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1.
Expert Rev Vaccines ; 22(1): 180-185, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36688599

RESUMO

OBJECTIVES: To boost COVID-19 vaccine uptake, an innovative 'vaccinate my village' (VMV) strategy using door-to-door vaccination by Health Surveillance Assistants (HSA) was adopted. In this study, we assessed the impact of the 'vaccinate my village' strategy on COVID-19 vaccine uptake. METHODS: This was a cross-sectional review of the data on COVID-19 vaccination obtained from the Ministry of Health, Malawi, from 11 March 2021 to September 2022. RESULTS: From March 2021-4 September 2022,091,551 COVID-19 vaccine doses were administered, out of which 2,253,546 were administered over just six months as a part of VMV as compared to 1,838,005 doses were administered over 13 months as a part of other strategies. The proportion of Malawi's population receiving at least one dose of the COVID-19 vaccine increased substantially from 4.66 to 15.4 with the implementation of the VMV strategy (p = 0.0001). District-wise coverage of the COVID-19 vaccine also increased significantly after its implementation (p = 0.0001). CONCLUSIONS: Door-to-door vaccination involving HSAs benefitted the COVID-19 vaccination program in Malawi by ensuring accessibility, availability, and acceptability.


Assuntos
Vacinas contra COVID-19 , COVID-19 , Humanos , Malaui/epidemiologia , Estudos Transversais , COVID-19/prevenção & controle , Vacinação
2.
Malar J ; 22(1): 16, 2023 Jan 13.
Artigo em Inglês | MEDLINE | ID: mdl-36635658

RESUMO

BACKGROUND: To achieve malaria elimination it is essential to understand the impact of insecticide-treated net (ITNs) programmes. Here, the impact of ITN access and use on malaria prevalence in children in Malawi was investigated using Malaria Indicator Survey (MIS) data. METHODS: MIS data from 2012, 2014 and 2017 were used to investigate the relationship between malaria prevalence in children (6-59 months) and ITN use. Generalized linear modelling (GLM), geostatistical mixed regression modelling and non-stationary GLM were undertaken to evaluate trends, spatial patterns and local dynamics, respectively. RESULTS: Malaria prevalence in Malawi was 27.1% (95% CI 23.1-31.2%) in 2012 and similar in both 2014 (32.1%, 95% CI 25.5-38.7) and 2017 (23.9%, 95% CI 20.3-27.4%). ITN coverage and use increased during the same time period, with household ITN access growing from 19.0% (95% CI 15.6-22.3%) of households with at least 1 ITN for every 2 people sleeping in the house the night before to 41.7% (95% CI 39.1-44.4%) and ITN use from 41.1% (95% CI 37.3-44.9%) of the population sleeping under an ITN the previous night to 57.4% (95% CI 55.0-59.9%). Both the geostatistical and non-stationary GLM regression models showed child malaria prevalence had a negative association with ITN population access and a positive association with ITN use although affected by large uncertainties. The non-stationary GLM highlighted the spatital heterogeneity in the relationship between childhood malaria and ITN dynamics across the country. CONCLUSION: Malaria prevalence in children under five had a negative association with ITN population access and a positive association with ITN use, with spatial heterogeneity in these relationships across Malawi. This study presents an important modelling approach that allows malaria control programmes to spatially disentangle the impact of interventions on malaria cases.


Assuntos
Mosquiteiros Tratados com Inseticida , Malária , Humanos , Criança , Malaui/epidemiologia , Malária/epidemiologia , Malária/prevenção & controle , Características da Família , Inquéritos e Questionários , Controle de Mosquitos
3.
BMC Med Ethics ; 24(1): 4, 2023 Jan 19.
Artigo em Inglês | MEDLINE | ID: mdl-36658544

RESUMO

BACKGROUND: Current advances in biomedical research have introduced new ethical challenges in obtaining informed consent in low and middle-income settings. For example, there are controversies about the use of broad consent in the collection of biological samples for use in future biomedical research. However, few studies have explored preferred informed consent models for future use of biological samples in Malawi and South Africa. Therefore, we conducted an empirical study to understand preferred consent models among key stakeholders in biomedical studies that involve collection of biological samples in Malawi and South Africa. The main objective of the study was to explore views of key stakeholders on current policies on informed consent in Malawi and South Africa. METHODS: This was a qualitative study involving in-depth interviews and focus group discussions. Thirty-four in-depth interviews and 6 focus group discussions were conducted with REC members, Funders, Policymakers, CAB members and Research Participants in Malawi and South Africa to gather their views on models of informed consent. The study was conducted in Cape Town, South Africa, and Blantyre and Lilongwe in Malawi. RESULTS: Most key stakeholders preferred broad consent and tiered consent to specific consent. Some participants expressed a strong preference for specific consent to other models of informed consent in biomedical research. Few participants did not have any preference for a consent model, opting for any consent model which provides adequate information about the proposed research and what their national consent regulations require. Finally, very few participants preferred blanket consent to other informed consent models. CONCLUSIONS: This study aimed to help fill the gap in the scientific literature on key stakeholder views on consent models for future use of biological samples in Malawi and South Africa. The findings of the study have provided some evidence that may support policies on permissible consent models for future use of biological samples in sub-Saharan Africa considering the differences in informed consent regulations and guidelines. Finally, the findings can inform ongoing discussions on permissible consent models to be used for future use of biological samples.


