Challenges and Opportunities in Rural Nursing Preceptorship: What Multimedia Participant Action Reveals (Défis et possibilités du préceptorat infirmier en milieu rural : ce qu’une participation multimédia révèle)

Background: Rural health care sites struggle to attract new nurses, owing to a widespread perception that the hardships of rural practice far outweigh the benefits. Preceptorships are a key means of recruiting nursing staff to rural locations, but innovative, firsthand messaging is needed to promote rural preceptorships and nursing careers. Objectives: The researchers sought to elicit compelling, multimedia, firsthand accounts of the challenges and opportunities of rural preceptorship through participant action. Additional goals were to explore the ways in which participants reify their experiences through digital media, and the potential for digitally-based participant action research to empower participants. Methods: The study was designed to engage participants in all phases of research: data collection, analysis, and dissemination of findings. It comprised three phases, each employing participant action methodology: photovoice data collection, collaborative thematic analysis, and authorship of digital stories. Participants: Through purposive and snowball sampling, the researchers recruited seven nursing students and five rural, registered nurses assigned to precept them. Inclusion criteria for the students were enrolment in the senior (final) preceptorship course prior to graduation, and the choice of a rural, semirural or suburban site. No exclusion criteria were warranted owing to the limited cohort of participants. Settings: Data were collected at six acute care sites and one community care site. The sites were rural, semi-rural and suburban, serving populations ranging from 800 to 18,000, between 42 km and 416 km distant from the students’ primary place of study. Results: It was found that rural preceptorships teach students to accept and manage limitations, while appreciating and capitalizing on opportunities; this finding was equally true for nominally suburban and semi-rural sites included in the study. Emerging from the interviews, challenges, being more concrete, were reflected in photographic data, while opportunities were more abstract and relational. Citing time constraints, most participants declined to author their own digital stories. Conclusions: Digitally-based participant action enables nurse preceptors and their students to make a compelling case for rural preceptorships and rural careers. However, digital media may also distort these participants’ experiences, and their involvement in all phases of research may be more burdensome than empowering. Résumé Contexte : Les établissements de soins de santé ruraux peinent à attirer de nouvelles infirmières en raison d’une perception répandue voulant que les inconvénients de la pratique en milieu rural dépassent de loin ses avantages. Si les stages avec préceptorat représentent un moyen essentiel pour recruter de nouvelles infirmières en milieu rural, un message novateur, à partir de l’expérience vécue, est nécessaire pour promouvoir le préceptorat et la carrière dans ce milieu. Objectifs : L’étude avait pour but de recueillir des témoignages éloquents, livrés directement par les participantes au moyen de divers médias, sur les défis et les possibilités du préceptorat en milieu rural, selon une approche participative. Elle visait également à explorer les méthodes utilisées par les participantes pour rendre leurs expériences sur un support numérique, ainsi que le potentiel d’habilitation d’une recherche participative par voie numérique pour les participantes. Méthodologie : Le devis de l’étude favorisait l’engagement des participantes dans toutes les phases de la recherche, soit la collecte et l’analyse des données, ainsi que la diffusion des résultats. Elle comprenait trois phases, chacune étant menée selon l’approche de recherche participative : collecte de données par la méthode Photovoice, analyse thématique collaborative et rédaction comme auteures des récits numériques. Participantes : Par échantillonnage intentionnel et boule de neige, les chercheuses ont recruté sept étudiantes en sciences infirmières et leurs préceptrices, soit cinq infirmières pratiquant en milieu rural. Les critères d’inclusion des étudiantes comprenaient l’inscription au dernier stage avec préceptorat avant l’obtention du diplôme, ainsi que la sélection d’un établissement rural, semi-rural ou suburbain. Compte tenu du caractère limité de la cohorte de participantes, les chercheuses n’ont retenu aucun critère d’exclusion. Milieux : La cueillette des données s’est déroulée dans six établissements de soins de courte durée et un établissement de soins communautaires. Ces sites desservaient de 800 à 18 000 personnes et étaient établis en zone rurale, semi-rurale et suburbaine, de 42 à 416 km de l’établissement d’enseignement principal des étudiantes. Résultats : L’étude indique que le préceptorat rural apprend aux étudiantes à accepter et à gérer les contraintes tout en appréciant et en exploitant les possibilités; ce résultat s’est aussi avéré pour les emplacements suburbains et semi-ruraux inclus dans l’étude. Les défis soulevés dans les entrevues, plutôt concrets, ont été illustrés par les données photographiques, alors que les possibilités identifiées étaient de nature abstraite et relationnelle. Évoquant la contrainte de temps, la plupart des participantes ont décliné la rédaction de leur propre récit numérique. Conclusions : La recherche participative par voie numérique permet aux infirmières préceptrices et à leurs étudiantes de livrer un vibrant plaidoyer en faveur du préceptorat et de la carrière en milieu rural. Cependant, les médias numériques peuvent aussi altérer l’expérience des participantes, et leur implication dans toutes les phases de la recherche peut constituer un fardeau plutôt qu’un facteur d’habilitation

Implementing electronic data capture at a well-established health and demographic surveillance site in rural northern Malawi.

