Operational research in Malawi: making a difference with cotrimoxazole preventive therapy in patients with tuberculosis and HIV.

BACKGROUND: In Malawi, high case fatality rates in patients with tuberculosis, who were also co-infected with HIV, and high early death rates in people living with HIV during the initiation of antiretroviral treatment (ART) adversely impacted on treatment outcomes for the national tuberculosis and ART programmes respectively. This article i) discusses the operational research that was conducted in the country on cotrimoxazole preventive therapy, ii) outlines the steps that were taken to translate these findings into national policy and practice, iii) shows how the implementation of cotrimoxazole preventive therapy for both TB patients and HIV-infected patients starting ART was associated with reduced death rates, and iv) highlights lessons that can be learnt for other settings and interventions. DISCUSSION: District and facility-based operational research was undertaken between 1999 and 2005 to assess the effectiveness of cotrimoxazole preventive therapy in reducing death rates in TB patients and subsequently in patients starting ART under routine programme conditions. Studies demonstrated significant reductions in case fatality in HIV-infected TB patients receiving cotrimoxazole and in HIV-infected patients about to start ART. Following the completion of research, the findings were rapidly disseminated nationally at stakeholder meetings convened by the Ministry of Health and internationally through conferences and peer-reviewed scientific publications. The Ministry of Health made policy changes based on the available evidence, following which there was countrywide distribution of the updated policy and guidelines. Policy was rapidly moved to practice with the development of monitoring tools, drug procurement and training packages. National programme performance improved which showed a significant decrease in case fatality rates in TB patients as well as a reduction in early death in people with HIV starting ART. SUMMARY: Key lessons for moving this research endeavour through to policy and practice were the importance of placing operational research within the programme, defining relevant questions, obtaining "buy-in" from national programme staff at the beginning of projects and having key actors or "policy entrepreneurs" to push forward the policy-making process. Ultimately, any change in policy and practice has to benefit patients, and the ultimate judge of success is whether treatment outcomes improve or not

36 GHz methanol lines from nearby galaxies: maser or quasi-thermal emission?

Methanol (CH3OH) is one of the most abundant interstellar molecules, offering a vast number of transitions to be studied, including many maser lines. While the strongest Galactic CH3OH lines, the so-called class II masers, show no indications for the presence of superluminous counterparts in external galaxies, the less luminous Galactic class I sources appear to be different. Here we report class I 36GHz CH3OH 4(-1) - 3(0) E line emission from the nearby galaxies Maffei2 and IC342, measured with the 100-m telescope at Effelsberg at three different epochs within a time span of about five weeks. The 36GHz methanol line of Maffei2 is the second most luminous among the sources detected with certainty outside the Local Group of galaxies. This is not matched by the moderate infrared luminosity of Maffei2. Higher resolution data are required to check whether this is related to its prominent bar and associated shocks. Upper limits for M82, NGC4388, NGC5728 and Arp220 are also presented. The previously reported detection of 36GHz maser emission in Arp220 is not confirmed. Non-detections are reported from the related class I 44GHz methanol transition towards Maffei2 and IC342, indicating that this line is not stronger than its 36GHz counterpart. In contrast to the previously detected 36GHz CH3OH emission in NGC253 and NGC4945, our 36GHz profiles towards Maffei2 and IC342 are similar to those of previously detected non-masing lines from other molecular species. However, by analogy to our Galactic center region, it may well be possible that the 36GHz methanol lines in Maffei~2 and IC~342 are composed of a large number of faint and narrow maser features that remain spatially unresolved. In view of this, a search for a weak broad 36GHz line component would also be desirable in NGC253 and NGC4945.Comment: Accepted by Astronomy & Astrophysics, 8 pages, 1 table, 3 figures, slight changes w.r.t. version 1 due to language editin

Patterns of malaria-related hospital admissions and mortality among Malawian children: an example of spatial modelling of hospital register data

