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1.
BMC Med ; 19(1): 298, 2021 11 10.
Artigo em Inglês | MEDLINE | ID: mdl-34753468

RESUMO

BACKGROUND: Ratios of bacteriologically positive tuberculosis (TB) prevalence to notification rates are used to characterise typical durations of TB disease. However, this ignores the clinical spectrum of tuberculosis disease and potentially long infectious periods with minimal or no symptoms prior to care-seeking. METHODS: We developed novel statistical models to estimate progression from initial bacteriological positivity including smear conversion, symptom onset and initial care-seeking. Case-detection ratios, TB incidence, durations, and other parameters were estimated by fitting the model to tuberculosis prevalence survey and notification data (one subnational and 11 national datasets) within a Bayesian framework using Markov chain Monte Carlo methods. RESULTS: Analysis across 11 national datasets found asymptomatic tuberculosis durations in the range 4-8 months for African countries; three countries in Asia (Cambodia, Lao PDR, and Philippines) showed longer durations of > 1 year. For the six countries with relevant data, care-seeking typically began half-way between symptom onset and notification. For Kenya and Blantyre, Malawi, individual-level data were available. The sex-specific durations of asymptomatic bacteriologically-positive tuberculosis were 9.0 months (95% credible interval [CrI]: 7.2-11.2) for men and 8.1 months (95% CrI: 6.2-10.3) for women in Kenya, and 4.9 months (95% CrI: 2.6-7.9) for men and 3.5 months (95% CrI: 1.3-6.2) for women in Blantyre. Age-stratified analysis of data for Kenya showed no strong age-dependence in durations. For Blantyre, HIV-stratified analysis estimated an asymptomatic duration of 1.3 months (95% CrI: 0.3-3.0) for HIV-positive people, shorter than the 8.5 months (95% CrI: 5.0-12.7) for HIV-negative people. Additionally, case-detection ratios were higher for people living with HIV than HIV-negative people (93% vs 71%). CONCLUSION: Asymptomatic TB disease typically lasts around 6 months. We found no evidence of age-dependence, but much shorter durations among people living with HIV, and longer durations in some Asian settings. To eradicate TB transmission, greater gains may be achieved by proactively screening people without symptoms through active case finding interventions.


Assuntos
Tuberculose , Teorema de Bayes , Feminino , Humanos , Incidência , Malaui/epidemiologia , Masculino , Prevalência , Tuberculose/diagnóstico , Tuberculose/epidemiologia
2.
Reprod Health ; 18(1): 222, 2021 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-34743711

RESUMO

The COVID-19 infection control and prevention measures have contributed to the increase in incidence of intimate partner violence (IPV) and negatively impacted access to health and legal systems. The purpose of this commentary is to highlight the legal context in relation to IPV, and impact of COVID-19 on IPV survivors and IPV prevention and response services in Kenya, Malawi, and Sudan. Whereas Kenya and Malawi have ratified the Convention on Elimination of all forms of Discrimination against Women (CEDAW) and have laws against IPV, Sudan has yet to ratify the convention and lacks laws against IPV. Survivors of IPV in Kenya, Malawi and Sudan have limited access to quality health care, legal and psychosocial support services due to COVID-19 infection control and prevention measures. The existence of laws in Kenya and Malawi, which have culminated into establishment of IPV services, allows a sizable portion of the population to access IPV services in the pandemic period albeit sub-optimal. The lack of laws in Sudan means that IPV services are hardly available and as such, a minimal proportion of the population can access services. Civil society's push in Kenya has led to prioritisation of IPV services. Thus, a vibrant civil society, committed governments and favourable IPV laws, can lead to better IPV services during the COVID-19 pandemic period.


Assuntos
COVID-19 , Violência por Parceiro Íntimo , Feminino , Humanos , Quênia/epidemiologia , Malaui/epidemiologia , Pandemias , SARS-CoV-2 , Sudão/epidemiologia
3.
Reprod Health ; 18(1): 229, 2021 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-34775983

