Prevalence and correlates of probable depression diagnosis and suicidal ideation among patients receiving HIV care in Lilongwe, Malawi

BackgroundDepression and suicide ideation among people living with HIV (PLHIV) can threaten the success of HIV care and treatment programs, particularly within high HIV prevalence settings. We describe the prevalence and correlates associated with depression and suicidal ideation among PLHIV receiving HIV care in Lilongwe, Malawi. MethodsFrom July to September 2013, 206 HIV clinic patients, who were ≥18 years of age and either pre-antiretroviral therapy (ART) or established on ART for ≥6 months prior to study, participated in a survey to assess the prevalence of a likely depressive disorder and suicidal ideation using the Patient Health Questionnaire-9. We explored factors associated with depression using bivariable linear regression and suicidal ideation using bivariable log-binomial regression. ResultsThe prevalence of a likely depressive disorder and suicidal ideation was 12% (95% CI: 8%, 17%) and 16% (95% CI: 11%, 21%), respectively. Pre-ART patients (β=1.17, 95% CI: 0.03, 2.30, p-value=0.04) and those with problematic alcohol use (β=0.49, 95% CI: 0.07, 0.92, p-value=0.02) were associated with a higher depression severity. Suicidal ideation was relatively common (8%, 95% CI: 5%, 13%) among those without a likely depressive disorder and significantly correlated with having no primary, secondary, or tertiary education (β=-1.52, 95% CI: -2.46, -0.59, p-value<0.01). ConclusionsInterventions that enhance identification and management of depressive disorders and suicidal ideation should be integrated within HIV care clinics in Malawi.

Effect of Acute Illness on Contact Patterns, Malawi, 2017.

The way persons interact when ill could profoundly affect transmission of infectious agents. To obtain data on these patterns in Africa, we recorded self-reported named contacts and opportunities for casual contact in rural northern Malawi. We interviewed 384 patients and 257 caregivers about contacts over three 24-hour periods: day of the clinic visit for acute illness, the next day, and 2 weeks later when well. For participants of all ages, the number of adult contacts and the proportion using public transportation was higher on the day of the clinic visit than later when well. Compared with the day after the clinic visit, well participants (2 weeks later) named a mean of 0.4 extra contacts; the increase was larger for indoor or prolonged contacts. When well, participants were more likely to visit other houses and congregate settings. When ill, they had more visitors at home. These findings could help refine models of infection spread

From kitchen to classroom: Assessing the impact of cleaner burning biomass-fuelled cookstoves on primary school attendance in Karonga district, northern Malawi

Household air pollution from burning solid fuels is responsible for an estimated 2.9 million premature deaths worldwide each year and 4.5% of global disability-adjusted life years, while cooking and fuel collection pose a considerable time burden, particularly for women and children. Cleaner burning biomass-fuelled cookstoves have the potential to lower exposure to household air pollution as well as reduce fuelwood demand by increasing the combustion efficiency of cooking fires, which may in turn yield ancillary benefits in other domains. The present paper capitalises on opportunities offered by the Cooking and Pneumonia Study (CAPS), the largest randomised trial of biomass-fuelled cookstoves on health outcomes conducted to date, the design of which allows for the evaluation of additional outcomes at scale. This mixed methods study assesses the impact of cookstoves on primary school absenteeism in Karonga district, northern Malawi, in particular by conferring health and time and resource gains on young people aged 5–18. The analysis combines quantitative data from 6168 primary school students with in-depth interviews and focus group discussions carried out among 48 students in the same catchment area in 2016. Negative binomial regression models find no evidence that the cookstoves affected primary school absenteeism overall [IRR 0.92 (0.71–1.18), p = 0.51]. Qualitative analysis suggests that the cookstoves did not sufficiently improve household health to influence school attendance, while the time and resource burdens associated with cooking activities—although reduced in intervention households—were considered to be compatible with school attendance in both trial arms. More research is needed to assess whether the cookstoves influenced educational outcomes not captured by the attendance measure available, such as timely arrival to school or hours spent on homework

