 pathogens from the mid-point (adjusted odds ratio, aOR = 1.1; 95% confidence interval = 0.73, 1.6) and surface samples (aOR = 0.80, 95% CI = 0.54, 1.2) compared with those samples taken from the maximum depth. Our results suggest that, for the purposes of routine pathogen monitoring, pit latrine sampling depth does not strongly influence the odds of detecting enteric pathogens by molecular methods. A single sample from the pit latrines' surface, or a composite of surface samples, may be preferred as the most recent material contributed to the pit and may be easiest to collect.

Evaluating self-reported measures and alternatives to monitor access to drinking water: A case study in Malawi.

Monitoring access to drinking water is complex, especially in settings where on premises water supply is not available. Although self-reported data are generally used to estimate coverage of access to drinking water, the relationship between self-reported time travelled and true time travelled is not well known in the context of water fetching. Further, water fetching is likely to impact the quantity and quality of water a household uses, but data and measures supporting this relationship are not well documented. The objective of this study was to appraise the validity and reliability of self-reported measurements used to estimate access coverage. A case study was conducted in Malawi to enhance understanding of the self-reported measures and alternatives available to assess and monitor access to drinking water in view of generating global estimates. Self-reported data were compared with objective observations and direct measurements of water quantity, quality and accessibility. Findings from this study highlight the variations between different measures such as self-reported and recorded collection time and raise awareness with regard to the use of self-reported data in the context of fetching water. Alternatives to self-reported indicators such as GPS-based or direct observations could be considered in surveys in view of improving data accuracy and global estimates.

Sludge bomb: The impending sludge emptying and treatment crisis in Blantyre, Malawi.

Blantyre, Malawi has approximately one million people who rely on pit latrines for sanitation and yet there is a limited pit-emptying sector to empty, transport and safely discharge the faecal sludge. Over three years, we monitored the volume of sludge that was safely discharged at the authorized Wastewater Treatment Plants (WWTP) and in parallel, estimated the volume of sludge that is currently buried within pit latrines of Blantyre, based on measurements at 321 households. Comparing the volumes of sludge emptied to the volumes of sludge buried, we highlight the fact that a) there is a suspiciously low volume of pit-derived faecal sludge being safely disposed; b) most safely discharged sludge is taken from the small proportion of septic tanks in the city, and not from pit latrines; and c) that the cost of safely discharging does not seem to correlate with the volumes delivered (despite an option to discharge for free). There is a large and growing amount of sludge buried beneath the city which will need to be safely emptied and treated in coming years. The city and the WWTPs must move quickly to ensure that the businesses and infrastructure are prepared for the future faecal sludge management challenges that lay ahead, especially if they are to achieve SDG 6 by 2030.

Household practices in accessing drinking water and post collection contamination: A seasonal cohort study in Malawi.

Lack of access to safe drinking water on premises remains widespread in low- and middle-income countries. Interventions to improve access to safe water at the point of collection are essential, but water safety at the point of consumption is also an important consideration. This research aimed to 1) improve understanding of household practices in collecting water with respect to seasonality, and 2) to further assess risk associated with post-collection contamination from the point of collection to the point of consumption. A seasonal cohort study, including 115 households, was conducted in Malawi. Along with household surveys and observations, samples of water were tested for microbial water quality at four different stages of water collection: water source, collection container, storage container, cup of drinking water. Using E. coli as an indicator of contamination (cfu/100 ml), the risk of post-collection contamination was assessed. The results indicate that most water sources were free from contamination; contamination was proportionally lower in the dry season when more sources were found to be classified as having a very low risk of contamination. However, the level of risk of contamination was more likely to increase following collection in water sources that were initially free from contamination. Results show that the degradation in water quality from the point of collection to the point of consumption was more important in the rainy season, which is likely to be driven by the effect of seasonality on the household environment. Filling the collection container at the point of collection and storage at the point of consumption were found to be critical stages for an increased risk of E. coli contamination. Understanding household practices in accessing and handling water during both rainy and dry season is necessary to target appropriate interventions to reduce post-collection contamination.

Clinical Characteristics Predict the Yield of Head Computed Tomography Scans among Intoxicated Trauma Patients: Implications for the Initial Work-up.

BACKGROUND AND AIMS: Alcohol intoxication may confound the clinical assessment of the trauma patient. Head computed tomography (h-CT) is the standard imaging technique to rule out intracranial injury in most intoxicated trauma patients. The objective of this study was to determine whether certain clinical findings (computed clinical score [CCS]) could predict the h-CT yield, admission, and neurosurgical consultation (NSC) among intoxicated trauma patients. MATERIALS AND METHODS: This is a 4-year retrospective cohort study (2013-2017) of trauma patients who presented to our level 1 trauma center emergency department with alcohol intoxication. For each patient, a computed clinical score (CCS) was generated based on the following findings: age ≥50 years, Glasgow Coma Scale <13, evidence of trauma above the clavicles, amnesia, loss of consciousness, headache, vomiting, and seizures. The primary endpoints were NSC, admission, and acute h-CT finding. Univariate and multivariate regressions were used to compare predictors of the primary endpoints. RESULTS: We identified 437 intoxicated trauma patients (median age: 35 years [interquartile range: 25-50]; 71.9% men; median blood alcohol content: 207.8 mg/dL). One hundred and twenty-four (30.4%) patients had acute findings on h-CT, 351 (80.3%) were admitted, and 112 (25.6%) received NSC. On multivariate analysis, CCS was the only predictor of acute h-CT (odds ratio [OR] =1.6; 95% confidence interval [CI]: 1.3-2.0; P < 0.0001) and the best predictor of admission (OR = 1.6; 95% CI: 1.3-1.9; P < 0.0001) and NSC (OR = 1.8; 95% CI: 1.5-2.3; P < 0.0001). CONCLUSIONS: One-third of intoxicated trauma patients have acute findings on h-CT. While the CCS was the best predictor of acute h-CT findings, hospital admission, and NSC, h-CT scanning should continue to be a standard of care.