RESUMO

BACKGROUND: Preconception care is one of the preventive strategies in maternal and new-born health as recommended by WHO. However, in sub-Saharan Africa there is poor preconception care practices. This study examined knowledge and perceptions of preconception care among health workers and women of reproductive age group in Mzuzu City, Malawi. METHODS: A descriptive cross-sectional study was conducted using a mixed methods approach. Selection of respondents was done through a multistage and purposive sampling techniques respectively. A total of 253 women of reproductive age from nine townships of Mzuzu City responded to the questionnaire and 20 health workers were interviewed. RESULTS: A total of 136 (54%) respondents had heard of preconception care. About 57.7% (n = 146) demonstrated a good level of knowledge of preconception care while 42.3% (n = 107) had poor knowledge. About 72% (n = 105) of those with good of knowledge of preconception care, lacked awareness on possibilities of talking to a health care provider on intentions of getting pregnant. About 74.7% (n = 189) of women had a positive perception towards preconception care. Knowledge of preconception care was a good predictor of positive perception (AOR = 2.5; 95% CI 1.2-5.0), however its predictability was influenced by the academic level attained. Those with secondary (AOR = 10.2; 95% CI 3.2-26.2) and tertiary (AOR = 2.3; 95% CI 1.1-4.9) were more likely to have good knowledge of preconception care than those with primary school education level. About 95% (n = 19) of health workers lacked details about preconception care but they admitted their role in preconception care. CONCLUSION: Preconception care practice among health workers and women of reproductive age in Mzuzu City was low. However there was positive perception towards preconception care in both parties. There is an opportunity in existing platforms for implementation of interventions targeting identified predictors for increased knowledge and uptake of preconception care.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Cuidado Pré-Concepcional , Estudos Transversais , Feminino , Pessoal de Saúde , Humanos , Malaui , Percepção , Gravidez
4.
Glob Health Action ; 14(1): 1989807, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34779363

RESUMO

BACKGROUND: The majority of deaths amongst children under 5 years are still due to preventable infectious causes. Emergency care has been identified as a key health system weakness, and referrals are often challenging. OBJECTIVE: We aimed to establish how prepared frontline facilities in Malawi are to implement WHO Emergency Triage Assessment and Treatment (ETAT) guidelines, to support policy and planning decisions. METHODS: We conducted a concurrent mixed-methods study, including facility audit; healthcare provider survey; focus group discussions (FGD) and semi-structured interviews with facility staff. The study was conducted in two districts in Malawi, Zomba and Mchinji, between January and May 2019. We included all frontline facilities, including dispensaries, primary health centres, rural and community hospitals. Quantitative data were described using proportions, means and linear regression. Qualitative data was analysed using a framework approach. Data were analysed separately and then triangulated into common themes. RESULTS: Forty-seven facilities and 531 healthcare providers were included in the audit and survey; 6 FGDs and 5 interviews were completed. Four common themes emerged: (1) current emergency case management; (2) referral practices; (3) trained staff capacity; (4) opportunities and barriers for ETAT. Triage was conducted in most facilities with various methods described, and 53% reporting all staff are responsible. Referrals were common, but challenging due to issues in transportation. Twelve percent of survey respondents had ETAT training, with clinical officers (41%) reporting this more frequently than other cadres. Training was associated with increased knowledge, independent of cadre. The main barriers to ETAT implementation were the lack of resources, but opportunities to improve quality of care were reported. CONCLUSIONS: Malawian frontline facilities are already providing a level of emergency paediatric care, but issues in training, drug supplies and equipment were present. To effectively scale-up ETAT, policies need to include supply chain management, maintenance and strengthening referral communication.


Assuntos
Serviço Hospitalar de Emergência , Triagem , Instituições de Assistência Ambulatorial , Criança , Pré-Escolar , Humanos , Malaui , Atenção Primária à Saúde
5.
Malawi Med J ; 33(2): 85-107, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34777704

RESUMO

The Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has triggered an international pandemic that has led to significant public health problems. To date, limited evidence exists to suggest that drugs are effective against the disease. As possible treatments are being investigated, herbal medicines have shown potential for producing novel antiviral agents for the COVID-19 disease. Aim: This review explored the potential of Malawi's traditional medicinal plants for the management of COVID-19. Methods: The authors searched on PubMed and Google scholar for medicinal plants that are used in Malawi and published in openly available peer reviewed journals. Plants linked with antiviral treatment, anti-COVID-19 activity or COVID-19 symptoms management were targeted. These included activity against pneumonia, inflammation, cough, difficulty in breathing, pain/aches, fever, diarrhoea, rheumatism, fatigue, asthma, immunocompromised and cardiovascular diseases. Results: 11 studies were found with 306 plant species. 127 plant species had at least one COVID-19 related pharmacological activity. Of these plant species, the number of herbal entities used for each indication was: pain/aches (87), fever (2), pneumonia (9), breathing/asthma problems (5), coughing (11), diarrhoea (1), immunosuppression (8), blood issues (10), fatigue (2), heart problems (11), inflammation (8), rheumatism (10) and viral diseases (12). Thirty (30) species were used for more than one disease and Azedarachta indica topped the list (6 of the 13 COVID-19 related diseases). The majority of the species had phytochemicals known to have antiviral activity or mechanisms of actions linked to COVID-19 and consequent diseases' treatment pathways. Conclusion: Medicinal plants are a promising source of compounds that can be used for drug development of COVID-19 related diseases. This review highlights potential targets for the World Health Organization and other research entities to explore in order to assist in controlling the pandemic.