Assuntos
Pesquisa Biomédica , Sujeitos da Pesquisa , Humanos , África do Sul , Malaui , Consentimento Livre e Esclarecido , Pesquisa Qualitativa
4.
BMC Public Health ; 23(1): 55, 2023 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-36624412

RESUMO

BACKGROUND: In seeking the attainment of Universal Health Coverage (UHC), there has been a renewed emphasis on the role of communities. This article focuses on social innovation and whether this concept holds promise to enhance equity in health services to achieve UHC and serve as a process to enhance community engagement, participation, and agency. METHODS: A cross-country case study methodology was adopted to analyze three social innovations in health in three low- and middle-income countries (LMICs): Philippines, Malawi, and Colombia. Qualitative methods were used in data collection, and a cross-case analysis was conducted with the aid of a simplified version of the conceptual framework on social innovation as proposed by Cajaiba-Santana. This framework proposes four dimensions of social innovation as a process at different levels of action: the actors responsible for the idea, the new idea, the role of the institutional environment, and the resultant changes in the health and social system. RESULTS: The study found that each of the three social innovation case studies was based on developing community capacities to achieve health through community co-learning, leadership, and accountability. The process was dependent on catalytic agents, creating a space for innovation within the institutional context. In so doing, these agents challenged the prevailing power dynamics by providing the communities with respect and the opportunity to participate equally in creating and implementing programs. In this way, communities were empowered; they were not simply participants but became active agents in conceptualizing, implementing, monitoring, and sustaining the social innovation initiatives. CONCLUSION: The study has illustrated how three creative social innovation approaches improved access and quality of health services for vulnerable rural populations and increased agency among the intervention communities. The processes facilitated empowerment, which in turn supported the sustained strengthening of the community system and the achievement of community goals in the domain of health and beyond.


Assuntos
Empoderamento , Cobertura Universal do Seguro de Saúde , Humanos , Malaui , Filipinas , Colômbia
5.
BMC Health Serv Res ; 23(1): 35, 2023 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-36642734

RESUMO

BACKGROUND: The need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. METHODS: The study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention. RESULTS: A shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up. CONCLUSIONS: Despite the identification of the facilitators of the scale-up, full integration of the intervention into the health system has proven challenging in all countries. Approaching scale-up from a systems change perspective could be useful in future scale-up efforts, as it focuses on sustainable systems change at scale (e.g. improving district health management) by testing a combination of interventions that could contribute to the envisaged change, rather than horizontally scaling up and trying to embed one particular intervention in the system.


Assuntos
Serviços de Saúde , Humanos , Uganda , Gana , Malaui , Pesquisa Qualitativa
6.
Arch Virol ; 168(2): 61, 2023 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-36631547

RESUMO

Although rabies is endemic in Malawi, there have been no studies in which rabies virus was systematically investigated and characterized in multiple animal hosts in that country. In order to provide molecular epidemiological data on rabies virus in Malawi, 683 suspected rabies case reports from 2008 to 2021 were examined, and 46 (dog = 40, cow = 5, and cat = 1) viable rabies-positive brain samples archived at the Central Veterinary Laboratory (CVL), Lilongwe, Malawi, were analyzed genetically. The results showed an increase in the submission of brain samples from 2008 to 2010, with the highest number of submissions observed in 2020. Of the 683 case reports analyzed for the period under review, 38.1% (260/683) (CI: 34.44 - 41.84) were confirmed by direct fluorescent antibody test. Among the confirmed cases, 65.4% (170/260) (CI: 59.23 - 71.09) were canine rabies. Further, phylogenetic analysis revealed that sequences from different animal hosts clustered together within the Africa 1b lineage, suggesting that the strains circulating in livestock are similar to those in domestic dogs. This finding supports the hypothesis that canine rabies is spilling over to livestock and emphasizes the need for further studies to provide data for effective control of rabies in Malawi.


Assuntos
Doenças do Cão , Vírus da Raiva , Raiva , Feminino , Bovinos , Animais , Cães , Vírus da Raiva/genética , Raiva/epidemiologia , Raiva/veterinária , Filogenia , Malaui/epidemiologia , Epidemiologia Molecular , Doenças do Cão/epidemiologia , Gado
7.
BMC Infect Dis ; 23(1): 56, 2023 Jan 26.
Artigo em Inglês | MEDLINE | ID: mdl-36703117

