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1.  Health systems challenges in cervical cancer prevention program in Malawi 
Global Health Action  2015;8:10.3402/gha.v8.26282.
Background
Cervical cancer remains the leading cause of cancer death among women in sub-Saharan Africa. In Malawi, very few women have undergone screening and the incidence of cervical cancer is on the increase as is the case in most developing countries. We aimed at exploring and documenting health system gaps responsible for the poor performance of the cervical cancer prevention program in Malawi.
Design
The study was carried out in 14 randomly selected districts of the 29 districts of Malawi. All cervical cancer service providers in these districts were invited to participate. Two semi-structured questionnaires were used, one for the district cervical cancer coordinators and the other for the service providers. The themes of both questionnaires were based on World Health Organization (WHO) health system frameworks. A checklist was also developed to audit medical supplies and equipment in the cervical cancer screening facilities. The two questionnaires together with the medical supplies and equipment checklist were piloted in Chikwawa district before being used as data collection tools in the study. Quantitative data were analyzed using STATA and qualitative in NVIVO.
Results
Forty-one service providers from 21 health facilities and 9 district coordinators participated in the study. Our findings show numerous health system challenges mainly in areas of health workforce and essential medical products and technologies. Seven out of the 21 health facilities provided both screening and treatment. Results showed challenges in the management of the cervical cancer program at district level; inadequate service providers who are poorly supervised; lack of basic equipment and stock-outs of basic medical supplies in some health facilities; and inadequate funding of the program. In most of the health facilities, services providers were not aware of the policy which govern their work and that they did not have standards and guidelines for cervical cancer screening and treatment.
Conclusion
Numerous health system challenges are prevailing in the cervical cancer prevention program in Malawi. These challenges need to be addressed if the health system is to improve on the coverage of cervical cancer screening and treatment.
doi:10.3402/gha.v8.26282
PMCID: PMC4306748  PMID: 25623612
cervical cancer prevention; health system gaps; Malawi
2.  Schistosomiasis in Malawi: a systematic review 
Parasites & Vectors  2014;7(1):570.
Introduction
Schistosomiasis remains an important public health problem that undermines social and economic development in tropical regions of the world, mainly Sub-Saharan Africa. We are not aware of any systematic review of the literature of the epidemiology and transmission of schistosomiasis in Malawi since 1985. Therefore, we reviewed the current state of knowledge of schistosomiasis epidemiology and transmission in this country and identified knowledge gaps and relevant areas for future research and research governance.
Methods
We conducted computer-aided literature searches of Medline, SCOPUS and Google Scholar using the keywords: “schistosomiasis”, “Bilharzia”, “Bulinus” and “Biomphalaria” in combination with “Malawi”. These searches were supplemented by iterative reviews of reference lists for relevant publications in peer reviewed international scientific journals or other media. The recovered documents were reviewed for their year of publication, location of field or laboratory work, authorship characteristics, ethics review, funding sources as well as their findings regarding parasite and intermediate host species, environmental aspects, geographical distribution, seasonality of transmission, and infection prevalence and intensities.
Review
A total of 89 documents satisfied the inclusion criteria and were reviewed. Of these, 76 were published in international scientific journals, 68 were peer reviewed and 54 were original research studies. Most of the documents addressed urinary schistosomiasis and about two thirds of them dealt with the definitive host. Few documents addressed the parasites and the intermediate hosts. While urinary schistosomiasis occurs in most parts of Malawi, intestinal schistosomiasis mainly occurs in the central and southern highlands, Likoma Island and Lower Shire. Studies in selected communities estimated prevalence rates of up to 94.9% for Schistosoma haematobium and up to 67.0% for Schistosoma mansoni with considerable geographical variation. The main intermediate host species are Bulinus globosus and Bulinus nyassanus for urinary schistosomiasis and Biomphalaria pfeifferi for intestinal schistosomiasis. Seasonality of transmission tends to vary according to geographical, environmental, biological and behavioural factors.