Assuntos
COVID-19 , Plantas Medicinais , Antivirais/uso terapêutico , Humanos , Malaui , Compostos Fitoquímicos , SARS-CoV-2
6.
J Glob Health ; 11: 04062, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34737862

RESUMO

Background: Existing scores to identify children at risk of hospitalized pneumonia-related mortality lack broad external validation. Our objective was to externally validate three such risk scores. Methods: We applied the Respiratory Index of Severity in Children (RISC) for HIV-negative children, the RISC-Malawi, and the Pneumonia Etiology Research for Child Health (PERCH) scores to hospitalized children in the Pneumonia REsearch Partnerships to Assess WHO REcommendations (PREPARE) data set. The PREPARE data set includes pooled data from 41 studies on pediatric pneumonia from across the world. We calculated test characteristics and the area under the curve (AUC) for each of these clinical prediction rules. Results: The RISC score for HIV-negative children was applied to 3574 children 0-24 months and demonstrated poor discriminatory ability (AUC = 0.66, 95% confidence interval (CI) = 0.58-0.73) in the identification of children at risk of hospitalized pneumonia-related mortality. The RISC-Malawi score had fair discriminatory value (AUC = 0.75, 95% CI = 0.74-0.77) among 17 864 children 2-59 months. The PERCH score was applied to 732 children 1-59 months and also demonstrated poor discriminatory value (AUC = 0.55, 95% CI = 0.37-0.73). Conclusions: In a large external application of the RISC, RISC-Malawi, and PERCH scores, a substantial number of children were misclassified for their risk of hospitalized pneumonia-related mortality. Although pneumonia risk scores have performed well among the cohorts in which they were derived, their performance diminished when externally applied. A generalizable risk assessment tool with higher sensitivity and specificity to identify children at risk of hospitalized pneumonia-related mortality may be needed. Such a generalizable risk assessment tool would need context-specific validation prior to implementation in that setting.


Assuntos
Regras de Decisão Clínica , Pneumonia , Criança , Saúde da Criança , Humanos , Malaui , Índice de Gravidade de Doença
7.
Reprod Health ; 18(1): 209, 2021 Oct 18.
Artigo em Inglês | MEDLINE | ID: mdl-34663362

RESUMO

BACKGROUND: The prevalence of teenage pregnancies in Malawi is 29%. About 25% of those are married while 30% are unmarried adolescents (15-19 years old) who use contraceptives. Data on contraceptive use has focused on older adolescents (15-19 years old) leaving out the young adolescents (10-14 years old). This study assessed factors that influence contraceptive decision-making and use among young adolescents aged 10-14 years. METHODS: This was a qualitative study that used the Theory of Reasoned Action (TRA) model to understand the processes that influence contraceptive decision-making among young adolescents (10-14 years old) in urban Lilongwe. The study was conducted in six youth health-friendly service centers and 12 youth clubs. Two focus group discussions and 26 in-depth interviews were conducted among sexually active in and out of school young adolescents and key informants. The results are organized into themes identified during the analysis. RESULTS: Results showed that contraceptive decision-making is influenced by social factors (individual, interpersonal, society) and adolescents' perceptions regarding hormonal contraceptives. There is also a disconnect between Education and Adolescent Sexual and Reproductive Health policies. CONCLUSION: The findings suggest that interventions that scale up contraceptive use need male and female involvement in decision making. Addressing myths around contraceptives, and harmonization of Education and Sexual and Reproductive Health policies in the country would motivate adolescents to use contraceptives.


Assuntos
Anticoncepcionais , Dispositivos Anticoncepcionais , Adolescente , Adulto , Criança , Tomada de Decisões , Feminino , Humanos , Malaui , Masculino , Gravidez , Comportamento Sexual , Adulto Jovem
8.
Artigo em Inglês | MEDLINE | ID: mdl-34639806

RESUMO

It is commonly claimed that thousands of women die every year from unsafe abortion in Malawi. This commentary critically assesses those claims, demonstrating that these estimates are not supported by the evidence. On the contrary, the latest evidence-itself from 15 to 20 years ago-suggests that 6-7% of maternal deaths in Malawi are attributable to induced and spontaneous abortion combined, totalling approximately 70-150 deaths per year. I then offer some evidence suggesting that a substantial proportion of these are attributable to spontaneous abortion. To reduce maternal mortality by large margins, emergency obstetric care should be prioritised, which will also save women from complications of induced and spontaneous abortion.


