Primary health care preparedness to integrate diabetes care in Blantyre, Malawi: A mixed methods study.

BackgroundThere is limited access to diabetes care services at primary care facilities in Malawi. Assessing the capacity of facilities to provide diabetes care is an initial step to integrating services at primary care.AimTo assess the preparedness for delivering diabetes services at primary care level within the Blantyre District Health Office (DHO) to support the response to NCD epidemic in Malawi.SettingBlantyre DHO primary care facilities.Materials and methodsA mixed methods approach nested in a national needs assessment for NCD response in Malawi was used. Fourteen primary healthcare facilities from Blantyre DHO were assessed. A tool adapted from the WHO rapid assessment questionnaire was used to identify human resource, equipment, supplies, and medication needed for comprehensive diabetes care. Descriptive statistics were done to analyze the quantitative data. Fisher's exact test was used to assess if there was a statistically significant difference between urban and rural facilities. Seventeen health care workers from the selected facilities participated in key informant interviews. Framework analysis method guided the qualitative data analysis. The quantitative and qualitative data were merged and displayed jointly.ResultsThe quantitative assessment showed that none of the facilities assessed had capacity to provide all the interventions recommended by WHO for diabetes care at primary level. Eight (57%) of the facilities had the capacity to diagnose diabetes, monitor glucose, prevent limb amputations and manage hypoglycemia and hyperglycemia. Four themes emerged from the qualitative data: differences in level of preparedness and implementation of diabetes care; disparities in resources between urban and rural facilities; low utilization of diabetes services; and strategy and policy recommendations for improvement of diabetes care.ConclusionInadequate health financing resulted in significant disparities in the available resources between the rural and urban facilities to offer diabetes care services. There is need to develop national policies and guidelines for diabetes care to strengthen the capacity of primary care facilities to facilitate achievement of universal health coverage

A hybrid design testing a 3-step implementation model for community scale-up of an HIV prevention intervention in rural Malawi: study protocol

Abstract Background Scaling-up evidence-based behavior change interventions can make a major contribution to meeting the UNAIDS goal of no new HIV infections by 2030. We developed an evidence-based peer group intervention for HIV prevention and testing in Malawi that is ready for wider dissemination. Our innovative approach turns over ownership of implementation to rural communities. We adapted a 3-Step Implementation Model (prepare, roll-out and sustain) for communities to use. Using a hybrid design, we simultaneously evaluate community implementation processes and program effectiveness. Methods Three communities in southern Malawi begin implementation in randomly-assigned order using a stepped wedge design. Our evaluation sample size of 144 adults and 144 youth per community provides sufficient power to examine primary outcomes of condom use and HIV testing. Prior to any implementation, the first participants in all three communities are recruited and complete the Wave 1 baseline survey. Waves 2–4 surveys occur after each community completes roll-out. Each community follows the model’s three steps. During Prepare, the community develops a plan and trains peer group leaders. During Roll-Out, peer leaders offer the program. During Sustain, the community makes and carries out plans to continue and expand the program and ultimately obtain local funding. We evaluate degree of implementation success (Aim 1) using the community’s benchmark scores (e.g, # of peer groups held). We assess implementation process and factors related to success (Aim 2) using repeated interviews and observations, benchmarks from Aim 1 and fidelity assessments. We assess effectiveness of the peer group intervention when delivered by communities (Aim 3) using multi-level regression models to analyze data from repeated surveys. Finally, we use mixed methods analyses of all data to assess feasibility, acceptability and sustainability (Aim 4). Discussion The project is underway, and thus far the first communities have enthusiastically begun implementation. We have had to make several modifications along the way, such as moving from rapid-tests of STIs to symptoms screening by a nurse due to problems with test reliability and availability. If successful, results will provide a replicable evidence-based model for future community implementation of this and other health interventions. Trial registration Clinical Trials.gov NCT02765659 Registered May 6, 2016