Conclusion
Transmission of schistosomiasis in Malawi appears to be highly focal, with considerable variation in space and time. Many locations have not been covered by epidemiological investigations and, thus, information on the transmission of schistosomiasis in Malawi remains fragmented. Functional infection risk assessment systems based on systematic investigations and surveillance are required for developing informed prevention and control strategies.
doi:10.1186/s13071-014-0570-y
PMCID: PMC4288699  PMID: 25490938
Bilharzia; Biomphalaria; Bulinus; Schistosomiasis; Schistosoma haematobium; Schistosoma mansoni; Malawi
3.  Maternal and perinatal mortality by place of delivery in sub-Saharan Africa: a meta-analysis of population-based cohort studies 
BMC Public Health  2014;14(1):1014.
Background
Facility-based delivery has gained traction as a key strategy for reducing maternal and perinatal mortality in developing countries. However, robust evidence of impact of place of delivery on maternal and perinatal mortality is lacking. We aimed to estimate the risk of maternal and perinatal mortality by place of delivery in sub-Saharan Africa.
Methods
We conducted a systematic review of population-based cohort studies reporting on risk of maternal or perinatal mortality at the individual level by place of delivery in sub-Saharan Africa. Newcastle-Ottawa Scale was used to assess study quality. Outcomes were summarized in pooled analyses using fixed and random effects models. We calculated attributable risk percentage reduction in mortality to estimate exposure effect. We report mortality ratios, crude odds ratios and associated 95% confidence intervals.
Results
We found 9 population-based cohort studies: 6 reporting on perinatal and 3 on maternal mortality. The mean study quality score was 10 out of 15 points. Control for confounders varied between the studies. A total of 36,772 pregnancy episodes were included in the analyses. Overall, perinatal mortality is 21% higher for home compared to facility-based deliveries, but the difference is only significant when produced with a fixed effects model (OR 1.21, 95% CI: 1.02-1.46) and not when produced by a random effects model (OR 1.21, 95% CI: 0.79-1.84). Under best settings, up to 14 perinatal deaths might be averted per 1000 births if the women delivered at facilities instead of homes. We found significantly increased risk of maternal mortality for facility-based compared to home deliveries (OR 2.29, 95% CI: 1.58-3.31), precluding estimates of attributable risk fraction.
Conclusion
Evaluating the impact of facility-based delivery strategy on maternal and perinatal mortality using population-based studies is complicated by selection bias and poor control of confounders. Studies that pool data at an individual level may overcome some of these problems and provide better estimates of relative effectiveness of place of delivery in the region.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-1014) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-1014
PMCID: PMC4194414  PMID: 25263746
Maternal and perinatal mortality risk; Place of delivery; Sub-Saharan Africa
4.  Client satisfaction with cervical cancer screening in Malawi 
Background
Assessing client and patient satisfaction towards a service is of programmatic importance. A study was conducted in Malawi between July and October 2013 to assess client satisfaction among women who had been screened for cervical cancer using Visual Inspection with Acetic acid test.
Methods
This was a cross sectional descriptive study which was conducted in 16 out of 43 cervical cancer screening centres. A semi structured questionnaire was used for data collection. Data were analyzed using STATA version 11 for windows. Descriptive statistics were computed to summarize participant characteristics. Logistic regression was also conducted to assess the relationship between client satisfaction with the service and the independent variables.
Results
One hundred and twenty women with a mean age of 33.7 (SD = 10.1) participated in the survey. All women reported being satisfied with the received service at the facility, with 68.33% reported to be very satisfied. All demographic characteristics such as age, marital status, level of education, with exception of distance to the nearest health facility had no statistically significant association with satisfaction at both univariate and multivariate analysis. However, previous knowledge about the cause of the disease itself, its prevention, knowledge that the disease can be cured, knowledge of clinic times, previous knowledge of the VIA screening test and the source from where they heard about cervical cancer had a statistical significant relationship with the outcome variable. Logistic regression revealed that satisfaction in this study was predicted by having an appointment before the screening with adjusted odd ratio of 5.71(95%CI: 1.75 – 18.63), having previous knowledge of the VIA test, AOR = 0.021(95% CI: 0.002-0.226) distance from the home to the health facility AOR = 0.11(95%CI: 0.02-0.65) and waiting time AOR = 0.09 with 95% CI: 0.09 – 0.83. Having an appointment had the only independent variable with a positive relationship with satisfaction.
Conclusion
Women were satisfied with the screening service. The study also showed several challenges in cervical cancer screening services which can be considered as areas of potential improvement.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6963-14-420) contains supplementary material, which is available to authorized users.
doi:10.1186/1472-6963-14-420
PMCID: PMC4180310  PMID: 25245860
Cervical cancer; Screening; Satisfaction; Visual inspection with acetic acid
5.  Follow-Up Visit Patterns in an Antiretroviral Therapy (ART) Programme in Zomba, Malawi 
PLoS ONE  2014;9(7):e101875.