Assuntos
Aborto Induzido , Aborto Espontâneo , Aborto Induzido/efeitos adversos , Aborto Espontâneo/epidemiologia , Feminino , Humanos , Malaui/epidemiologia , Mortalidade Materna , Gravidez
9.
BMC Public Health ; 21(1): 1957, 2021 10 28.
Artigo em Inglês | MEDLINE | ID: mdl-34711179

RESUMO

BACKGROUND: Voluntary medical male circumcision (VMMC) is becoming more popular as an important HIV prevention strategy. Malawi, with a high HIV and AIDS prevalence rate of 8.8% and a low male circumcision prevalence rate of 28% in 2016, is one of the priority countries recommended for VMMC scale-up. This paper investigates the attitudes and key challenges to VMMC adoption in a traditionally circumcising community in Malawi where male circumcision is culturally significant. METHODS: A mixed design study using quantitative and qualitative data collection methods was carried out to determine the attitudes of 262 randomly selected males towards VMMC in a culturally circumcising community in Malawi. Statistical Package for the Social Sciences (SPSS) version 20 was used to analyse the quantitative data. To identify predictors of VMMC uptake, we used logistic regression analysis. To identify the themes, qualitative data were analysed using content analysis. RESULTS: The findings indicate that, while more males in this community prefer medical circumcision, traditional circumcision is still practised. Panic (63%) perceived surgical complications (31%), and cost (27%) in accessing VMMC services were some of the barriers to VMMC uptake. Age and culture were found to be statistically significant predictors of voluntary medical male circumcision in the logistic analysis. According to qualitative data analysis, the key challenges to VMMC uptake were the involvement of female health workers in the circumcision team and the incentives provided to traditional circumcisers. CONCLUSION: According to the findings of this study, VMMC services should be provided in a culturally competent manner that respects and considers existing cultural beliefs and practices in the community. Coordination between local leaders and health workers should be encouraged so that VMMC services are provided in traditional settings, allowing for safe outcomes, and increasing VMMC uptake.


Assuntos
Síndrome de Imunodeficiência Adquirida , Circuncisão Masculina , Infecções por HIV , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Humanos , Malaui , Masculino , Motivação , Programas Voluntários
10.
BMJ Glob Health ; 6(10)2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34635550

RESUMO

INTRODUCTION: Air pollution through cooking on open fires or inefficient cookstoves using biomass fuels has been linked with impaired lung health and with over 4 million premature deaths per annum. However, use of cleaner cookstoves is often sporadic and there are indications that longer-term health benefits are not prioritised by users. There is also limited information about how recipients of cookstoves perceive the health benefits of clean cooking interventions. We therefore conducted a qualitative study alongside the Cooking and Pneumonia Study (CAPS). METHODS: Qualitative methods and the participatory methodology Photovoice were used in an in-depth examination of health perceptions and understandings of CAPS trial participants. Fifty participants in five CAPS intervention villages collected images about cooking. These were discussed in village-level focus groups and in interviews with 12 representative participants. Village community representatives were also interviewed. Four female and eight male CAPS fieldworkers took part in gender-specific focus groups and two female and two male fieldworkers were interviewed. A thematic content approach was used for data analysis. RESULTS: We found a disconnect between locally situated perceptions of health and the biomedically focused trial model. This included the development of potentially harmful understandings such as that pneumonia was no longer a threat and potential confusion between the symptoms of pneumonia and malaria. Study participants perceived health and well-being benefits including: cookstoves saved bodily energy; quick cooking helped maintain family harmony. CONCLUSION: A deeper understanding of narratives of health within CAPS showed how context-specific perceptions of the health benefits of cookstoves were developed. This highlighted the conflicting priorities of cookstove intervention researchers and participants, and unintended and potentially harmful health understandings. The study also emphasises the importance of including qualitative explorations in similar complex interventions where potential pathways to beneficial (and harmful) effects, cannot be completely explicated through biomedical models alone.