A health intervention or a kitchen appliance? Household costs and benefits of a cleaner burning biomass-fuelled cookstove in Malawi

Pneumonia is the leading cause of mortality for children under five years in sub-Saharan Africa. Household air pollution has been found to increase risk of pneumonia, especially due to exposure from dirty burning biomass fuels. It has been suggested that advanced stoves, which burn fuel more efficiently and reduce smoke emissions, may help to reduce household air pollution in poor, rural settings. This qualitative study aims to provide an insight into the household costs and perceived benefits from use of the stove in Malawi. It was conducted alongside The Cooking and Pneumonia Study (CAPS), the largest village cluster-level randomised controlled trial of an advanced combustion cookstove intervention to prevent pneumonia in children under five to date. In 2015, using 100 semi-structured interviews this study assessed household time use and perceptions of the stove from both control and intervention participants taking part in the CAPS trial in Chilumba. Household direct and indirect costs associated with the intervention were calculated. Users overwhelming liked using the stove. The main reported benefits were reduced cooking times and reduced fuel consumption. In most interviews, the health benefits were not initially identified as advantages of the stove, although when prompted, respondents stated that reduced smoke emissions contributed to a reduction in respiratory symptoms. The cost of the stove was much higher than most respondents said they would be willing to pay. The stoves were not primarily seen as health products. Perceptions of limited impact on health was subsequently supported by the CAPS trial data which showed no significant effect on pneumonia. While the findings are encouraging from the perspective of acceptability, without innovative financing mechanisms, general uptake and sustained use of the stove may not be possible in this setting. The findings also raise the question of whether the stoves should be marketed and championed as ‘health interventions’

Association between physical multimorbidity and common mental health disorders in rural and urban Malawian settings:Preliminary findings from Healthy Lives Malawi long-term conditions survey

In low-income Africa, the epidemiology of physical multimorbidity and associated mental health conditions is not well described. We investigated the multimorbidity burden, disease combinations, and relationship between physical multimorbidity and common mental health disorders in rural and urban Malawi using early data from 9,849 adults recruited to an on-going large cross-sectional study on long-term conditions, initiated in 2021. Multimorbidity was defined as having two or more measured (diabetes, hypertension) or self-reported (diabetes, hypertension, disability, chronic pain, HIV, asthma, stroke, heart disease, and epilepsy) conditions. Depression and anxiety symptoms were measured using the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item General Anxiety Disorder scale (GAD-7) and defined by the total score (range 0-27 and 0-21, respectively). We determined age-standardized multimorbidity prevalence and condition combinations. Additionally, we used multiple linear regression models to examine the association between physical multimorbidity and depression and anxiety symptom scores. Of participants, 81% were rural dwelling, 56% were female, and the median age was 30 years (Inter Quartile Range 21-43). The age-standardized urban and rural prevalence of multimorbidity was 14.1% (95% CI, 12.5-15.8%) and 12.2% (95% CI, 11.6-12.9%), respectively. In adults with two conditions, hypertension, and disability co-occurred most frequently (18%), and in those with three conditions, hypertension, disability, and chronic pain were the most common combination (23%). Compared to adults without physical conditions, having one (B-Coefficient (B) 0.79; 95% C1 0.63-0.94%), two- (B 1.36; 95% CI 1.14-1.58%), and three- or more- physical conditions (B 2.23; 95% CI 1.86-2.59%) were associated with increasing depression score, p-trend &lt;0.001. A comparable 'dose-response' relationship was observed between physical multimorbidity and anxiety symptom scores. While the direction of observed associations cannot be determined with these cross-sectional data, our findings highlight the burden of multimorbidity and the need to integrate mental and physical health service delivery in Malawi.</p

The longitudinal association of stressful life events with depression remission among SHARP trial participants with depression and hypertension or diabetes in Malawi