BACKGROUND: Malaria is a leading cause of hospitalization and in-hospital mortality among children in Africa, yet, few studies have described the spatial distribution of the two outcomes. Here spatial regression models were applied, aimed at quantifying spatial variation and risk factors associated with malaria hospitalization and in-hospital mortality. METHODS: Paediatric ward register data from Zomba district, Malawi, between 2002 and 2003 were used, as a case study. Two spatial models were developed. The first was a Poisson model applied to analyse hospitalization and minimum mortality rates, with age and sex as covariates. The second was a logistic model applied to individual level data to analyse case-fatality rate, adjusting for individual covariates. RESULTS AND CONCLUSION: Rates of malaria hospitalization and in-hospital mortality decreased with age. Case fatality rate was associated with distance, age, wet season and increased if the patient was referred to the hospital. Furthermore, death rate was high on first day, followed by relatively low rate as length of hospital stay increased. Both outcomes showed substantial spatial heterogeneity, which may be attributed to the varying determinants of malaria risk, health services availability and accessibility, and health seeking behaviour. The increased risk of mortality of children referred from primary health facilities may imply inadequate care being available at the referring facility, or the referring facility are referring the more severe cases which are expected to have a higher case fatality rate. Improved prognosis as the length of hospital stay increased suggest that appropriate care when available can save lives. Reducing malaria burden may require integrated strategies encompassing availability of adequate care at primary facilities, introducing home or community case management as well as encouraging early referral, and reinforcing interventions to interrupt malaria transmission

Too few staff, too many patients: A qualitative study of the impact on obstetric care providers and on quality of care in Malawi

Background: Shortages of staff have a significant and negative impact on maternal outcomes in low-income countries, but the impact on obstetric care providers in these contexts is less well documented. Despite the government of Malawi's efforts to increase the number of human resources for health, maternal mortality rates remain persistently high. Health workers' perceptions of insufficient staff or time to carry out their work can predict key variables concerning motivation and attrition, while the resulting sub-standard care and poor attitudes towards women dissuade women from facility-based delivery. Understanding the situation from the health worker perspective can inform policy options that may contribute to a better working environment for staff and improved quality of care for Malawi's women. Methods: A qualitative research design, using critical incident interviews, was used to generate a deep and textured understanding of participants' experiences. Eligible participants had performed at least one of the emergency obstetric care signal functions a in the previous three months and had experienced a demotivating critical incident within the same timeframe. Data were analysed using NVivo software. Results: Eighty-four interviews were conducted. Concerns about staff shortages and workload were key factors for over 40% of staff who stated their intention to leave their current post and for nearly two-thirds of the remaining health workers who were interviewed. The main themes emerging were: too few staff, too many patients; lack of clinical officers/doctors; inadequate obstetric skills; undermining performance and professionalism; and physical and psychological consequences for staff. Underlying factors were inflexible scheduling and staff allocations that made it impossible to deliver quality care. Conclusion: This study revealed the difficult circumstances under which maternity staff are operating and the professional and emotional toll this exacts. Systems failures and inadequate human resource management are key contributors to the gaps in provision of obstetric care and need to be addressed. Thoughtful strategies that match supply to demand, coupled with targeted efforts to support health workers, are necessary to mitigate the effects of working in this context and to improve the quality of obstetric care for women in Malawi

The impact of a hybrid social marketing intervention on inequities in access, ownership and use of insecticide-treated nets