Assuntos
Poluição do Ar em Ambientes Fechados , Pneumonia , Poluição do Ar em Ambientes Fechados/análise , Culinária , Feminino , Humanos , Malaui/epidemiologia , Masculino , Percepção
11.
Artigo em Inglês | MEDLINE | ID: mdl-34682414

RESUMO

The aim of this systematic review was to provide an update on caries prevalence in older adults aged 60 years or above around the globe. Two independent reviewers performed a systematic literature search of English publications from January 2016 to December 2020 using Pubmed, Scopus, Embase/Ovid and Web of Science. The MeSH terms used were "dental caries", "root caries", "DMF index", "aged" and "aged 80 and over". Further searches in Google Scholar retrieved eight additional publications. The epidemiological surveys reporting the prevalence of dental caries or root caries or caries experience using DMFT (decayed, missing and filled teeth) and DFR (decayed and filled root) in older adults aged 60 years or above were included. Quality of the publications was assessed using the JBI Critical Appraisal Checklist for Studies Reporting Prevalence Data. Among the 5271 identified publications, 39 articles of moderate or good quality were included. Twenty studies were conducted in Asia (China, India, Vietnam, Singapore and Turkey), ten in Europe (Ireland, Norway, Finland, Germany, Portugal, Poland, Romania and Kosovo), three in North America (USA and Mexico), one in South America (Brazil), two in Oceania (Australia) and three in Africa (Malawi, Egypt and South Africa). The prevalence of dental caries ranged from 25% (Australia) to 99% (South Africa), while the prevalence of root caries ranged from 8% (Finland) to 74% (Brazil) in community dwellers. The situation was even worse in institutionalised older adults of which the mean DMFT score varied from 6.9 (Malawi) to 29.7 (South Africa). Based on the included studies published in the last 5 years, caries is still prevalent in older adults worldwide and their prevalence varies across countries.


Assuntos
Cárie Dentária , Idoso , Idoso de 80 Anos ou mais , Brasil , Índice CPO , Cárie Dentária/epidemiologia , Suscetibilidade à Cárie Dentária , Humanos , Malaui , Prevalência
13.
Afr J Prim Health Care Fam Med ; 13(1): e1-e10, 2021 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-34636606

RESUMO

BACKGROUND: Patient-centred care (PCC) is one of the pillars of Malawi's quality of care policy initiatives. The role of PCC in facilitating quality service delivery is well documented, and its importance may heighten in chronic disease management. Yet, PCC conceptualisation is known to be context specific. AIM: The study aimed to understand the conceptualisation of PCC amongst patients, healthcare providers (HCP) and policy makers in Diabetes Mellitus (DM) management. SETTING: This study was conducted in DM clinics in Southern Malawi. METHODS: Our qualitative exploratory research study design used in-depth and focus group interviews. We interviewed patients with DM, HCPs and policy makers. The study used framework analysis guided by Mead and Bower's work. RESULTS: Patient-centred care conceptualisations from groups of participants showed convergence. However, they differed in emphasis in some elements. The prominent themes emerging from the participants' conceptualisation of PCC included the following: meeting individual needs, goals and expectations, accessing medication, supporting relationship building, patient involvement, information sharing, holistic care, timeliness and being realistic. CONCLUSION: Patient-centred care conceptualisation in Malawi goes beyond the patient-HCP relational framework to include the technical aspects of care. Contrary to the global view, accessing medication and timeliness are major elements in PCC conceptualisation in Malawi. Whilst PCC conceptualisation is contextual, meeting expectations and needs of patients is fundamental.


Assuntos
Diabetes Mellitus , Logradouros Públicos , Formação de Conceito , Diabetes Mellitus/terapia , Humanos , Malaui , Assistência Centrada no Paciente
14.
J Med Internet Res ; 23(10): e25777, 2021 10 20.
Artigo em Inglês | MEDLINE | ID: mdl-34668872