Depressive disorders are leading contributors to morbidity in low- and middle-income countries and are particularly prevalent among people with non-communicable diseases (NCD). Stressful life events (SLEs) are risk factors for, and can help identify those at risk of, severe depressive illness requiring more aggressive treatment. Yet, research on the impact of SLEs on the trajectory of depressive symptoms among NCD patients indicated for depression treatment is lacking, especially in low resource settings. This study aims to estimate the longitudinal association of SLEs at baseline with depression remission achievement at three, six, and 12 months among adults with either hypertension or diabetes and comorbid depression identified as being eligible for depression treatment. Participants were recruited from 10 NCD clinics in Malawi from May 2019-December 2021. SLEs were measured by the Life Events Survey and depression remission was defined as achieving a Patient Health Questionaire-9 (PHQ-9) score <5 at follow-up. The study population (n = 737) consisted predominately of females aged 50 or higher with primary education and current employment. At baseline, participants reported a mean of 3.5 SLEs in the prior three months with 90% reporting ≥1 SLE. After adjustment, each additional SLE was associated with a lower probability of achieving depression remission at three months (cumulative incidence ratio (CIR) 0.94; 95% confidence interval: 0.90, 0.98, p = 0.002), six months (0.95; 0.92, 0.98, p = 0.002) and 12 months (0.96; 0.94, 0.99, p = 0.011). Re-expressed per 3-unit change, the probability of achieving depression remission at three, six, and 12 months was 0.82, 0.86, and 0.89 times lower per 3 SLEs (the median number of SLEs). Among NCD patients identified as eligible for depression treatment, recent SLEs at baseline were associated with lower probability of achieving depression remission at three, six, and 12 months. Findings suggest that interventions addressing SLEs during integrated NCD and depression care interventions (e.g., teaching and practicing SLE coping strategies) may improve success of depression treatment among adult patient populations in low-resource settings and may help identify those at risk of severe and treatment resistant depression

Association between physical multimorbidity and common mental health disorders in rural and urban Malawian settings: Preliminary findings from Healthy Lives Malawi long-term conditions survey.

In low-income Africa, the epidemiology of physical multimorbidity and associated mental health conditions is not well described. We investigated the multimorbidity burden, disease combinations, and relationship between physical multimorbidity and common mental health disorders in rural and urban Malawi using early data from 9,849 adults recruited to an on-going large cross-sectional study on long-term conditions, initiated in 2021. Multimorbidity was defined as having two or more measured (diabetes, hypertension) or self-reported (diabetes, hypertension, disability, chronic pain, HIV, asthma, stroke, heart disease, and epilepsy) conditions. Depression and anxiety symptoms were measured using the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item General Anxiety Disorder scale (GAD-7) and defined by the total score (range 0-27 and 0-21, respectively). We determined age-standardized multimorbidity prevalence and condition combinations. Additionally, we used multiple linear regression models to examine the association between physical multimorbidity and depression and anxiety symptom scores. Of participants, 81% were rural dwelling, 56% were female, and the median age was 30 years (Inter Quartile Range 21-43). The age-standardized urban and rural prevalence of multimorbidity was 14.1% (95% CI, 12.5-15.8%) and 12.2% (95% CI, 11.6-12.9%), respectively. In adults with two conditions, hypertension, and disability co-occurred most frequently (18%), and in those with three conditions, hypertension, disability, and chronic pain were the most common combination (23%). Compared to adults without physical conditions, having one (B-Coefficient (B) 0.79; 95% C1 0.63-0.94%), two- (B 1.36; 95% CI 1.14-1.58%), and three- or more- physical conditions (B 2.23; 95% CI 1.86-2.59%) were associated with increasing depression score, p-trend <0.001. A comparable 'dose-response' relationship was observed between physical multimorbidity and anxiety symptom scores. While the direction of observed associations cannot be determined with these cross-sectional data, our findings highlight the burden of multimorbidity and the need to integrate mental and physical health service delivery in Malawi

Association between physical multimorbidity and common mental health disorders in rural and urban Malawian settings: preliminary findings from Healthy Lives Malawi long-term conditions survey

