Commentary (The Lancet) Bednets and malaria in Africa

No Abstract

Development of a psycho-social intervention for reducing psychological distress among parents of children with intellectual disabilities in Malawi

BACKGROUND:The burden of intellectual disabilities in low and middle income countries (LMIC) is high and is associated with parental psychological distress. There are few services for children and parents in most developing countries and few interventions have been created that target the psychological issues among parents of such children. This study aimed to develop a contextualized intervention to provide psychological support for parents of children with intellectual disabilities in an African setting. METHODS:Six steps were adopted from the Medical Research Council framework for designing complex interventions. This include: literature review of similar interventions and models, qualitative studies to gain insights of lived experiences of parents of such children, a consensus process with an expert panel of professionals working with children with disabilities and piloting and pre-testing the draft intervention for its acceptability and practicability in this settings. RESULTS:21 intervention modules were found from a systematic search of the literature which were listed for possible use in our intervention along with four themes from our qualitative studies. An expert panel formed consensus on the eight most pertinent and relevant modules for our setting. This formed the intervention; "Titukulane." This intervention was piloted and found to have high acceptability and practicability when contextualized in the field. CONCLUSION:The use of a systematic framework for designing a complex intervention for supporting the mental health of parents of children with disabilities enables good acceptability and practicability for future use in low resource settings

Abstracts of the 20th College of Medicine Research Dissemination Conference

No Abstract

Elevated dry-season malaria prevalence associated with fine-scale spatial patterns of environmental risk: a case–control study of children in rural Malawi

Abstract Background Understanding the role of local environmental risk factors for malaria in holo-endemic, poverty-stricken settings will be critical to more effectively implement- interventions aimed at eventual elimination. Household-level environmental drivers of malaria risk during the dry season were investigated in rural southern Malawi among children < five years old in two neighbouring rural Traditional Authority (TA) regions dominated by small-scale agriculture. Methods Ten villages were randomly selected from TA Sitola (n = 6) and Nsamala (n = 4). Within each village, during June to August 2011, a census was conducted of all households with children under-five and recorded their locations with a geographic position system (GPS) device. At each participating house, a nurse administered a malaria rapid diagnostic test (RDT) to children under five years of age, and a questionnaire to parents. Environmental data were collected for each house, including land cover within 50-m radius. Variables found to be significantly associated with P. falciparum infection status in bivariate analysis were included in generalized linear models, including multivariate logistic regression (MLR) and multi-level multivariate logistic regression (MLLR). Spatial clustering of RDT status, environmental factors, and Pearson residuals from MLR and MLLR were analysed using the Getis-Ord Gi* statistic. Results Of 390 children enrolled from six villages in Sitola (n = 162) and four villages in Nsamala (n = 228), 45.6% tested positive (n = 178) for Plasmodium infection by RDT. The MLLR modelled the statistical relationship of Plasmodium positives and household proximity to agriculture ( 2.58, p < 0.01) predominantly within TA Sitola, while residuals from MLLR showed no such clustering. Conclusion This study provides evidence for significant, dry-season heterogeneity of malaria prevalence strongly linked to peridomestic land use, and particularly of elevated risk associated with nearby crop production.http://deepblue.lib.umich.edu/bitstream/2027.42/112703/1/12936_2013_Article_3017.pd

Clinical outcomes among febrile children aged 2 to 59 months with negative malaria rapid diagnostic test results in Mchinji District, Malawi

BackgroundMalawi malaria treatment guidelines recommend a definitive diagnosis, using a malaria rapid diagnostic test (mRDT), for all patients with fever or history of fever. Improving the management and outcomes of febrile children with negative mRDT results should be a priority.MethodsThrough a prospective cohort study designed to investigate clinical outcomes of children treated at the community level, we followed, for 7 days, children aged 2 to 59 months, who had negative mRDT results and were treated with antipyretic medication. Clinical outcomes were assessed on days 3 and 7 post-recruitment.ResultsThe median age of recruited children was 19 months. Of the 285 children enrolled, 139 (48.8%) were females. Of the children for whom data were available for analysis, 95/236 (40.3%) had fever (temperature ≥ 37.5°C) at enrolment, and almost half of the sick children (125/268; 46.6%) had symptoms of upper respiratory tract infection. Most sick children (89.6%; 95% confidence interval, CI = 84.2 to 93.3) recovered, while 10.4% (95% CI: 6.7 to 15.8) were still sick by day 7 of follow-up. There were no deaths reported during the 7 days of follow-up. Being afebrile at enrolment (odds ratio, OR = 2.5; 95% CI = 1.1 to 6.0; P = 0.027) and sleeping under an insecticide-treated net (ITN) (OR = 2.7; 95% CI = 1.2 to 6.2; P = 0.011) were associated with recovery by day 7. In multivariable analysis, sleeping under an ITN the previous night was the only factor associated with recovery by day 7. Microscopy did not detect any malaria parasites in the blood of recruited children, at recruitment or on day 7.ConclusionsIn this community-level study, the majority of febrile children with negative mRDT results recovered within 7 days of health worker consultation for a febrile illness, having only taken antipyretics