Background
Identifying follow-up (FU) visit patterns, and exploring which factors influence them are likely to be useful in determining which patients on antiretroviral therapy (ART) may become Lost to Follow-Up (LTFU). Using an operation and implementation research approach, we sought 1) to describe the timing of FU visits amongst patients who have been on ART for shorter and longer periods of time; and 2) to determine the median time to late visits, and 3) to identify specific factors that may be associated with these patterns in Zomba, Malawi.
Methods and Findings
Using routinely collected programme monitoring data from Zomba District, we performed descriptive analyses on all ART visits among patients who initiated ART between Jan. 1, 2007–June 30, 2010. Based on an expected FU date, each FU visit was classified as early (≥4 day before an expected FU date), on time (3 days before an expected FU date/up to 6 days after an expected FU date), or late (≥7 days after an expected FU date). In total, 7,815 patients with 76417 FU visits were included. Ninety-two percent of patients had ≥2 FU visits. At the majority of visits, patients were either on time or late. The median time to a first late visit among those with 2 or more visits was 216 days (IQR: 128–359). Various patient- and visit-level factors differed significantly across Early, On Time, and Late visit groups including ART adherence and frequency of, and type of side effects.
Discussion
The majority of patients do not demonstrate consistent FU visit patterns. Individuals were generally on ART for at least 6 months before experiencing their first late visit. Our findings have implications for the development of effective interventions that meet patient needs when they present early and can reduce patient losses to follow-up when they are late. In particular, time-varying visit characteristics need further research.
doi:10.1371/journal.pone.0101875
PMCID: PMC4102478  PMID: 25033285
6.  Stakeholders’ perceptions on factors influencing male involvement in prevention of mother to child transmission of HIV services in Blantyre, Malawi 
BMC Public Health  2014;14:691.
Background
Male Involvement (MI) in the Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) services is essential in a patriarchal society where men are decision makers of the household. Male partners have a role in the woman’s risk of acquiring HIV, uptake of HIV testing and participation in Mother to Child Transmission (MTCT) prevention programmes. Although MI is important for uptake of PMTCT interventions, it remains low in Africa. The purpose of this study was to identify factors that promote and hinder MI in PMTCT services in antenatal care (ANC) services in Blantyre, Malawi. Understanding of the factors that influence MI will assist in developing strategies that will involve men more in the programme thereby improving the uptake of PMTCT and HIV testing and counselling services by women and men respectively.
Methods
An exploratory qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) in Blantyre, Malawi. It consisted of six face to face Key Informant Interviews (KIIs) with health care workers and four Focus Group discussions (FGDs) with 18 men and 17 pregnant women attending antenatal care at the clinic. The FGDs were divided according to sex and age. All FGDs and KIIs were digitally recorded and simultaneously transcribed and translated verbatim into English. Data were analysed using thematic content analysis.
Results
Participants in both FGDs and KIIs identified the following barriers: lack of knowledge of MI in PMTCT, socioeconomic factors, relationship issues, timidity to be seen in a woman’s domain, unplanned and or extramarital pregnancies, fear of knowing one's HIV status, unwillingness to be associated with the service, health facility based factors, peer influence and cultural factors. The factors that would potentially promote male involvement were categorized into community, health facility and personal or family level factors.
Conclusions
The factors that may hinder or promote MI arise from different sources. The success of MI lies on recognizing sources of barriers and averting them. Factors that promote MI need to be implemented at different levels of health care.
doi:10.1186/1471-2458-14-691
PMCID: PMC4226974  PMID: 24998152
7.  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.
doi:10.1186/1472-6963-14-180
PMCID: PMC4006400  PMID: 24751213
Mixed methods; Impact evaluation; Performance-based incentives; Study design
8.  Specialization training in Malawi: a qualitative study on the perspectives of medical students graduating from the University of Malawi College of Medicine 
Background
There is a critical shortage of healthcare workers in sub-Saharan Africa, and Malawi has one of the lowest physician densities in the region. One of the reasons for this shortage is inadequate retention of medical school graduates, partly due to the desire for specialization training. The University of Malawi College of Medicine has developed specialty training programs, but medical school graduates continue to report a desire to leave the country for specialization training. To understand this desire, we studied medical students’ perspectives on specialization training in Malawi.