RESUMO

BACKGROUND: Integrated community case management (CCM) has led to reductions in child mortality in Malawi resulting from illnesses such as malaria, pneumonia, and diarrhea. However, adherence to CCM guidelines is often poor, potentially leading to inappropriate clinical decisions and poor outcomes. We determined the impact of an e-CCM app on the referral, reconsultation, and hospitalization rates of children presenting to village clinics in Malawi. OBJECTIVE: We determined the impact of an electronic version of a smartphone-based CCM (e-CCM) app on the referral, reconsultation, and hospitalization rates of children presenting to village clinics in Malawi. METHODS: We used a stepped-wedge, cluster-randomized trial to compare paper-based CCM (control) with and without the use of an e-CCM app on smartphones from November 2016 to February 2017. A total of 102 village clinics from 2 districts in northern Malawi were assigned to 1 of 6 clusters, which were randomized on the sequencing of the crossover from the control phase to the intervention phase as well as the duration of exposure in each phase. Children aged ≥2 months to <5 years who presented with acute illness were enrolled consecutively by health surveillance assistants. The primary outcome of urgent referrals to higher-level facilities was evaluated by using multilevel mixed effects models. A logistic regression model with the random effects of the cluster and the fixed effects for each step was fitted. The adjustment for potential confounders included baseline factors, such as patient age, sex, and the geographical location of the village clinics. Calendar time was adjusted for in the analysis. RESULTS: A total of 6965 children were recruited-49.11% (3421/6965) in the control phase and 50.88% (3544/6965) in the intervention phase. After adjusting for calendar time, children in the intervention phase were more likely to be urgently referred to a higher-level health facility than children in the control phase (odds ratio [OR] 2.02, 95% CI 1.27-3.23; P=.003). Overall, children in the intervention arm had lower odds of attending a repeat health surveillance assistant consultation (OR 0.45, 95% CI 0.34-0.59; P<.001) or being admitted to a hospital (OR 0.75, 95% CI 0.62-0.90; P=.002), but after adjusting for time, these differences were not significant (P=.07 for consultation; P=.30 for hospital admission). CONCLUSIONS: The addition of e-CCM decision support by using smartphones led to a greater proportion of children being referred to higher-level facilities, with no apparent increase in hospital admissions or repeat consultations in village clinics. Our findings provide support for the implementation of e-CCM tools in Malawi and other low- and middle-income countries with a need for ongoing assessments of effectiveness and integration with national digital health strategies. TRIAL REGISTRATION: ClinicalTrials.gov NCT02763345; https://clinicaltrials.gov/ct2/show/NCT02763345.


Assuntos
Administração de Caso , Smartphone , Criança , Hospitalização , Humanos , Malaui , Encaminhamento e Consulta
15.
Glob Health Sci Pract ; 9(3): 611-625, 2021 09 30.
Artigo em Inglês | MEDLINE | ID: mdl-34593585

RESUMO

BACKGROUND: Depression is highly prevalent among people living with HIV in Malawi. Depression can undermine engagement in HIV care and worsen HIV morbidity and mortality. The Ministry of Health integrated a pilot depression management program into HIV care at 2 clinics. This program included a measurement-based care protocol for prescribing antidepressants and an adapted Friendship Bench psychotherapy protocol for providing problem solving. Early evaluations indicated successful integration of the initial stages of training and depression screening, diagnosis, and treatment initiation. This follow-up mixed-method investigation contextualizes our previous findings and shares insights from the implementation experience. METHODS: We conducted a mixed-methods process evaluation drawing on both patient clinical data and qualitative interviews with patients and clinic staff. We focus on the following implementation outcomes: fidelity, acceptability, and sustainability. RESULTS: Although fidelity to depression screening and treatment initiation was high, fidelity to the follow-up treatment protocol was poor. Antidepressants and problem-solving therapy were acceptable to patients, but clinic staff found delivering treatment challenging given constrained human resources and infrastructure. The program was not sustained after the project. Key identified needs included substantial support to supervise the implementation of the program, continue to build and maintain the capacity of providers, integrate the program into the electronic medical records system, and ensure the availability of Friendship Bench counselors. CONCLUSIONS: Although initial steps were successful, sustained integration of this depression treatment program into HIV care in this setting met greater challenges. Implementation science studies that support both implementation and evaluation should recognize the potential for clinical implementers to rely on evaluation staff for clinical support and consider distancing evaluation staff from the actual program implementation. Further research is needed to test enhanced implementation strategies for integrating evidence-based mental health interventions into existing health care systems in a sustainable fashion, particularly in low-resource settings.


Assuntos
Depressão , Infecções por HIV , Atenção à Saúde , Depressão/diagnóstico , Depressão/terapia , Infecções por HIV/diagnóstico , Infecções por HIV/terapia , Humanos , Malaui , Saúde Mental
16.
Nat Commun ; 12(1): 5870, 2021 10 07.
Artigo em Inglês | MEDLINE | ID: mdl-34620871

RESUMO

Epigenetic variation modulates gene expression and can be heritable. However, knowledge of the contribution of epigenetic divergence to adaptive diversification in nature remains limited. The massive evolutionary radiation of Lake Malawi cichlid fishes displaying extensive phenotypic diversity despite extremely low sequence divergence is an excellent system to study the epigenomic contribution to adaptation. Here, we present a comparative genome-wide methylome and transcriptome study, focussing on liver and muscle tissues in phenotypically divergent cichlid species. In both tissues we find substantial methylome divergence among species. Differentially methylated regions (DMR), enriched in evolutionary young transposons, are associated with transcription changes of ecologically-relevant genes related to energy expenditure and lipid metabolism, pointing to a link between dietary ecology and methylome divergence. Unexpectedly, half of all species-specific DMRs are shared across tissues and are enriched in developmental genes, likely reflecting distinct epigenetic developmental programmes. Our study reveals substantial methylome divergence in closely-related cichlid fishes and represents a resource to study the role of epigenetics in species diversification.