In low-income Africa, the epidemiology of physical multimorbidity and associated mental health conditions is not well described. We investigated the multimorbidity burden, disease combinations, and relationship between physical multimorbidity and common mental health disorders in rural and urban Malawi using early data from 9,849 adults recruited to an on-going large cross-sectional study on long-term conditions, initiated in 2021. Multimorbidity was defined as having two or more measured (diabetes, hypertension) or self-reported (diabetes, hypertension, disability, chronic pain, HIV, asthma, stroke, heart disease, and epilepsy) conditions. Depression and anxiety symptoms were measured using the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item General Anxiety Disorder scale (GAD-7) and defined by the total score (range 0–27 and 0–21, respectively). We determined age-standardized multimorbidity prevalence and condition combinations. Additionally, we used multiple linear regression models to examine the association between physical multimorbidity and depression and anxiety symptom scores. Of participants, 81% were rural dwelling, 56% were female, and the median age was 30 years (Inter Quartile Range 21–43). The age-standardized urban and rural prevalence of multimorbidity was 14.1% (95% CI, 12.5–15.8%) and 12.2% (95% CI, 11.6–12.9%), respectively. In adults with two conditions, hypertension, and disability co-occurred most frequently (18%), and in those with three conditions, hypertension, disability, and chronic pain were the most common combination (23%). Compared to adults without physical conditions, having one (B-Coefficient (B) 0.79; 95% C1 0.63–0.94%), two- (B 1.36; 95% CI 1.14–1.58%), and three- or more- physical conditions (B 2.23; 95% CI 1.86–2.59%) were associated with increasing depression score, p-trend &lt;0.001. A comparable ‘dose-response’ relationship was observed between physical multimorbidity and anxiety symptom scores. While the direction of observed associations cannot be determined with these cross-sectional data, our findings highlight the burden of multimorbidity and the need to integrate mental and physical health service delivery in Malawi

Evaluating the validity of depression-related stigma measurement among diabetes and hypertension patients receiving depression care in Malawi: A mixed-methods analysis

Mental illness stigma research is sparse in Malawi. Our team previously analyzed the reliability and statistical validity of a quantitative tool to measure depression-related stigma among participants with depressive symptoms using quantitative psychometric methods. This analysis aims to further evaluate the content validity of the stigma tool by comparing participants’ quantitative responses with qualitative data. The SHARP project conducted depression screening and treatment at 10 noncommunicable disease clinics across Malawi from April 2019 through December 2021. Eligible participants were 18–65 years with depressive symptoms indicated by a PHQ-9 score ≥5. Questionnaires at each study timepoint included a vignette-based quantitative stigma instrument with three thematic domains: disclosure carryover (i.e., concerns about disclosure), treatment carryover (i.e., concerns about external stigma because of receiving depression treatment), and negative affect (i.e., negative attitudes about people having depression). Sub-scores were aggregated for each domain, with higher scores indicating greater stigma. To better understand participants’ interpretation of this quantitative stigma questionnaire, we asked a subset of six participants a parallel set of questions in semi-structured qualitative interviews in a method similar to cognitive interviewing. Qualitative responses were linked with participants’ most recent quantitative follow-up interviews using Stata 16 and NVivo software. Participants with lower quantitative stigma disclosure sub-scores had qualitative responses that indicated less stigma around disclosure, while participants with higher quantitative stigma sub-scores had qualitative responses indicating greater stigma. Similarly, in the negative affect and treatment carryover domains, participants had parallel quantitative and qualitative responses. Further, participants identified with the vignette character in their qualitative interviews, and participants spoke about the character’s projected feelings and experiences based on their own lived experiences. The stigma tool was interpreted appropriately by participants, providing strong evidence for the content validity of the quantitative tool to measure these stigma domains

A cleaner burning biomass-fuelled cookstove intervention to prevent pneumonia in children under 5 years old in rural Malawi (the Cooking and Pneumonia Study): a cluster randomised controlled trial

Medical Research Council, UK Department for International Development, and Wellcome Trust