This article aims to assess multiple issues of resources, staffing, local opinion, data quality, cost, and security while transitioning to electronic data collection (EDC) at a long-running community research site in northern Malawi. Levels of missing and error fields, delay from data collection to availability, and average number of interviews per day were compared between EDC and paper in a complex, repeated annual household survey. Three focus groups with field and data staff with experience using both methods, and in-depth interviews with participants were carried out. Cost for each method were estimated and compared. Missing data was more common on paper questionnaires than on EDC, and a similar number were carried out per day. Fieldworkers generally preferred EDC, but data staff feared for their employment. Most respondents had no strong preference for a method. The cost of the paper system was estimated to be higher than using EDC. The existing infrastructure and technical expertise could be adapted to using EDC, but changes have an impact on data processing jobs as fewer, and better qualified staff are required. EDC is cost-effective, and, for a long-running site, may offer further savings, as devices can be used in multiple studies and perform several other functions. EDC is accepted by fieldworkers and respondents, has good levels of quality and timeliness, and security can be maintained. EDC is well-suited for use in a well-established research site using and developing existing infrastructure and expertise

Patient-, health worker-, and health facility-level determinants of correct malaria case management at publicly funded health facilities in Malawi: results from a nationally representative health facility survey

BACKGROUND: Prompt and effective case management is needed to reduce malaria morbidity and mortality. However, malaria diagnosis and treatment is a multistep process that remains problematic in many settings, resulting in missed opportunities for effective treatment as well as overtreatment of patients without malaria. METHODS: Prior to the widespread roll-out of malaria rapid diagnostic tests (RDTs) in late 2011, a national, cross-sectional, complex-sample, health facility survey was conducted in Malawi to assess patient-, health worker-, and health facility-level factors associated with malaria case management quality using multivariate Poisson regression models. RESULTS: Among the 2,019 patients surveyed, 34% had confirmed malaria defined as presence of fever and parasitaemia on a reference blood smear. Sixty-seven per cent of patients with confirmed malaria were correctly prescribed the first-line anti-malarial, with most cases of incorrect treatment due to missed diagnosis; 31% of patients without confirmed malaria were overtreated with an anti-malarial. More than one-quarter of patients were not assessed for fever or history of fever by health workers. The most important determinants of correct malaria case management were patient-level clinical symptoms, such as spontaneous complaint of fever to health workers, which increased both correct treatment and overtreatment by 72 and 210%, respectively (p < 0.0001). Complaint of cough was associated with a 27% decreased likelihood of correct malaria treatment (p = 0.001). Lower-level cadres of health workers were more likely to prescribe anti-malarials for patients, increasing the likelihood of both correct treatment and overtreatment, but no other health worker or health facility-level factors were significantly associated with case management quality. CONCLUSIONS: Introduction of RDTs holds potential to improve malaria case management in Malawi, but health workers must systematically assess all patients for fever, and then test and treat accordingly, otherwise, malaria control programmes might miss an opportunity to dramatically improve malaria case management, despite better diagnostic tools

Dynamics of SARS-CoV-2 exposure in Malawian infants between February 2020 and May 2021

Background: Very limited information is available on SARS-CoV-2 seroprevalence in infants in sub-Saharan countries. Objective: In this study, we aimed to determine the rate and the temporal evolution of SARS CoV-2 seropositivity in breastfed Malawian infants. Study design: Blood samples (n = 250) from 158 infants, born to HIV-negative women and women living with HIV, collected from February 2020 to May 2021, were first tested using an Anti-IgG/A/M SARS CoV 2 ELISA assay against trimeric spike protein, and then, if positive, confirmed using a second ELISA assay detecting IgG against Receptor Binding Domain. Results: The confirmed prevalence of anti-SARS CoV-2 antibodies was 31.0% (95% CI: 23.7%-38.3%) with no significant difference between HIV-exposed and HIV-unexposed infants (29.3% and 37.1% respectively, P = 0.410). The presence of anti-SARS-CoV-2 IgG was not associated with maternal socioeconomic or demographic indices. Conclusions: Our data underline the wide spread of the SARS-CoV-2 infection in the pediatric population in sub-Saharan Africa. Design of more specific serological tests for African samples and improvements in serosurveillance programs are needed for more rigorous monitoring of the dynamics of SARS-CoV-2 infection in Africa

Clinical and socio-behavioral correlates of tooth loss: a study of older adults in Tanzania