Distance to health services influences insecticide-treated net possession and use among six to 59 month-old children in Malawi

<p>Abstract</p> <p>Background</p> <p>Health ministries and providers are rapidly scaling up insecticide-treated nets (ITN) distribution to control malaria, yet possession and proper use typically remain below targeted levels. In Malawi, health facilities (HFs) are currently the principal points of ITN distribution, making it important to understand how access to these ITN sources affects ownership, possession, and use. The authors evaluated the association between proximity to HFs and ITN possession or use among Malawian children six to 59 months of age.</p> <p>Methods</p> <p>A household malaria survey undertaken in eight districts of Malawi during 2007 was used to characterize ITN possession and use. The location of each respondent's household was geocoded as was those of Ministry of Health (MoH) HFs and other health centres. Euclidean distance from each household to the nearest HF was calculated. Patterns of net possession and use were determined through descriptive methods. The authors then analysed the significance of distance and ITN possession/use through standard statistical tests, including logistic regression.</p> <p>Results</p> <p>Median distance to HFs was greater among households that did not possess ITNs and did not use an ITN the previous evening. Descriptive statistical methods confirmed a pattern of decreasing ITN possession and use with increasing distance from HFs. Logistic regression showed the same statistically significant association of distance to HFs, even when controlling for age and gender of the child, ratio of nets to children in household, community net possession and use, and household material wealth.</p> <p>Conclusions</p> <p>Strategies that exclusively distribute ITNs through HFs are likely to be less effective in increasing possession and use in communities that are more distant from those health services. Health providers should look towards community-based distribution services that take ITNs directly to community members to more effectively scale up ITN possession and regular use aimed at protecting children from malaria.</p

Design of an impact evaluation using a mixed methods model – an explanatory assessment of the effects of results-based financing mechanisms on maternal healthcare services in Malawi

Background: In this article we present a study design to evaluate the causal impact of providing supply-side performance-based financing incentives in combination with a demand-side cash transfer component on equitable access to and quality of maternal and neonatal healthcare services. This intervention is introduced to selected emergency obstetric care facilities and catchment area populations in four districts in Malawi. We here describe and discuss our study protocol with regard to the research aims, the local implementation context, and our rationale for selecting a mixed methods explanatory design with a quasi-experimental quantitative component. Design: The quantitative research component consists of a controlled pre- and post-test design with multiple post-test measurements. This allows us to quantitatively measure ‘equitable access to healthcare services’ at the community level and ‘healthcare quality’ at the health facility level. Guided by a theoretical framework of causal relationships, we determined a number of input, process, and output indicators to evaluate both intended and unintended effects of the intervention. Overall causal impact estimates will result from a difference-in-difference analysis comparing selected indicators across intervention and control facilities/catchment populations over time. To further explain heterogeneity of quantitatively observed effects and to understand the experiential dimensions of financial incentives on clients and providers, we designed a qualitative component in line with the overall explanatory mixed methods approach. This component consists of in-depth interviews and focus group discussions with providers, service user, non-users, and policy stakeholders. In this explanatory design comprehensive understanding of expected and unexpected effects of the intervention on both access and quality will emerge through careful triangulation at two levels: across multiple quantitative elements and across quantitative and qualitative elements. Discussion Combining a traditional quasi-experimental controlled pre- and post-test design with an explanatory mixed methods model permits an additional assessment of organizational and behavioral changes affecting complex processes. Through this impact evaluation approach, our design will not only create robust evidence measures for the outcome of interest, but also generate insights on how and why the investigated interventions produce certain intended and unintended effects and allows for a more in-depth evaluation approach