RESUMO

INTRODUCTION: The introduction of PCV13 to the Malawi infant immunization schedule in 2011 has been associated with reduced disease from Streptococcus pneumoniae. Improved understanding of serotypes with high invasive potential can guide future vaccination interventions. We aimed to estimate pneumococcal serotypes associated with acute respiratory infection (ARI) and invasive pneumococcal disease (IPD) in hospitalized children in Blantyre, Malawi. METHODS: We analysed data from healthy children under 5 years in the community in Blantyre and children admitted to Queen Elizabeth Central Hospital with ARI between 2015 and 2018. Nasopharyngeal swabs from children were tested for S. pneumoniae and serotyped by latex agglutination if positive. We analysed culture-positive blood and cerebrospinal fluid samples from admitted children between 2012 and 2018 to identify cases of IPD after the introduction of PCV13. We calculated the age-adjusted odds ratio (OR) of carriage for S. pneumoniae vaccine serotypes (VT) comparing those with ARI to healthy children. We also calculated age-adjusted ORs comparing serotypes causing IPD to carriage in the community with OR > 1 indicating high invasive potential. RESULTS: Serotypes 5 (OR 24.73 [95% CI 7.90-78.56] p < 0.001), 1 (OR 23.38 [95% CI 9.75-56.06] p < 0.001), and 6B (OR 4.73 [95% CI 1.66-11.64] p = 0.001) had high invasive potential. Serotype 6B was no longer significant (OR 1.34 [95% CI 0.07-6.87] p = 0.777) in a sensitivity analysis accounting for year of recruitment. The prevalence of S. pneumoniae carriage in the community was 72.6% [95% CI 71.3-74.0] (3078/4238) and 23.4% (719/3078) of positive community samples were VT. The carriage prevalence in those hospitalised with ARI was 45.5% [95% CI 42.1-48.9] (389/855) and 43.8% of hospital attendees reported antibiotic use prior to admission. We did not identify significant associations with carriage of any serotypes in those with ARI. CONCLUSIONS: Pneumococcal serotypes 5 and 1 are associated with high invasive potential. Despite high community pneumococcal carriage, pre-hospital antibiotic usage likely reduces pneumococcal detection among children admitted in this setting and further research is needed to investigate serotypes associated with ARI. Data from this study can guide future preventative vaccination strategies in Malawi.


Assuntos
Infecções Pneumocócicas , Infecções Respiratórias , Lactente , Criança , Humanos , Pré-Escolar , Sorogrupo , Malaui/epidemiologia , Portador Sadio/epidemiologia , Nasofaringe , Streptococcus pneumoniae , Infecções Pneumocócicas/epidemiologia , Infecções Pneumocócicas/prevenção & controle , Vacinas Pneumocócicas , Antibacterianos
8.
Malar J ; 22(1): 32, 2023 Jan 27.
Artigo em Inglês | MEDLINE | ID: mdl-36707795

RESUMO

BACKGROUND: When people with human immunodeficiency virus (HIV) infection (PWH) develop malaria, they are at risk of poor anti-malarial treatment efficacy resulting from impairment in the immune response and/or drug-drug interactions that alter anti-malarial metabolism. The therapeutic efficacy of artemether-lumefantrine was evaluated in a cohort of PWH on antiretroviral therapy (ART) and included measurement of day 7 lumefantrine levels in a subset to evaluate for associations between lumefantrine exposure and treatment response. METHODS: Adults living with HIV (≥ 18 years), on ART for ≥ 6 months with undetectable HIV RNA viral load and CD4 count ≥ 250/mm3 were randomized to daily trimethoprim-sulfamethoxazole (TS), weekly chloroquine (CQ) or no prophylaxis. After diagnosis of uncomplicated Plasmodium falciparum malaria, a therapeutic efficacy monitoring was conducted with PCR-correction according to WHO guidelines. The plasma lumefantrine levels on day 7 in 100 episodes of uncomplicated malaria was measured. A frailty proportional hazards model with random effects models to account for clustering examined the relationship between participant characteristics and malaria treatment failure within 28 days. Pearson's Chi-squared test was used to compare lumefantrine concentrations among patients with treatment failure and adequate clinical and parasitological response (ACPR). RESULTS: 411 malaria episodes were observed among 186 participants over 5 years. The unadjusted ACPR rate was 81% (95% CI 77-86). However, after PCR correction to exclude new infections, ACPR rate was 94% (95% CI 92-97). Increasing age and living in Ndirande were associated with decreased hazard of treatment failure. In this population of adults with HIV on ART, 54% (51/94) had levels below a previously defined optimal day 7 lumefantrine level of 200 ng/ml. This occurred more commonly among participants who were receiving an efavirenz-based ART compared to other ART regimens (OR 5.09 [95% CI 1.52-7.9]). Participants who experienced treatment failure had lower day 7 median lumefantrine levels (91 ng/ml [95% CI 48-231]) than participants who experienced ACPR (190 ng/ml [95% CI 101-378], p-value < 0.008). CONCLUSION: Recurrent malaria infections are frequent in this population of PWH on ART. The PCR-adjusted efficacy of AL meets the WHO criteria for acceptable treatment efficacy. Nevertheless, lumefantrine levels tend to be low in this population, particularly in those on efavirenz-based regimens, with lower concentrations associated with more frequent malaria infections following treatment. These results highlight the importance of understanding drug-drug interactions when diseases commonly co-occur.