Methods
We conducted semi-structured interviews of medical students in the final year of their degree program. We developed an interview guide through an iterative process, and recorded and transcribed all interviews for analysis. Two independent coders coded the manuscripts and assessed inter-coder reliability, and the authors used an “editing approach” to qualitative analysis to identify and categorize themes relating to the research aim. The University of Pittsburgh Institutional Review Board and the University of Malawi College of Medicine Research and Ethics Committee approved this study and authors obtained written informed consent from all participants.
Results
We interviewed 21 medical students. All students reported a desire for specialization training, with 12 (57%) students interested in specialties not currently offered in Malawi. Students discussed reasons for pursuing specialization training, impressions of specialization training in Malawi, reasons for staying or leaving Malawi to pursue specialization training and recommendations to improve training.
Conclusions
Graduating medical students in Malawi have mixed views of specialization training in their own country and still desire to leave Malawi to pursue further training. Training institutions in sub-Saharan Africa need to understand the needs of the country’s healthcare workforce and the needs of their graduating medical students to be able to match opportunities and retain graduating students.
doi:10.1186/1472-6920-14-2
PMCID: PMC3884020  PMID: 24393278
Medical education; Postgraduate medical education; Specialization training; Medical migration; Sub-Saharan Africa; Qualitative research
9.  Assessment of strategies for male involvement in the prevention of mother-to-child transmission of HIV services in Blantyre, Malawi 
Global Health Action  2013;6:10.3402/gha.v6i0.22780.
Background
Despite the documented benefits of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) services, the uptake remains low in sub-Saharan Africa. The lack of male involvement (MI) may be one of the reasons for this. However, there are limited data on strategies for MI in PMTCT.
Objective
The objective of this study was to identify strategies that may promote MI in PMTCT services in antenatal care (ANC) services in Blantyre, Malawi.
Study design
An exploratory qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) in Blantyre, Malawi. It consisted of six face-to-face key informant interviews (KIIs) with healthcare workers and four focus group discussions (FGDs) with 18 men and 17 pregnant women attending ANC at SLHC. The FGDs were divided according to sex and age. All FGDs and KIIs were digitally recorded and simultaneously transcribed and translated verbatim into English. Data were analyzed using thematic content analysis.
Results
Three major themes with several subcategories emerged. Theme 1 was a gatekeeping strategy with two subcategories: (1) healthcare workers refusing service provision to women accessing antenatal clinic without their partners and (2) women refusing ANC attention in the absence of a partner. Theme 2 comprised extending invitations and had six subcategories: (1) word of mouth, (2) card invites, (3) woman's health passport book invites, (4) telephonic invites, (5) use of influential people, and (6) home visits. Theme 3 was information education and communication, such as health education forums and advertisements. Of all the strategies, an invitation card addressed to the male partner was most preferred by study participants.
Conclusions
There are several strategies by which men may be involved in PMTCT. Healthcare workers should offer a pregnant woman all strategies available for MI for her to select the appropriate one. Further research and consultations with men should continue to achieve higher levels of MI.
doi:10.3402/gha.v6i0.22780
PMCID: PMC3866839  PMID: 24345635
male involvement; HIV and AIDS; PMTCT
10.  Health Workforce Brain Drain: From Denouncing the Challenge to Solving the Problem 
PLoS Medicine  2013;10(9):e1001514.
Giorgio Cometto and colleagues discuss the study by Tankwanchi and colleagues on physician migration to the United States from sub-Saharan Africa and the steps that the US, other destination countries, and SSA countries can take to address the problem.
Please see later in the article for the Editors' Summary
doi:10.1371/journal.pmed.1001514
PMCID: PMC3775719  PMID: 24068895
11.  Using concept mapping to explore why patients become lost to follow up from an antiretroviral therapy program in the Zomba District of Malawi 
Background
Retention in antiretroviral therapy (ART) programmes remains a challenge in many settings including Malawi, in part due to high numbers of losses to follow-up. Concept Mapping (CM), a mix-method participatory approach, was used to explore why patients on ART are lost to follow-up (LTFU) by identifying: 1) factors that influence patient losses to follow-up and 2) barriers to effective and efficient tracing in Zomba, Malawi.