Risk factors for Anopheles mosquitoes in rural and urban areas of Blantyre District, southern Malawi

BackgroundAlthough urban malaria transmission is low and seasonal, it remains a major public health problem. This study aimed at demonstrating the presence of Anopheles mosquitoes and their potential to transmit malaria in urban settings.MethodsTwo cross-sectional surveys were carried out in Blantyre District, Malawi, during the dry and wet seasons of 2008 and 2010, respectively. A map of Blantyre was divided into a grid of 400 cells, of which 60 cells were randomly selected. Five households located within 100 m from the centre of each selected cell were enrolled, a standard questionnaire was administered, and indoor resting mosquitoes were sampled.ResultsIn 2008 and 2010, a total of 960 and 1045 mosquitoes were collected,  respectively. Anopheles funestus comprised 9.9% (n = 95) and 10.3% (n = 108) during the two surveys, respectively. Anopheles gambiae sensu lato (s.l.) was rarely detected during the second survey (n = 6; 0.6%). Molecular identification was performed on samples collected during the first survey, and An. funestus sensu stricto (s.s.) was the only sibling species detected. All the Anopheles mosquitoes were collected from households located in rural areas of Blantyre and none from urban areas. In univariate analysis, the presence of open eaves was associated with increased Anopheles prevalence, both during the dry (incidence rate ratio, IRR = 4.3; 95% CI 2.4 – 7.6) and wet (IRR = 2.47; 95% CI 1.7 – 3.59) seasons.  Chances of detecting Anopheles spp. decreased with increasing altitude (IRR = 0.996; 95% CI 0.995 – 0.997) and during the dry season, but increased during the wet season (IRR = 1.0017; 95% CI 1.0012 – 1.0023). These factors remained significant following a multiple Poisson regression analysis. No association was found between insecticide-treated bednet ownership and the number of Anopheles mosquitoes detected.ConclusionsThe presence of An. funestus s.s and An. gambiae s.l. in the periphery of Blantyre city was an indication that malaria transmission was potentially taking place in these areas

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

Household-level and surrounding peri-domestic environmental characteristics associated with malaria vectors Anopheles arabiensis and Anopheles funestus along an urban–rural continuum in Blantyre, Malawi

Abstract Background Malaria is increasing in some recently urbanized areas that historically were considered lower risk. Understanding what drives urban transmission is hampered by inconsistencies in how “urban” contexts are defined. A dichotomized “urban–rural” approach, based on political boundaries may misclassify environments or fail to capture local drivers of risk. Small-scale agriculture in urban or peri-urban settings has been shown to be a major risk determinant. Methods Household-level Anopheles abundance patterns in and around Malawi’s commercial capital of Blantyre (~ 1.9 M pop.) were analysed. Clusters (N = 64) of five houses each located at 2.5 km intervals along eight transects radiating out from Blantyre city centre were sampled during rainy and dry seasons of 2015 and 2016. Mosquito densities were measured inside houses using aspirators to sample resting mosquitoes, and un-baited CDC light traps to sample host seeking mosquitoes. Results Of 38,895 mosquitoes captured, 91% were female and 87% were Culex spp. Anopheles females (N = 5058) were primarily captured in light traps (97%). Anopheles abundance was greater during rainy seasons. Anopheles funestus was more abundant than Anopheles arabiensis, but both were found on all transects, and had similar associations with environmental risk factors. Anopheles funestus and An. arabiensis females significantly increased with distance from the urban centre, but this trend was not consistent across all transects. Presence of small-scale agriculture was predictive of greater Anopheles spp. abundance, even after controlling for urbanicity, number of nets per person, number of under-5-year olds, years of education, and season. Conclusions This study revealed how small-scale agriculture along a rural-to-urban transition was associated with An. arabiensis and An. funestus indoor abundances, and that indoor Anopheles density can be high within Blantyre city limits, particularly where agriculture is present. Typical rural areas with lower house density and greater distance from urban centres reflected landscapes more suitable for Anopheles reproduction and house invasion. However, similar characteristics and elevated Anopheles abundances were also found around some houses within the city limits. Thus, dichotomous designations of “urban” or “rural” can obscure important heterogeneity in the landscape of Plasmodium transmission, suggesting the need for more nuanced assessment of urban malaria risk and prevention efforts.https://deepblue.lib.umich.edu/bitstream/2027.42/144215/1/12936_2018_Article_2375.pd