The diversity of smallholder farmers and their adoption of the sustainable intensification practices in Malawi

Low agricultural productivity and the associated poverty caused by the rapid degradation of soil fertility have negatively affected agricultural based livelihoods in Malawi. As a result, sustainable improved practices (SIPs) such as improved maize and legume seeds and conservation agriculture packages, among others, have been developed and promoted as suitable options to reverse the issue of low food production. Although there have been strong-minded efforts by scientists and agriculture extension staff to improve the adoption of these technologies, questions remain regarding their uptake among smallholder farmers. Furthermore, even in places where the technologies have been in practice, this process has been very slow, with big variations of adoption across all smallholder farmers. This study draws its empirical data from two sources: Firstly, from collaborative work between the International Maize and Wheat Improvement Centre (CIMMYT) and the Department of Agricultural Research Services (DARS)in Malawi. Secondly from the data collected by Western Sydney University in collaboration with assistance of Bunda College of Agriculture under the University of Malawi (now LUARNAR). Data collection was mainly through farmer household surveys and farmer focus group discussions conducted between 2011 and 2013. The research took place in 6 target districts on a total of 1293 (891 and 402) farmers in the north, central and southern Malawi. Therefore, this study sought to address three main objectives by administering and evaluating a structured questionnaire specifically to capture farm household data on: a) the diversity that exist among the smallholder farmers which influences their use of sustainable intensification practices, b) opportunities and constraints for the intensifications of improved maize-legume varieties among smallholder farmers for dietary intensification and ecological intensification, c) the stepwise adoption and factors that influence farmers decision to adopt the individual components of the adapted conservation agriculture package in Malawi. Three standalone empirical chapters are merged to form the core of this thesis which has been integrated and synthesised in the final chapter. Overall, this thesis contributes both to literature and methodology. Overall, this thesis contributes both to literature and methodology. Results from principal component analysis (PCA) and cluster analysis (CA) technics consistently indicated that there is diversity among the smallholder farmers revealing four different farmer classes which influenced their adoption of the improved soil fertility technologies. These farm types were: a) type 1 farms (35.13%) were classed as ‗small subsistence-oriented family farms‘ practiced crop residue retention and crop rotation, b) type 2 (31.43%) were ‗small semi-subsistence family farms‘, type 3 (25.36%) were ‗survivalist‘ (small, independent, semi-specialized family farms whose main objective was family sustenance) and, c) type 4 (7.52%) were ‗production-oriented, small, dependent, semi-specialized family farms‘. Farm typologies indicated that farm types 1 and 2 practiced crop residue retention and crop rotation by intercropping of maize–legumes improved varieties, potentially making them the possible adopters of improved farm technologies among the rest of the farm types. Minimum tillage adoptions remained sparse. Type 3 farms, in addition to being family sustenance-oriented, specialised in a cash crop such as tobacco, cotton, legume which made them party commercial, which had a negative impact on practicing of improved farm technology. Type 4 farms were like type 3 but different high level of specialization as tenants in tobacco growing largely dictated by their landlords, which limited their adoption of improved farm technology. Evaluation of the opportunities and constraints for maize-legume intensification among the smallholder farmers for dietary fortification and ecological intensification was done by comparing results of three random effects regression models using multilevel logistic analysis. Two different methods - first multivariate and second econometric technics were applied to correct for potential bias in estimating the factors that influenced adoption of maize-legume intensification. The results of the models indicated that farmers who had a shorter distance to walk to the farm inputs market and village market, had a higher participation in the intensification of maize-legume by 72 % of the farmers. The thesis indicated that farmers decision to adopt or not to adopt each component combination from the adapted CA package (residue retention, minimum tillage, crop rotation and use of herbicides) was considered to be sequential and incremental. The results also revealed that the households‘ decision to adopt the individual component depended on farmers experience in growing cowpeas, soil depth and the households‘ food availability throughout the year. However, crop residue retention was the highest adopted (85%), followed by minimum tillage ate 70% and use of herbicide at 69%, with crop rotation the least at 30%

Qualitative assessment of attitudes and knowledge on preterm birth in Malawi and within country framework of care