Methods
CM sessions (brainstorming, sorting and rating, interpretation) were conducted in urban and rural settings in Zomba, Malawi. Participants included ART patients, ART providers, Health Surveillance Assistants, and health managers from the Zomba District Health Office. In brainstorming, participants generated statements in response to “A specific reason why an individual on ART becomes lost to follow-up is…” Participants then sorted and rated the consolidated list of brainstormed items. Analysis included inductive qualitative methods for grouping of data and quantitative cluster identification to produce visual maps which were then interpreted by participants.
Results
In total, 90 individuals brainstormed 371 statements, 64 consolidated statements were sorted (participant n = 46), and rated on importance and feasibility (participant n = 69). A nine-cluster concept map was generated and included both patient- and healthcare-related clusters such as: Stigma and Fears, Beliefs, Acceptance and Knowledge of ART, Access to ART, Poor Documentation, Social and Financial Support Issues, Health Worker Attitudes, Resources Needed for Effective Tracing, and Health Worker Issues Related to Tracing. Strategies to respond to the clusters were generated in Interpretation.
Conclusions
Multiple patient- and healthcare focused factors influence why patients become LTFU. Findings have implications particularly for programs with limited resources struggling with the retention of ART patients.
doi:10.1186/1472-6963-13-210
PMCID: PMC3698212  PMID: 23758879
Concept mapping; HIV/AIDS; Antiretroviral therapy (ART); Losses to follow-up; Malawi
12.  Cannabis use and its socio-demographic correlates among in-school adolescents in Zambia 
Background
Cannabis dependence in adolescents predicts increased risks of using other illicit drugs, poor academic performance and reporting psychotic symptoms. The prevalence of cannabis use was estimated two decades ago in Zambia among secondary school students. There are no recent estimates of the extent of the problem; further, correlates for its use have not been documented in Zambia. The objective of study was to estimate the current prevalence of cannabis use and its socio-demographic correlates among in-school adolescents.
Methods
We conducted secondary analysis of data that was obtained from the 2004 Zambia Global School-Based Health Survey. Logistic regression analysis was conducted to identify the socio-demographic factors associated with cannabis use.
Results
A total of 2,257 adolescents participated in the survey of which 53.9% were females. The overall prevalence of self reported ever-used cannabis was 37.2% (34.5% among males and 39.5% among females). In multivariate analysis, males were 8% (AOR = 0.92; 95% CI [0.89, 0.95]) less likely to have ever smoked cannabis. Compared to adolescents aged 16 years or older, adolescents aged 14 years were 45% (AOR = 1.45; 95% CI [1.37, 1.55]) more likely, and those aged 15 years were 44% (AOR = 0.56; 95% CI [0.53, 0.60]) less likely to report to have ever smoked cannabis. Other factors that were significantly associated with cannabis use were history of having engaged in sexual intercourse (AOR = 2.55; 95% CI [2.46, 2.64]), alcohol use (AOR = 4.38; 95% CI [4.24, 4.53]), and having been bullied (AOR = 1.77; 95% CI [1.71, 1.83]). Adolescents who reported being supervised by parents during free time were less likely to have smoked cannabis (AOR = 0.92; 95% CI [0.88, 0.95]).
Conclusions
The use of cannabis is prevalent among Zambian in-school adolescents. Efforts to prevent adolescents’ psychoactive drug use in Zambia should be designed considering the significant factors associated with drug use in the current study.
doi:10.1186/1824-7288-39-13
PMCID: PMC3599579  PMID: 23415178
Prevalence; Cannabis use; In-school; Adolescents; Zambia
13.  Primary health care in rural Malawi - a qualitative assessment exploring the relevance of the community-directed interventions approach 
Background
Primary Health Care (PHC) is a strategy endorsed for attaining equitable access to basic health care including treatment and prevention of endemic diseases. Thirty four years later, its implementation remains sub-optimal in most Sub-Saharan African countries that access to health interventions is still a major challenge for a large proportion of the rural population. Community-directed treatment with ivermectin (CDTi) and community-directed interventions (CDI) are participatory approaches to strengthen health care at community level. Both approaches are based on values and principles associated with PHC. The CDI approach has successfully been used to improve the delivery of interventions in areas that have previously used CDTi. However, little is known about the added value of community participation in areas without prior experience with CDTi. This study aimed at assessing PHC in two rural Malawian districts without CDTi experience with a view to explore the relevance of the CDI approach. We examined health service providers’ and beneficiaries’ perceptions on existing PHC practices, and their perspectives on official priorities and strategies to strengthen PHC.