Trends in access to water and sanitation in Malawi: progress and inequalities (1992-2017).

Billions of people globally gained access to improved drinking water sources and sanitation in the last decades, following effort towards achieving the Millennium Development Goals. Global progress remains a general indicator as it is unclear if access is equitable across groups of the population. Agenda 2030 calling for `leaving no one behind', there is a need to focus on the variations of access in different groups of the population, especially in the context of low- and middle-income countries including Malawi. We analyzed data from Demographic Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) to describe emerging trends on progress and inequalities in water supply and sanitation services over a 25-year period (1992-2017), as well as to identify the most vulnerable populations in Malawi. Data were disaggregated with geographic and socio-economic characteristics including regions, urban and rural areas, wealth and education level. Analysis of available data revealed progress in access to water and sanitation among all groups of the population. The largest progress was generally observed in the groups that were further behind at the baseline year, which likely reflects good targeting in interventions/improvements to reduce the gap in the population. Overall, results demonstrated that some segments of the population - foremost poorest Southern rural populations - still have limited access to water and are forced to practise open defecation. Finally, we suggest including standardized indicators that address safely managed drinking water and sanitation services in future surveys and studies to increase the accuracy of national estimates.

Self-Reported Versus Observed Measures: Validation of Child Caregiver Food Hygiene Practices in Rural Malawi.

Few studies have attempted to measure the differences between self-reported and observed food hygiene practices in a household setting. We conducted a study to measure the level of agreement between self-reported and observed food hygiene practices among child caregivers with children under the age of five years in rural Malawi. Fifty-eight child caregivers from an intervention and 29 from a control group were recruited into the study. At the end of a nine-month food hygiene intervention, household observations were conducted followed by self-reported surveys. Overall, practices were found to be more frequently reported than observed in both groups. However, the difference between self-reports and observed practices was minimal in the intervention compared to the control group. The odds ratio results confirm that more desirable practices were observed in the intervention group compared to the control group. Despite the effects of reactivity during observations, the study results imply that the intervention group did not just improve their knowledge, but also translated the messaging into better practice. Researchers and implementing agencies in water, sanitation and hygiene and food hygiene sector should ensure that interventions are context-appropriate, and that effective methods of observation are used to confirm any reported effects of an intervention.

Power, danger, and secrecy-A socio-cultural examination of menstrual waste management in urban Malawi.

Menstrual blood is not just a physical substance; it is laden with symbolism and often powerfully stigmatised. It is important to understand local perceptions and attitudes towards menstrual blood, as well as the preferred practices of menstruating women, in order to design appropriate sanitation and solid waste systems to support menstruation. Failure to take account of socio-cultural factors can jeopardise the effectiveness of such infrastructure. This study, conducted in Blantyre, Malawi, is a qualitative socio-cultural examination of how women manage and view menstruation. Thirty nine interviews, conducted with individuals and with small groups of friends, were carried out with thirty one women using pit latrines, flush toilets, and urine-diverting dry toilets in early 2019. Menstruation in Blantyre was found to be shrouded in secrecy because it was viewed as 'dirty', and therefore remained concealed. There was widespread anxiety about menstrual blood being used in ufiti (witchcraft), which affected how women used and disposed of their menstrual absorbents. At the same time, menstrual blood was also viewed as a powerful healing substance with uses in traditional medicine. The type of infrastructure required by women to support their menstruation depended on the type of menstrual absorbent used. Those using reusable cloth generally preferred a private bathroom with discreet drainage, whilst those using disposable pads needed a discreet and convenient disposal system. Increased preference for disposable pads over reusable cloth (particularly for younger women in education or employment) suggested that menstrual waste profiles of urban areas may be changing. Understanding these changing needs will be crucial for planning effective, sustainable waste disposal and sanitation infrastructure.

The impact of self-advocacy organizations on the subjective well-being of people with intellectual disabilities: A systematic review of the literature.

BACKGROUND: A high sense of subjective well-being has been associated with more prosocial behaviours, better health, work productivity and positive relationships. The aim of this systematic review was to explore what impact self-advocacy has on the subjective well-being of people with intellectual disabilities. METHOD: The authors reviewed articles focusing on the perspectives of adults with intellectual disabilities engaged with self-advocacy groups. Searches were performed in PsychINFO, Web of Science, SCOPUS, MEDLINE and CIHNL databases, resulting in 16 articles meeting the inclusion criteria. A framework synthesis approach was used to extract data deductively based on the Dynamic Model of Wellbeing. RESULTS: While self-advocacy has a positive impact on all domains of the Dynamic Model of Wellbeing, negative impacts associated with participation in a self-advocacy group were also reported. CONCLUSIONS: The benefits of participating in self-advocacy groups on the well-being of individuals with intellectual disabilities outweigh the disadvantages.

"This is our next problem": Cleaning up from the COVID-19 response.

The purpose of this discussion is to highlight the essential role that solid waste management must play in a humanitarian response towards disasters, in particular the ongoing Covid-19 pandemic. We highlight a number of potential avenues for scholarly investigation into the waste impacts of our response to Covid-19, but in particular, briefly unpacks the relationship between disasters, consumption and disposability as one potential research topic. The discussion is intended to start a conversation that is, at the moment, critically relevant, and to contribute to a more inclusive, and less normatively Western waste management studies discourse.