Assuntos
Antimaláricos , Artemisininas , Infecções por HIV , Malária Falciparum , Malária , Humanos , Adulto , Antimaláricos/uso terapêutico , Malaui , Artemisininas/uso terapêutico , Artemeter/uso terapêutico , Combinação de Medicamentos , Combinação Arteméter e Lumefantrina/uso terapêutico , Malária/tratamento farmacológico , Malária Falciparum/tratamento farmacológico , Malária Falciparum/prevenção & controle , Lumefantrina/uso terapêutico , Infecções por HIV/tratamento farmacológico , Resultado do Tratamento , Etanolaminas/uso terapêutico , Fluorenos/uso terapêutico
9.
BMJ Open ; 13(1): e062009, 2023 01 06.
Artigo em Inglês | MEDLINE | ID: mdl-36609325

RESUMO

OBJECTIVES: A cross-sectional and a policy document review study was performed to investigate perceived acceptability and feasibility to implementing different integration measures for tuberculosis (TB) and diabetes mellitus (DM) healthcare among healthcare workers (HCWs) and health managers, and to describe policy influence through a policy documents review in Malawi. SETTING: The survey was performed at eight hospitals, ministry of health offices and 10 non-governmental organisations. We collected data in March and April 2021. PARTICIPANTS: Of 95 HCWs and health managers invited; 92 participated. 21/92 (23%) were female, and 17/92 (18%) participants were from clinics that piloted the integrated care for TB and DM. OUTCOME MEASURES: We described awareness levels on TB/DM comorbidity, perceptions and experiences in TB/DM care. Furthermore, development processes and contents of included documents were analysed. RESULTS: 16/17 (94%) of HCWs from clinics piloting integrated care and 65/75 (86%) HCWs from hospitals that do not use integrated care for TB and DM responded that integrated care was acceptable and feasible. In qualitative data, shortage of resources, inadequate information sharing were common themes. We included seven relevant documents for the analysis. On development process and content, six of seven documents were scored ≥70%. In these documents, DM is a recognised risk factor for TB, and integration of healthcare services for infectious diseases and non-communicable diseases is recommended, however, these documents lacked information specifically on integrated care for TB and DM. CONCLUSION: In this study, we identified inadequate information sharing, and lack of resources as major factors impeding implementation of integration of services, however, awareness on TB/DM comorbidity was high.


Assuntos
Diabetes Mellitus , Tuberculose , Feminino , Humanos , Masculino , Estudos Transversais , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Diabetes Mellitus/diagnóstico , Estudos de Viabilidade , Malaui/epidemiologia , Programas de Rastreamento , Políticas , Tuberculose/diagnóstico , Tuberculose/epidemiologia , Tuberculose/terapia
10.
BMJ Open ; 13(1): e065074, 2023 01 06.
Artigo em Inglês | MEDLINE | ID: mdl-36609331

RESUMO

OBJECTIVES: To demonstrate acceptability and operational feasibility of introducing human papillomavirus (HPV) testing as a principal cervical cancer screening method in public health programmes in sub-Saharan Africa. SETTING: 45 primary and secondary health clinics in Malawi, Nigeria, Senegal, Uganda and Zimbabwe. PARTICIPANTS: 15 766 women aged 25-54 years presenting at outpatient departments (Senegal only, general population) or at antiretroviral therapy clinics (all other countries, HIV-positive women only). Eligibility criteria followed national guidelines for cervical cancer screening. INTERVENTIONS: HPV testing was offered to eligible women as a primary screening for cervical cancer, and HPV-positive women were referred for visual inspection with acetic acid (VIA), and if lesions identified, received treatment or referral. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were the proportion of HPV-positive women who received results and linked to VIA and the proportion of HPV-positive and VIA-positive women who received treatment. RESULTS: A total of 15 766 women were screened and tested for HPV, among whom 14 564 (92%) had valid results and 4710/14 564 (32%) were HPV positive. 13 837 (95%) of valid results were returned to the clinic and 3376 (72%) of HPV-positive women received results. Of women receiving VIA (n=2735), 715 (26%) were VIA-positive and 622 (87%) received treatment, 75% on the same day as VIA. CONCLUSIONS: HPV testing was found to be feasible across the five study countries in a public health setting, although attrition was seen at several key points in the cascade of care, namely results return to women and linkage to VIA. Once women received VIA, if eligible, the availability of on-site cryotherapy and thermal ablation allowed for same-day treatment. With sufficient resources and supportive infrastructure to ensure linkage to treatment, use of HPV testing for cervical cancer screening as recommended by WHO is a promising model in low-income and middle-income countries.


Assuntos
Ácidos Nucleicos , Infecções por Papillomavirus , Neoplasias do Colo do Útero , Humanos , Feminino , Neoplasias do Colo do Útero/prevenção & controle , Detecção Precoce de Câncer/métodos , Infecções por Papillomavirus/prevenção & controle , Programas de Rastreamento/métodos , Ácido Acético , Malaui , Papillomaviridae/genética
11.
BMJ Open ; 13(1): e058261, 2023 01 17.
Artigo em Inglês | MEDLINE | ID: mdl-36653056