Assuntos
Mapeamento Cromossômico , Ciclídeos/genética , Epigênese Genética , Evolução Molecular , Animais , Elementos de DNA Transponíveis , Epigenoma , Expressão Gênica , Genômica , Lagos , Fígado , Malaui , Análise de Sequência de DNA , Especificidade da Espécie
17.
Sex Reprod Healthc ; 30: 100670, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34600417

RESUMO

The Swedish care model MIDWIZE defined as midwife-led interdisciplinary care and zero separation between mother and newborn, was implemented in 2020-21 in Ethiopia, Kenya, Malawi, and Somalia in a capacity building programme funded by the Swedish Institute. OBJECTIVE: To determine the feasibility of using an internet-based capacity building programme contributing to effective midwifery practices in the labour rooms through implementation of dynamic birthing positions, delayed umbilical cord clamping and skin-to-skin care of newborns in the immediate postnatal period. METHODS: The design is inspired by process evaluation. Focus group discussions with policy leaders, academicians, and clinicians who participated in the capacity building programme were carried out. Before and after the intervention, the numbers for dynamic birthing positions, delayed umbilical cord clamping and skin-to-skin care of the newborn in the immediate postnatal period were detected. RESULTS: Participants believed the internet-based programme was appropriate for their countries' contexts based on their need for improved leadership and collaboration, the need for strengthened human resources, and the vast need for improved outcomes of maternal and newborn health. CONCLUSION: The findings provide insight into the feasibility to expand similar online capacity building programmes in collaboration with onsite policy leaders, academicians, and clinicians in sub-Saharan African countries with an agenda for improvements in maternal and child health.


Assuntos
Tocologia , Fortalecimento Institucional , Criança , Etiópia , Feminino , Humanos , Recém-Nascido , Internet , Quênia , Malaui , Gravidez , Somália
18.
Elife ; 102021 10 21.
Artigo em Inglês | MEDLINE | ID: mdl-34672946

RESUMO

Background: Monitoring malaria transmission is a critical component of efforts to achieve targets for elimination and eradication. Two commonly monitored metrics of transmission intensity are parasite prevalence (PR) and the entomological inoculation rate (EIR). Comparing the spatial and temporal variations in the PR and EIR of a given geographical region and modelling the relationship between the two metrics may provide a fuller picture of the malaria epidemiology of the region to inform control activities. Methods: Using geostatistical methods, we compare the spatial and temporal patterns of Plasmodium falciparum EIR and PR using data collected over 38 months in a rural area of Malawi. We then quantify the relationship between EIR and PR by using empirical and mechanistic statistical models. Results: Hotspots identified through the EIR and PR partly overlapped during high transmission seasons but not during low transmission seasons. The estimated relationship showed a 1-month delayed effect of EIR on PR such that at lower levels of EIR, increases in EIR are associated with rapid rise in PR, whereas at higher levels of EIR, changes in EIR do not translate into notable changes in PR. Conclusions: Our study emphasises the need for integrated malaria control strategies that combine vector and human host managements monitored by both entomological and parasitaemia indices. Funding: This work was supported by Stichting Dioraphte grant number 13050800.


Assuntos
Anopheles/parasitologia , Malária Falciparum/epidemiologia , Mosquitos Vetores/parasitologia , Plasmodium falciparum/isolamento & purificação , Adolescente , Adulto , Animais , Pré-Escolar , Feminino , Humanos , Lactente , Malária Falciparum/parasitologia , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Prevalência , Análise Espaço-Temporal , Adulto Jovem
19.
Lancet Glob Health ; 9(10): e1451-e1459, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34534489