BACKGROUND: An ITN intervention was initiated in three predominantly rural districts of Eastern Province, Zambia, that lacked commercial distribution and communication infrastructures. Social marketing techniques were used for product and message development. Public sector clinics and village-based volunteers promoted and distributed subsidized ITNs priced at $2.5 per net. A study was conducted to assess the effects of the intervention on inequities in knowledge, access, ownership and use of ITNs. METHODS: A post-test only quasi-experimental study design was used to compare intervention and comparison districts. A total of 2,986 respondents were interviewed. Survey respondents were grouped into four socio-economic (SES) categories: low, medium-low, medium and high. Knowledge, access, ownership and use indicators are compared. Concentration index scores are calculated. Interactions between intervention status and SES help determine how different SES groups benefited from the intervention. RESULTS: Although overall use of nets remained relatively low, post-test data show that knowledge, access, ownership and use of mosquito nets was higher in intervention districts. A decline in SES inequity in access to nets occurred in intervention districts, resulting from a disproportionately greater increase in access among the low SES group. Declines in SES inequities in net ownership and use of nets were associated with the intervention. The largest increases in net ownership and use occurred among medium and high SES categories. CONCLUSION: Increasing access to nets among the poorest respondents in rural areas may not lead to increases in net use unless the price of nets is no longer a barrier to their purchase

A partnership-based model for embedding employability in urban planning education

This paper proposes a partnership-based model for embedding employability in urban planning education. The model is based on the author’s experiences of implementing an international project which supported the development of employability skills in urban and regional planning education in Malawi. Since independence, urban planners have typically trained outside the country, attending university in the UK and other Commonwealth countries. More recently, the paradigm has shifted towards in-country education delivered by academic staff cognisant with the opportunities and challenges of development in Malawi. There remains, though, a gap between graduate knowledge of the subject and the skills necessary to pursue a professional career in the sector. Although there is no consensus yet on the meaning of employability in the literature, lessons from the project indicate that academic–public–private collaboration helps incorporate in curriculum skills that employers anticipate. Applicability of these principles is however context dependent, particularly in the emerging economy context where institutional capacity may be less developed compared to elsewhere

Healthcare seeking practices and barriers to accessing under-five child health services in urban slums in Malawi: a qualitative study

BACKGROUND: Access to child health services is an important determinant of child health. Whereas, child health indicators are generally better in urban than rural areas, some population groups in urban areas, such as children residing in urban slums do not enjoy this urban health advantage. In the context of increasing urbanisation and urban poverty manifesting with proliferation of urban slums, the health of under-five children in slum areas remains a public health imperative in Malawi. This paper explores healthcare-seeking practices for common childhood illnesses focusing on use of biomedical health services and perceived barriers to accessing under-five child health services in urban slums of Lilongwe, Malawi’s capital city. METHODS: Qualitative data from 8 focus group discussions with caregivers and 11 in-depth interviews with key informants conducted from September 2012 to April 2013 were analysed using conventional content analysis. RESULTS: Whereas, caregivers sought care from biomedical health providers, late care-seeking also emerged as a major theme and phenomenon. Home management was actively undertaken for childhood illnesses. Various health system barriers: lack of medicines and supplies; long waiting times; late facility opening times; negative attitude of health workers; suboptimal examination of the sick child; long distance to health facility; and cost of healthcare were cited in this qualitative inquiry as critical health system factors affecting healthcare-seeking for child health services. CONCLUSIONS: Interventions to strengthen the health system’s responsiveness to expectations are essential to promote utilisation of child health services among urban slum populations, and ultimately improve child health and survival. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12913-016-1678-x) contains supplementary material, which is available to authorized users

Differentiated legitimacy, differentiated resilience: beyond the natural in ‘natural disasters’

This paper starts with a flood in southern Malawi. Although apparently a ‘natural’ event, those most affected argued that it was made much worse by the rehabilitation of a nearby irrigation scheme. We use this example to interrogate the current interest in resilience from a perspective informed by political ecology and political economy, arguing that a focus on resilience should not be at the expense of understanding the conditions that shape vulnerability, including the ways in which ‘communities’ are differentiated. Complex factors are at play – and the ways in which these combine can result in a ‘perfect storm’ for some individuals and households. These factors include the effects of history combining with ethnicity, of legitimacy influencing voice, and of the interplay of political dynamics at different levels. In particular, processes of commodification have played an important role in shaping how some may benefit at the cost of catastrophic harm to others