RESUMO

OBJECTIVES: Given the decline in physical activity levels in Malawi, like other sub-Saharan African countries, and its implication for non-communicable disease (NCD) prevention, this study aimed to compare and contrast accounts of practices and attitudes towards physical activity among Malawian men and women (previously identified as having pre-diabetes) in urban and rural settings. SETTING: Two communities: one urban (Lilongwe) and one rural (Karonga). PARTICIPANTS: 14 men (urban N=6, rural N=8) and 18 women (urban N=9, rural N=9) classified as prediabetic during their participation in an NCD survey 3-5 years previously. DESIGN: A qualitative focus group study (N=4) and thematic analysis, with the ecological model used as a framework to characterise the types of physical activity people engaged in and potential ways to support them to exercise more. RESULTS: Participants reported undertaking different types of physical activity across all ecological model domains (household, occupational, transport, recreational). Rural participants reported more vigorous physical activities than urban participants, and women reported more household activities than men. Many participants recognised a need to promote physical activity in Malawi, and the health benefits of doing so, including the importance of physical activity in helping them stay strong to maintain physical functioning. Barriers to physical activity included competing priorities (especially urban men), societal expectations around wealth, use of motorised transport, lack of accessible facilities for women, ageing and ill health. CONCLUSIONS: Physical activity is declining in Malawi as working and transport practices change in response to economic development, making promotion of alternative forms of physical activity a public health priority. Multilevel interventions emphasising the personal benefits/value of physical activity for all ages, and routine and group-based exercising, as well as investment in accessible recreational facilities (including for women) and active travel infrastructure should be considered to improve physical activity levels in Malawi.


Assuntos
Doenças não Transmissíveis , Estado Pré-Diabético , Masculino , Humanos , Feminino , Malaui , Pesquisa Qualitativa , Exercício Físico , População Rural
12.
World J Surg ; 47(1): 78-85, 2023 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-36241858

RESUMO

BACKGROUND: Trauma scoring systems can identify patients who should be transferred to referral hospitals, but their utility in LMICs is often limited. The Malawi Trauma Score (MTS) reliably predicts mortality at referral hospitals but has not been studied at district hospitals. We sought to validate the MTS at a Malawi district hospital and evaluate whether MTS is predictive of transfer to a referral hospital. METHODS: We performed a retrospective study using trauma registry data from Salima District Hospital (SDH) from 2017 to 2021. We excluded patients brought in dead, discharged from the Casualty Department, or missing data needed to calculate MTS. We used logistic regression modeling to study the relationship between MTS and mortality at SDH and between MTS and transfer to a referral hospital. We used receiver operating characteristic analysis to validate the MTS as a predictor of mortality. RESULTS: We included 2196 patients (84.3% discharged, 12.7% transferred, 3.0% died). These groups had similar ages, sex, and admission vitals. Mean (SD) MTS was 7.9(3.0) among discharged patients, 8.4(3.9) among transferred patients, and 14.2(8.0) among patients who died (p < 0.001). Higher MTS was associated with increased odds of mortality at SDH (OR 1.21, 95% CI 1.14-1.29, p < 0.001) but was not related to transfer. ROC area for mortality was 0.73 (95% CI 0.65-0.80). CONCLUSIONS: MTS is predictive of district hospital mortality but not inter-facility transfer. We suggest that MTS be used to identify patients with severe trauma who are most likely to benefit from transfer to a referral hospital.


Assuntos
Países em Desenvolvimento , Hospitais de Distrito , Humanos , Malaui/epidemiologia , Estudos Retrospectivos
13.
Lancet Glob Health ; 11(2): e197-e206, 2023 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-36528031

RESUMO

BACKGROUND: Tracking progress and providing timely evidence is a fundamental step forward for countries to remain aligned with the targets set by WHO to eliminate cervical cancer as a public health problem (ie, to reduce the incidence of the disease below a threshold of 4 cases per 100 000 women-years). We aimed to assess the extent of global inequalities in cervical cancer incidence and mortality, based on The Global Cancer Observatory (GLOBOCAN) 2020 estimates, including geographical and socioeconomic development, and temporal aspects. METHODS: For this analysis, we used the GLOBOCAN 2020 database to estimate the age-specific and age-standardised incidence and mortality rates of cervical cancer per 100 000 women-years for 185 countries or territories aggregated across the 20 UN-defined world regions, and by four-tier levels of the Human Development Index (HDI). Time trends (1988-2017) in incidence were extracted from the Cancer Incidence in Five Continents (CI5) plus database. Mortality estimates were obtained using the most recent national vital registration data from WHO. FINDINGS: Globally in 2020, there were an estimated 604 127 cervical cancer cases and 341 831 deaths, with a corresponding age-standardised incidence of 13·3 cases per 100 000 women-years (95% CI 13·3-13·3) and mortality rate of 7·2 deaths per 100 000 women-years (95% CI 7·2-7·3). Cervical cancer incidence ranged from 2·2 (1·9-2·4) in Iraq to 84·6 (74·8-94·3) in Eswatini. Mortality rates ranged from 1·0 (0·8-1·2) in Switzerland to 55·7 (47·7-63·7) in Eswatini. Age-standardised incidence was highest in Malawi (67·9 [95% CI 65·7 -70·1]) and Zambia (65·5 [63·0-67·9]) in Africa, Bolivia (36·6 [35·0-38·2]) and Paraguay (34·1 [32·1-36·1]) in Latin America, Maldives (24·5 [17·0-32·0]) and Indonesia (24·4 [24·2-24·7]) in Asia, and Fiji (29·8 [24·7-35·0]) and Papua New Guinea (29·2 [27·3-31·0]) in Melanesia. A clear socioeconomic gradient exists in cervical cancer, with decreasing rates as HDI increased. Incidence was three times higher in countries with low HDI than countries with very high HDI, whereas mortality rates were six times higher in low HDI countries versus very high HDI countries. In 2020 estimates, a general decline in incidence was observed in most countries of the world with representative trend data, with incidence becoming stable at relatively low levels around 2005 in several high-income countries. By contrast, in the same period incidence increased in some countries in eastern Africa and eastern Europe. We observed different patterns of age-specific incidence between countries with well developed population-based screening and treatment services (eg, Sweden, Australia, and the UK) and countries with insufficient and opportunistic services (eg, Colombia, India, and Uganda). INTERPRETATION: The burden of cervical cancer remains high in many parts of the world, and in most countries, the incidence and mortality of the disease remain much higher than the threshold set by the WHO initiative on cervical cancer elimination. We identified substantial geographical and socioeconomic inequalities in cervical cancer globally, with a clear gradient of increasing rates for countries with lower levels of human development. Our study provides timely evidence and impetus for future strategies that prioritise and accelerate progress towards the WHO elimination targets and, in so doing, address the marked variations in the global cervical cancer landscape today. FUNDING: French Institut National du Cancer, Horizon 2020 Framework Programme for Research and Innovation of the European Commission; and EU4Health Programme.