RESUMO

BACKGROUND: A large, double-blind, randomised, placebo-controlled trial of repeat BCG found 49% efficacy against leprosy but no protection against tuberculosis after 6-9 years' follow-up in 1995. We report here additional follow-up, which resulted in greatly increased tuberculosis case numbers, and allowed subgroup analysis. METHODS: Nearly 47 000 individuals of all ages living in northern Malawi with a BCG vaccine scar were randomly assigned (1:1) between 1986 and 1989 to receive a second BCG or placebo. The investigators and project staff remained masked to all interventions. Enhanced passive surveillance ensured ascertainment of tuberculosis and leprosy to the end of 2018. Tuberculosis case definitions included rigorous microbiological or histological confirmation. Prespecified subgroup analyses were by tuberculosis type, age at vaccination, time since vaccination, previous tuberculin reactivity, HIV status and Mycobacterium tuberculosis lineage. The original trial is registered with ISRCTN registry, ISRCTN11311670. FINDINGS: In follow-up until Dec 31, 2018, 824 participants had developed tuberculosis, including 786 with pulmonary disease, of whom 383 (63%) of 607 with known HIV status were HIV positive. There was no effect of a second BCG overall (odds ratio [OR] 0·92; 95% CI 0·80-1·05), or for pulmonary (0·93; 0·81-1·07), or lymph node tuberculosis (0·60; 0·31-1·17). The OR was lower for those with known HIV-negative tuberculosis (0·77; 0·59-1·00), for those vaccinated as children (aged <5 years, 0·74; 0·41-1·35; aged 5-14 years, 0·77; 0·60-0·99), and for cases arising at least 20 years after vaccination (0·79; 0·63-1·01). There were no differences by tuberculin status at vaccination, or lineage. There was no evidence of protection against leprosy beyond 10 years after vaccination (although there have been only nine diagnostically certain cases since 1995). INTERPRETATION: There was no evidence that repeat BCG vaccination provides appreciable protection against overall tuberculosis in this rural African population with a high prevalence of HIV. Subgroup effects should not be overinterpreted given the multiple analyses done. However, the evidence for modest protection against HIV-negative tuberculosis, and for a delayed benefit in those vaccinated as children, is consistent with other observations in the literature. FUNDING: LEPRA, Wellcome Trust, Bill & Melinda Gates Foundation.


Assuntos
Vacina BCG , Vacinação , Método Duplo-Cego , Seguimentos , Humanos , Malaui/epidemiologia
20.
N Engl J Med ; 385(12): 1104-1115, 2021 09 16.
Artigo em Inglês | MEDLINE | ID: mdl-34525285

RESUMO

BACKGROUND: Typhoid fever caused by multidrug-resistant H58 Salmonella Typhi is an increasing public health threat in sub-Saharan Africa. METHODS: We conducted a phase 3, double-blind trial in Blantyre, Malawi, to assess the efficacy of Vi polysaccharide typhoid conjugate vaccine (Vi-TCV). We randomly assigned children who were between 9 months and 12 years of age, in a 1:1 ratio, to receive a single dose of Vi-TCV or meningococcal capsular group A conjugate (MenA) vaccine. The primary outcome was typhoid fever confirmed by blood culture. We report vaccine efficacy and safety outcomes after 18 to 24 months of follow-up. RESULTS: The intention-to-treat analysis included 28,130 children, of whom 14,069 were assigned to receive Vi-TCV and 14,061 were assigned to receive the MenA vaccine. Blood culture-confirmed typhoid fever occurred in 12 children in the Vi-TCV group (46.9 cases per 100,000 person-years) and in 62 children in the MenA group (243.2 cases per 100,000 person-years). Overall, the efficacy of Vi-TCV was 80.7% (95% confidence interval [CI], 64.2 to 89.6) in the intention-to-treat analysis and 83.7% (95% CI, 68.1 to 91.6) in the per-protocol analysis. In total, 130 serious adverse events occurred in the first 6 months after vaccination (52 in the Vi-TCV group and 78 in the MenA group), including 6 deaths (all in the MenA group). No serious adverse events were considered by the investigators to be related to vaccination. CONCLUSIONS: Among Malawian children 9 months to 12 years of age, administration of Vi-TCV resulted in a lower incidence of blood culture-confirmed typhoid fever than the MenA vaccine. (Funded by the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT03299426.).


Assuntos
Polissacarídeos Bacterianos , Febre Tifoide/prevenção & controle , Vacinas Tíficas-Paratíficas , Criança , Pré-Escolar , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Incidência , Lactente , Análise de Intenção de Tratamento , Malaui , Masculino , Vacinas Meningocócicas/efeitos adversos , Polissacarídeos Bacterianos/efeitos adversos , Salmonella typhi , Febre Tifoide/epidemiologia , Vacinas Tíficas-Paratíficas/efeitos adversos , Vacinas Conjugadas
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