BACKGROUND: Focusing 50 year olds and above, this study assessed the frequency, extent and correlates of tooth loss due to various reasons. Frequency and correlates of posterior occluding support was also investigated. METHOD: A cross-sectional household survey was conducted in Pwani region and in Dar es Salaam in 2004/2005. One thousand and thirty-one subjects, mean age 62.9 years participated in a clinical examination and completed interviews. RESULTS: The prevalence of tooth loss due to any reason was 83.5 %, due to caries 63.4% and due to other reasons than caries, 32.5%. A total of 74.9% had reduced number of posterior occluding units. Compared to subjects having less than 5 teeth lost due to caries, those with 5 or more lost teeth were more likely to be females, having decayed teeth, confirming dental attendance and to be among the least poor residents. Compared to subjects who had lost less than 5 teeth due to reasons other than caries, those who had lost 5 or more teeth were more likely to be of higher age, having mobile teeth, being males, being very poor and to disconfirm dental attendance when having problems. Predictors of prevalence of tooth loss (1 or more lost tooth) due to various reasons and reduced number of occluding units followed similar patterns of relationships. CONCLUSION: The results are consistent with prevalence and extent of tooth loss due to caries and due to reasons other than caries being differently related to disease- and socio- behavioral risk indicators. Caries was the principle cause of tooth loss and molar teeth were the teeth most commonly lost

The Malawi National Tuberculosis Programme: an equity analysis

<p>Abstract</p> <p>Background</p> <p>Until 2005, the Malawi National Tuberculosis Control Programme had been implemented as a vertical programme. Working within the Sector Wide Approach (SWAp) provides a new environment and new opportunities for monitoring the equity performance of the programme. This paper synthesizes what is known on equity and TB in Malawi and highlights areas for further action and advocacy.</p> <p>Methods</p> <p>A synthesis of a wide range of published and unpublished reports and studies using a variety of methodological approaches was undertaken and complemented by additional analysis of routine data on access to TB services. The analysis and recommendations were developed, through consultation with key stakeholders in Malawi and a review of the international literature.</p> <p>Results</p> <p>The lack of a prevalence survey severely limits the epidemiological knowledge base on TB and vulnerability. TB cases have increased rapidly from 5,334 in 1985 to 28,000 in 2006. This increase has been attributed to HIV/AIDS; 77% of TB patients are HIV positive. The age/gender breakdown of TB notification cases mirrors the HIV epidemic with higher rates amongst younger women and older men. The WHO estimates that only 48% of TB cases are detected in Malawi. The complexity of TB diagnosis requires repeated visits, long queues, and delays in sending results. This reduces poor women and men's ability to access and adhere to services. The costs of seeking TB care are high for poor women and men – up to 240% of monthly income as compared to 126% of monthly income for the non-poor. The TB Control Programme has attempted to increase access to TB services for vulnerable groups through community outreach activities, decentralising DOT and linking with HIV services.</p> <p>Conclusion</p> <p>The Programme of Work which is being delivered through the SWAp is a good opportunity to enhance equity and pro-poor health services. The major challenge is to increase case detection, especially amongst the poor, where we assume most 'missing cases' are to be found. In addition, the Programme needs a prevalence survey which will enable thorough equity monitoring and the development of responsive interventions to promote service access amongst 'missing' women, men, boys and girls.</p

Effect of cytomegalovirus infection on breastfeeding transmission of HIV and on the health of infants born to HIV-infected mothers

Cytomegalovirus (CMV) infection can be acquired in utero or postnatally through horizontal transmission and breastfeeding. The effect of postnatal CMV infection on postnatal HIV transmission is unknown

Adherence to extended postpartum antiretrovirals is associated with decreased breast milk HIV-1 transmission

Estimate association between postpartum antiretroviral adherence and breastmilk HIV-1 transmissio

Plasma Micronutrient Concentrations Are Altered by Antiretroviral Therapy and Lipid-Based Nutrient Supplements in Lactating HIV-Infected Malawian Women

Background: Little is known about the influence of antiretroviral therapy with or without micronutrient supplementation on the micronutrient concentrations of HIV-infected lactating women in resource-constrained settings

Do rope and washer pumps provide safe water and satisfied users? A case study piloting new rural water supply technology in Rumphi District, Malawi

Innovation is needed to develop rural water supply to support sub-Saharan Africa communities that are hard to reach. The purpose of this study was to critically review rope and washer pumps that have been installed on manually drilled boreholes in 48 communities as part of a pilot project in Rumphi District, Malawi, and which serve as a sustainable source of drinking water from both technical (water quality and functionality) and social (user satisfaction) perspectives. At each water source, an infrastructure checklist was used (n = 48); 10 users were interviewed (n = 472); and, if the pump had water, water quality samples were collected (n = 24). The results show that use of a professional driller does not guarantee a functioning rope and washer pump that produces safe water. Where the pumps were functional, most provided safe drinking water. However, only 8% (4/48) of pumps had good water quality, a flow rate of &gt;20 L/min and a full consensus of positive satisfaction among users. Pumps are not necessarily working better or worse in more remote areas. A process of introducing and creating evaluative guidelines for new (approved) technologies for rural water supply has not been established in Malawi. Sub-Saharan African governments need to be open to innovative solutions while making sure that standards, including those for functionality, water quality, user satisfaction, private operators, and human capacity for local government regulators, are being followed to ensure safe water for rural communities