BACKGROUND: The overarching goal of this study was to qualitatively assess baseline knowledge and perceptions regarding preterm birth (PTB) and oral health in an at-risk, low resource setting surrounding Lilongwe, Malawi. The aims were to determine what is understood regarding normal length of gestation and how gestational age is estimated, to identify common language for preterm birth, and to assess what is understood as options for PTB management. As prior qualitative research had largely focused on patient or client-based focused groups, we primarily focused on groups comprised of community health workers (CHWs) and providers. METHODS: A qualitative study using focus-group discussions, incidence narrative, and informant interviews amongst voluntary participants. Six focus groups were comprised of CHWs, patient couples, midwives, and clinical officers (n = 33) at two rural health centers referring to Kamuzu Central Hospital. Semi-structured questions facilitated discussion of PTB and oral health (inclusive of periodontal disease), including definitions, perception, causation, management, and accepted interventions. RESULTS: Every participant knew of women who had experienced “a baby born too soon”, or preterm birth. All participants recognized both an etiology conceptualization and disease framework for preterm birth, distinguished PTB from miscarriage and macerated stillbirth, and articulated a willingness to engage in studies aimed at prevention or management. Identified gaps included: (1) discordance in the definition of PTB (i.e., 28–34 weeks or less than the 8(th) month, but with a corresponding fetal weight ranging 500 to 2300 grams); (2) utility and regional availability of antenatal steroids for prevention of preterm infant morbidity and mortality; (3) need for antenatal referral for at-risk women, or with symptoms of preterm birth. There was no evident preference for route of progesterone for the prevention of recurrent PTB. CONCLUSIONS: Qualitative research was useful in (1) identifying gaps in knowledge in urban and rural Malawi, and (2) informing the development of educational materials and implementation of programs or trials ultimately aimed at reducing PTB. As a result of this qualitative work, implementation planning was focused on the gaps in knowledge, dissemination of knowledge (to both patients and providers), and practical solutions to barriers in known efficacious therapies

The health policy response to COVID-19 in Malawi

Malawi declared a state of national disaster due to the COVID-19 pandemic on 20th March 2020 and registered its first confirmed coronavirus case on the 2 April 2020. The aim of this paper was to document policy decisions made in response to the COVID-19 pandemic from January to August 2020. We reviewed policy documents from the Public Health Institute of Malawi, the Malawi Gazette, the Malawi Ministry of Health and Population and the University of Oxford Coronavirus Government Response Tracker. We found that the Malawi response to the COVID-19 pandemic was multisectoral and implemented through 15 focused working groups termed clusters. Each cluster was charged with providing policy direction in their own area of focus. All clusters then fed into one central committee for major decisions and reporting to head of state. Key policies identified during the review include international travel ban, school closures at all levels, cancellation of public events, decongesting workplaces and public transport, and mandatory face coverings and a testing policy covering symptomatic people. Supportive interventions included risk communication and community engagement in multiple languages and over a variety of mediums, efforts to improve access to water, sanitation, nutrition and unconditional social- cash transfers for poor urban and rural households

Associations Between Indoor Air Pollutants and Risk Factors for Acute Respiratory Infection Symptoms in Children Under 5: An Analysis of Data From the Indonesia Demographic Health Survey

Objectives The study investigated the association between indoor air pollution (IAP) and risk factors for acute respiratory infection (ARI) symptoms in children under 5 years of age. Methods A cross-sectional study was conducted using data derived from Indonesia Demographic and Health Survey in 2017. Binary logistic regression modeling was employed to examine each predictor variable associated with ARI among children under 5 years of age in Indonesia. Results The study included a total of 4936 households with children. Among children under 5 years old, 7.2% reported ARI symptoms. The presence of ARI symptoms was significantly associated with the type of residence, wealth index, and father’s smoking frequency, which were considered the sample’s socio-demographic characteristics. In the final model, living in rural areas, having a high wealth index, the father’s smoking frequency, and a low education level were all linked to ARI symptoms. Conclusions The results revealed that households in rural areas had a substantially higher level of reported ARI symptoms among children under 5 years old. Furthermore, the father’s smoking frequency and low education level were associated with ARI symptoms

Using Geographic Information Systems and Spatial Analysis Methods to Assess Household Water Access and Sanitation Coverage in the SHINE Trial

Access to water and sanitation are important determinants of behavioral responses to hygiene and sanitation interventions. We estimated cluster-specific water access and sanitation coverage to inform a constrained randomization technique in the SHINE trial. Technicians and engineers inspected all public access water sources to ascertain seasonality, function, and geospatial coordinates. Households and water sources were mapped using open-source geospatial software. The distance from each household to the nearest perennial, functional, protected water source was calculated, and for each cluster, the median distance and the proportion of households within 1500 m of such a water source. Cluster-specific sanitation coverage was ascertained using a random sample of 13 households per cluster. These parameters were included as covariates in randomization to optimize balance in water and sanitation access across treatment arms at the start of the trial. The observed high variability between clusters in both parameters suggests that constraining on these factors was needed to reduce risk of bia

Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study

Objective To determine whether training traditional birth attendants to manage several common perinatal conditions could reduce neonatal mortality in the setting of a resource poor country with limited access to healthcare