Assuntos
Neoplasias do Colo do Útero , Humanos , Feminino , Neoplasias do Colo do Útero/prevenção & controle , Incidência , Organização Mundial da Saúde , Malaui , Uganda , Saúde Global
14.
Am J Trop Med Hyg ; 108(2): 394-402, 2023 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-36535249

RESUMO

Few studies have compared clinical outcomes in HIV-exposed uninfected (HEU) and HIV-unexposed uninfected (HUU) infants in the current scenario of universal and lifelong maternal antiretroviral therapy (ART). HIV-uninfected and HIV-infected Malawian women receiving ART and their breastfed infants were followed for 12 months postpartum, analyzing the rates of infectious and noninfectious events and assessing infant growth at 6 weeks, 6 months, and 12 months. The cohorts included 227 mothers (70 HIV-negative, 157 HIV-positive) and 235 infants (72 HUU, 163 HEU). No maternal or infant deaths occurred during follow-up. HIV-negative women were less likely to complete follow-up (48.6% versus 91.1%). Mothers with and without HIV had similar rates of both infectious and noninfectious events per person-month. Infants who were HEU, compared with HUU, had higher rates of events of any type, lower respiratory tract infections (LRTI), and noninfectious events. HEU had lower body mass index (BMI) at 6 weeks but did not differ from HUU in all anthropometric measures at 6 and 12 months; in growth between 6 weeks and 12 months; and in occurrence of stunting, underweight, and wasting at 6 weeks, 6 months, and 12 months. During the first year of life, infants who were HEU, compared with HUU, showed a transiently lower BMI and an increased risk of LRTI.


Assuntos
Doenças Transmissíveis , Infecções por HIV , Infecções Respiratórias , Lactente , Humanos , Feminino , Estudos Prospectivos , Malaui/epidemiologia , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Aleitamento Materno
15.
BMC Med Ethics ; 23(1): 125, 2022 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-36471294

RESUMO

BACKGROUND: Obtaining consent has become a standard way of respecting the patient's rights and autonomy in clinical research. Ethical guidelines recommend that the child's parent/s or authorised legal guardian provides informed consent for their child's participation. However, obtaining informed consent in paediatric research is challenging. Parents become vulnerable because of stress related to their child's illness. Understanding the views held by guardians and researchers about the consent process in Malawi, where there are limitations in health care access and research literacy will assist in developing appropriate consent guidelines. METHODS: We conducted 20 in-depth interviews with guardians of children and research staff who had participated in paediatric clinical trial and observational studies in acute and non-acute settings in the Southern Region of Malawi. Interviews were audio-recorded, transcribed verbatim, and thematically analysed. Interviews were compared across studies and settings to identify differences and similarities in participants' views about informed consent processes. Data analysis was facilitated by NVIVO 11 software. RESULTS: All participants across study types and settings reported that they associated participating in research with therapeutic benefits. Substantial differences were noted in the decision-making process across study settings. Guardians from acute studies felt that the role of their spouses was neglected during consenting, while staff reported that they had problems obtaining consent from guardians when their partners were not present. Across all study types and settings, research staff reported that they emphasised the benefits more than the risks of the study to participants, due to pressure to recruit. Participants from non-acute settings were more likely to recall information shared during the consent process than participants in the acute setting. CONCLUSION: The health care context, culture and research process influenced participants' understanding of study information across study types and settings. We advise research managers or principal investigators to define minimum requirements that would not compromise the consent process and conduct study specific training for staff. The use of one size fits all consent process may not be ideal. More guidance is needed on how these differences can be incorporated during the consent process to improve understanding and delivery of consent. Trial registration Not applicable.