Methods
We conducted 27 key informant interviews with health officials and partners at national, district and health centre levels; 32 focus group discussions with community members and in-depth interviews with 32 community members and 32 community leaders. Additionally, official PHC related documents were reviewed.
Results
The findings show that there is a functional PHC system in place in the two study districts, though its implementation is faced with various challenges related to accessibility of services and shortage of resources. Health service providers and consumers shared perceptions on the importance of intensifying community participation to strengthen PHC, particularly within the areas of provision of insecticide treated bed nets, home case management for malaria, management of diarrhoeal diseases, treatment of schistosomiasis and provision of food supplements against malnutrition.
Conclusion
Our study indicates that intensified community participation based on the CDI approach can be considered as a realistic means to increase accessibility of certain vital interventions at community level.
doi:10.1186/1472-6963-12-328
PMCID: PMC3576236  PMID: 22995125
14.  Postgraduate career intentions of medical students and recent graduates in Malawi: a qualitative interview study 
BMC Medical Education  2012;12:87.
Background
In 2004, the Malawian Ministry of Health declared a human resource crisis and launched a six year Emergency Human Resources Programme. This included salary supplements for key health workers and a tripling of doctors in training. By 2010, the number of medical graduates had doubled and significantly more doctors were working in rural district hospitals. Yet there has been little research into the views of this next generation of doctors in Malawi, who are crucial to the continuing success of the programme. The aim of this study was to explore the factors influencing the career plans of medical students and recent graduates with regard to four policy-relevant aspects: emigration outside Malawi; working at district level; private sector employment and postgraduate specialisation.
Methods
Twelve semi-structured interviews were conducted with fourth year medical students and first year graduates, recruited through purposive and snowball sampling. Key informant interviews were also carried out with medical school faculty. Recordings were transcribed and analysed using a framework approach.
Results
Opportunities for postgraduate training emerged as the most important factor in participants’ career choices, with specialisation seen as vital to career progression. All participants intended to work in Malawi in the long term, after a period of time outside the country. For nearly all participants, this was in the pursuit of postgraduate study rather than higher salaries. In general, medical students and young doctors were enthusiastic about working at district level, although this is curtailed by their desire for specialist training and frustration with resource shortages. There is currently little intention to move into the private sector.
Conclusions
Future resourcing of postgraduate training opportunities is crucial to preventing emigration as graduate numbers increase. The lesser importance put on salary by younger doctors may be an indicator of the success of salary supplements. In order to retain doctors at district levels for longer, consideration should be given to the introduction of general practice/family medicine as a specialty. Returning specialists should be encouraged to engage with younger colleagues as role models and mentors.
doi:10.1186/1472-6920-12-87
PMCID: PMC3480922  PMID: 22978475
Doctors; Medical students; Postgraduate education; Specialisation; Malawi; Rural health; Brain drain; Emigration
15.  Prevalence and correlates of obesity among Lusaka residents, Zambia: a population-based survey 
Background
Non-communicable lifestyle diseases are a growing public health concern globally. Obesity is a risk factor for premature mortality from cardiovascular diseases and diabetes as well as all-cause mortality. The objective of the study was to estimate the prevalence and associated factors for obesity among Zambian adults in Lusaka district.
Methods
A community-based study was done among adults in Zambia. Descriptive and co-relational analyses were conducted to estimate the prevalence of being obese as well as identify associated factors.
Results
A total of 1,928 individuals participated in the survey, of which 33.0% were males. About half of the participants were aged 25–34 years (53.2%), and about two-thirds had attended at least secondary level of education (63.9%). Overall, 14.2% of the participants (5.1% of males, and 18.6% of females) were obese. Significant factors associated with obesity were sex, age, education, cigarette smoking and blood pressure. Male participants were 55% (AOR = 0.45; 95% CI [0.29, 0.69]) less likely to be obese compared to female participants. Compared to participants who were of age 45 years or older, participants of age 25–34 years were 61% (AOR = 0.39 (95% CI [0.23, 0.67]) less likely to be obese. Compared to participants who attained college or university level of education, participants who had no formal education were 63% (AOR = 0.37; 95% CI [0.15, 0.91]) less likely to be obese; and participants who had attained secondary level of education were 2.22 (95% CI [1.21, 4.07]) times more likely to be obese. Participants who smoked cigarettes were 67% (AOR = 0.33; 95% CI [0.12, 0.95]) less likely to be obese compared to participants who did not smoke cigarettes. Compared to participants who had severe hypertension, participants who had moderate hypertension were 3.46 (95% CI [1.34, 8.95]) times more likely to be obese.