Molecular malaria surveillance using a novel protocol for extraction and analysis of nucleic acids retained on used rapid diagnostic tests

The use of malaria rapid diagnostic tests (RDTs) as a source for nucleic acids that can be analyzed via nucleic acid amplification techniques has several advantages, including minimal amounts of blood, sample collection, simplified storage and shipping conditions at room temperature. We have systematically developed and extensively evaluated a procedure to extract total nucleic acids from used malaria RDTs. The co-extraction of DNA and RNA molecules from small volumes of dried blood retained on the RDTs allows detection and quantification of P. falciparum parasites from asymptomatic patients with parasite densities as low as 1 Pf/µL blood using reverse transcription quantitative PCR. Based on the extraction protocol we have developed the ENAR (Extraction of Nucleic Acids from RDTs) approach; a complete workflow for large-scale molecular malaria surveillance. Using RDTs collected during a malaria indicator survey we demonstrated that ENAR provides a powerful tool to analyze nucleic acids from thousands of RDTs in a standardized and high-throughput manner. We found several, known and new, non-synonymous single nucleotide polymorphisms in the propeller region of the kelch 13 gene among isolates circulating on Bioko Island, Equatorial Guinea

Costs and Cost-Effectiveness of Training Traditional Birth Attendants to Reduce Neonatal Mortality in the Lufwanyama Neonatal Survival Study (LUNESP)

The Lufwanyama Neonatal Survival Project (“LUNESP”) was a cluster randomized, controlled trial that showed that training traditional birth attendants (TBAs) to perform interventions targeting birth asphyxia, hypothermia, and neonatal sepsis reduced all-cause neonatal mortality by 45%. This companion analysis was undertaken to analyze intervention costs and cost-effectiveness, and factors that might improve cost-effectiveness.We calculated LUNESP's financial and economic costs and the economic cost of implementation for a forecasted ten-year program (2011–2020). In each case, we calculated the incremental cost per death avoided and disability-adjusted life years (DALYs) averted in real 2011 US dollars. The forecasted 10-year program analysis included a base case as well as ‘conservative’ and ‘optimistic’ scenarios. Uncertainty was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. The estimated financial and economic costs of LUNESP were $118,574 and$127,756, respectively, or $49,469 and$53,550 per year. Fixed costs accounted for nearly 90% of total costs. For the 10-year program, discounted total and annual program costs were $256,455 and$26,834 respectively; for the base case, optimistic, and conservative scenarios, the estimated cost per death avoided was $1,866,$591, and $3,024, and cost per DALY averted was$74, $24, and$120, respectively. Outcomes were robust to variations in local costs, but sensitive to variations in intervention effect size, number of births attended by TBAs, and the extent of foreign consultants' participation.Based on established guidelines, the strategy of using trained TBAs to reduce neonatal mortality was ‘highly cost effective’. We strongly recommend consideration of this approach for other remote rural populations with limited access to health care

A comparison of four epidemic waves of COVID-19 in Malawi; an observational cohort study

Background: Compared to the abundance of clinical and genomic information available on patients hospitalised with COVID-19 disease from high-income countries, there is a paucity of data from low-income countries. Our aim was to explore the relationship between viral lineage and patient outcome. Methods: We enrolled a prospective observational cohort of adult patients hospitalised with PCR-confirmed COVID-19 disease between July 2020 and March 2022 from Blantyre, Malawi, covering four waves of SARS-CoV-2 infections. Clinical and diagnostic data were collected using an adapted ISARIC clinical characterization protocol for COVID-19. SARS-CoV-2 isolates were sequenced using the MinION™ in Blantyre. Results: We enrolled 314 patients, good quality sequencing data was available for 55 patients. The sequencing data showed that 8 of 11 participants recruited in wave one had B.1 infections, 6/6 in wave two had Beta, 25/26 in wave three had Delta and 11/12 in wave four had Omicron. Patients infected during the Delta and Omicron waves reported fewer underlying chronic conditions and a shorter time to presentation. Significantly fewer patients required oxygen (22.7% [17/75] vs. 58.6% [140/239], p < 0.001) and steroids (38.7% [29/75] vs. 70.3% [167/239], p < 0.001) in the Omicron wave compared with the other waves. Multivariable logistic-regression demonstrated a trend toward increased mortality in the Delta wave (OR 4.99 [95% CI 1.0–25.0 p = 0.05) compared to the first wave of infection. Conclusions: Our data show that each wave of patients hospitalised with SARS-CoV-2 was infected with a distinct viral variant. The clinical data suggests that patients with severe COVID-19 disease were more likely to die during the Delta wave