Assuntos
Consentimento Livre e Esclarecido , Pais , Criança , Humanos , Malaui , Pesquisa Qualitativa , Hospitais
16.
BMC Health Serv Res ; 22(1): 1471, 2022 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-36461125

RESUMO

BACKGROUND: In Malawi, abortion is only legal to save a pregnant woman's life. Treatment for complications after unsafe abortions has a massive impact on the already impoverished health care system. Even though manual vacuum aspiration (MVA) and misoprostol are the recommended treatment options for incomplete abortion in the first trimester, surgical management using sharp curettage is still one of the primary treatment methods in Malawi. Misoprostol and MVA are safer and cheaper, whilst sharp curettage has more risk of complications such as perforation and bleeding and requires general anesthesia and a clinician. Currently, efforts are being made to increase the use of misoprostol in the treatment of incomplete abortions in Malawi. To achieve successful implementation of misoprostol, health care providers' perceptions on this matter are crucial. METHODS: A qualitative approach was used to explore health care providers' perceptions of misoprostol for the treatment of incomplete abortion using semi-structured in-depth interviews. Ten health care providers were interviewed at one urban public hospital. Each interview lasted 45 min on average. Health care providers of different cadres were interviewed in March and April 2021, nine months after taking part in a training intervention on the use of misoprostol. Interviews were recorded, transcribed verbatim and analyzed using 'Systematic Text Condensation'. RESULTS: The health care providers reported many advantages with the increased use of misoprostol, such as reduced workload, less hospitalization, fewer infections, and task-shifting. Availability of the drug and benefits for the patients were also highlighted as important. However, some challenges were revealed, such as deciding who was eligible for the drug and treatment failure. For these reasons, some health care providers still choose surgical treatment as their primary method. CONCLUSION: Findings in this study support the recommendation of increased use of misoprostol as a treatment for incomplete abortion in Malawi, as the health care providers interviewed see many advantages with the drug. To scale up its use, proper training and supervision are essential. A sustainable and predictable supply is needed to change clinical practice. Unsafe abortion is a major contributor to maternal mortality worldwide. Unsafe abortion is the termination of an unintended pregnancy by a person without the required skills or equipment, which might lead to serious complications. In Malawi, post-abortion complications are common, and the maternal mortality ratio is among the highest in the world. Retained products of conception, referred to as an incomplete abortion, are common after spontaneous miscarriages and unsafe induced abortions. There are several ways to treat incomplete abortion, and the drug misoprostol has been successful in the treatment of incomplete abortion in other low-income countries. This study explored perceptions among health care providers using misoprostol to treat incomplete abortions and whether the drug can be fully embraced by Malawian health care professionals. Health personnel at a Malawian hospital were interviewed individually regarding the use of the drug for treating incomplete abortions. This study revealed that health care providers interviewed are satisfied with the increased use of misoprostol. They highlighted several benefits, such as reduced workload and that it enabled task-shifting so that various hospital cadres could now treat patients with incomplete abortions. The health care workers also observed benefits for women treated with the drug compared to other treatments. The challenges mentioned were finding out who was eligible for the drug and drug failure. This study supports scaling up the use of misoprostol in the treatment of incomplete abortions in Malawi; the Ministry of Health and policymakers should support future interventions to increase its use.


Assuntos
Aborto Incompleto , Aborto Induzido , Aborto Espontâneo , Misoprostol , Gravidez , Humanos , Feminino , Aborto Incompleto/tratamento farmacológico , Misoprostol/uso terapêutico , Malaui , Aborto Induzido/efeitos adversos , Pessoal de Saúde , Hospitais Públicos
17.
J Midwifery Womens Health ; 67(6): 728-734, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-36527397

RESUMO

The use of ultrasound to determine gestational age is fundamental to the optimum management of pregnancy and is recommended for all women by the World Health Organization. However, this modality remains unavailable to many women in low-income countries where trained practitioners are scarce. Although previous initiatives have demonstrated efficacy in training midwives and technicians to perform antenatal ultrasound, these programs have often been too long and too complex to be realistic within the specific constraints of this context, highlighting the need for a novel and pragmatic approach. We describe the development and piloting of a bespoke course to teach midwives 3 fundamental components of early antenatal ultrasound scanning: (1) to identify the number of fetuses, (2) to confirm fetal viability, and (3) to determine gestational age. Having established that 5 days is insufficient, we propose that the minimum duration required to train ultrasound-naive midwives to competency is 10 days. Our completed program therefore consists of one and one-half days of didactic teaching, followed by 8 and one-half days of supervised hands-on practical training in which trainees are assessed on their skills. This package has subsequently been successfully implemented across 6 sites in Malawi, where 28 midwives have achieved competency. By describing the processes involved in our cross-continental collaboration, we explain how unexpected challenges helped shape and improve our program, demonstrating the value of preimplementation piloting and a pragmatic and adaptive approach.


Assuntos
Tocologia , Enfermeiras Obstétricas , Feminino , Gravidez , Humanos , Tocologia/educação , Enfermeiras Obstétricas/educação , Malaui
18.
BMC Psychiatry ; 22(1): 833, 2022 12 29.
Artigo em Inglês | MEDLINE | ID: mdl-36581849

RESUMO

BACKGROUND: Perinatal depression (PND) is prevalent and negatively impacts HIV care among women living with HIV (WLHIV), yet PND remains under-identified in Malawian WLHIV. Accordingly, this formative study explored perceptions of the feasibility and acceptability of an integrated, task-shifted approach to PND screening and treatment in maternity clinics. METHODS: We completed consecutive PND screenings of HIV+ women attending pre- or post-natal appointments at 5 clinics in Lilongwe district, Malawi. We conducted in-depth interviews with the first 4-5 women presenting with PND per site (n = 24 total) from July to August 2018. PND classification was based on a score ≥ 10 on the Edinburgh Postnatal Depression Scale (EPDS). We conducted 10 additional in-depth interviews with HIV and mental health providers at the 5 clinics. RESULTS: Most participants endorsed the feasibility of integrated PND screening, as they believed that PND had potential for significant morbidity. Among providers, identified barriers to screening were negative staff attitudes toward additional work, inadequate staffing numbers and time constraints. Suggested solutions to barriers were health worker training, supervision, and a brief screening tool. Patient-centered counselling strategies were favored over medication by WLHIV as the acceptable treatment of choice, with providers supporting the role of medication to be restricted to severe depression. Providers identified nurses as the most suitable health workers to deliver task-shifted interventions and emphasized further training as a requirement to ensure successful task shifting. CONCLUSION: Improving PND in a simple, task-shifted intervention is essential for supporting mental health among women with PND and HIV. Our results suggest that an effective PND intervention for this population should include a brief, streamlined PND screening questionnaire and individualized counselling for those who have PND, with supplemental support groups and depression medication readily available. These study results support the development of a PND intervention to address the gap in treatment of PND and HIV among WLHIV in Malawi.


Assuntos
Depressão Pós-Parto , Transtorno Depressivo , Infecções por HIV , Feminino , Humanos , Gravidez , Depressão/complicações , Depressão/diagnóstico , Depressão/terapia , Malaui , Estudos de Viabilidade , Transtorno Depressivo/terapia , Infecções por HIV/complicações , Infecções por HIV/terapia , Infecções por HIV/psicologia , Depressão Pós-Parto/epidemiologia
19.
Afr J Prim Health Care Fam Med ; 14(1): e1-e4, 2022 Dec 14.
Artigo em Inglês | MEDLINE | ID: mdl-36546498

RESUMO

In the third week of January 2022, the southern districts of Malawi were hit by Cyclone Ana. The worst affected areas were Chikwawa and Nsanje. Four weeks following Cyclone Ana, a rather smaller cyclone, Dumako, hit the same areas, causing more damage. The Partners in Health or Abwenzi Pa Za Umoyo, an international humanitarian nongovernmental organisation that provides primary health care (PHC), organised teams to join Chikwawa District Council - Health, providing PHC assistance in the most affected district (Chikwawa); these teams were joined by three senior residents in family medicine from Kamuzu University of Health Sciences.Contribution: From the experiences of the interventions reported here, it was learnt that a multidisciplinary team of PHC providers is the key to the success of the emergency PHC programmes in times of natural disasters. While immediate PHC may be important at the actual time of disaster, it was learnt that PHC is also very important for continuation of care for chronic conditions, antenatal clinics and other clinics that are interrupted by the disaster. The experiences emphasised the importance of involving the PHC physicians and other PHC cadres in planning PHC programmes in natural disaster-prone areas.


Assuntos
Tempestades Ciclônicas , Humanos , Feminino , Gravidez , Malaui
20.
J Econ Entomol ; 115(6): 1783-1789, 2022 12 14.
Artigo em Inglês | MEDLINE | ID: mdl-36515111

RESUMO

Fall armyworm (Spodoptera frugiperda Smith), a serious pest of cereals from the Americas, has spread across sub-Saharan Africa and Asia since 2016, threatening the food security and incomes of millions of smallholder farmers. To measure the impact of S. frugiperda under different management approaches, we established on-farm trials across 12 landscapes (615-1,379 mm mean annual rainfall) in Malawi and Zambia during the 2019/2020 and 2020/2021 seasons. Here we present the results from our conventional tillage, monocrop maize, no pesticide treatment, which served to monitor the background S. frugiperda impact in the absence of control measures. Median plot-level S. frugiperda incidence ranged between 0.00 and 0.52 across landscapes. Considering severe leaf damage (Davis score ≥5), the proportion of affected plants varied between 0.00 and 0.30 at the plot scale, but only 3% of plots had ≥10% severely damaged plants. While incidence and damage severity varied substantially among sites and seasons, our models indicate that they were lower in high tree cover landscapes, in the late season scouting, and in the 2020/2021 season. Yield could not be predicted from S. frugiperda incidence or leaf damage. Our results suggest S. frugiperda impacts may have been overestimated at many sites across sub-Saharan Africa. S. frugiperda incidence and damage declined through the cropping season, indicating that natural mortality factors were limiting populations, and none of our plots were heavily impacted. Long-term S. frugiperda management should be based on Integrated Pest Management (IPM) principles, including minimising the use of chemical pesticides to protect natural enemies.


Assuntos
Mariposas , Praguicidas , Animais , Spodoptera , Zâmbia , Malaui , Controle de Pragas , Zea mays
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