Conclusions
The findings from this study indicate that Zambian women are more at risk of being obese. Prevention and control measures are needed to address high prevalence and gender inequalities in risks for non-communicable diseases in Zambia. Such measures should include policies that support gender specific approaches for the promotion of health behavior changes.
doi:10.1186/1755-7682-5-14
PMCID: PMC3403883  PMID: 22551418
Obesity; Smoking; Lusaka; Zambia
16.  Prevalence and correlates for school truancy among pupils in grades 7-10: results from the 2004 Zambia Global School-based Health Survey 
BMC Research Notes  2012;5:48.
Background
There are limited data on the prevalence and associated factors of truancy in southern Africa. Yet truancy should attract the attention of public health professionals, educators and policy makers as it may be associated with adolescent problem behaviours. The objectives of the study were to estimate the prevalence and determine correlates of school truancy among pupils in Zambia.
Findings
We used data collected in 2004 in the Zambia Global School-based Health Survey. Logistic regression analysis was conducted to identify factors associated with truancy. A total of 2257 pupils participated in the survey of whom 53.9% were male. Overall 58.8% of the participants (58.1% of males and 58.4% of females) reported being truant in the past 30 days. Factors associated with truancy were having been bullied (AOR = 1.34, 95% CI [1.32, 1.36]), current alcohol use (AOR = 2.19, 95% CI [2.16, 2.23]), perception that other students were kind and helpful (AOR = 1.12, 95% CI [1.10, 1.14]), being male and being from the lowest school grade. Pupils whose parents or guardians checked their homework (AOR = 0.91 95% CI, [0.89, 0.92]) and those who reported parental supervision (AOR = 0.94, 95% CI [0.92-0.95]) were less likely to report being truant.
Conclusions
We found a high prevalence of truancy among pupils in grades 7-10 in Zambia. Interventions aimed to reduce truancy should be designed and implemented with due consideration of the associated factors.
doi:10.1186/1756-0500-5-48
PMCID: PMC3284399  PMID: 22260248
17.  Victimization from bullying among school-attending adolescents in grades 7 to 10 in Zambia 
Abstract:
Background:
Among school- attending adolescents, victimization from bullying is associated with anxiety, depression and poor academic performance. There are limited reports on victimization from bullying in Zambia; we therefore conducted this study to determine the prevalence and correlates for victimization from bullying among adolescents in grades 7 to 10 in the country in order to add information on the body of knowledge on victimization from bullying.
Methods:
The 2004 Zambia Global School-based Health Survey (GSHS) data among adolescents in grades 7 to 10 were obtained from the World Health Organization. We estimated the prevalence of victimization from bullying. We also conducted weighted multivariate logistic regression analysis to determine independent factors associated with victimization from bullying, and report adjusted odds ratios (AOR) and their 95% confidence intervals (CI).
Results:
Of 2136 students who participated in the 2004 Zambia GSHS, 1559 had information on whether they were bullied or not. Of these, 1559 students, 62.8% (60.0% of male and 65.0% of female) participants reported having been bullied in the previous 30 days to the survey. We found that respondents of age less than 14 years were 7% (AOR=0.93; 95%CI [0.91, 0.95]) less likely to have been bullied compared to those aged 16 years or older. Being a male (AOR=1.07; 95%CI [1.06, 1.09]), lonely (AOR=1.24; 95%CI [1.22, 1.26]), worried (AOR=1.12; 95%CI [1.11, 1.14]), consuming alcohol (AOR=2.59; 95%CI [2.55, 2.64]), missing classes (AOR=1.30; 95%CI [1.28, 1.32]), and considering attempting suicide (AOR=1.20; 95%CI [1.18, 1.22]) were significantly associated with bullying victimization.
Conclusions:
Victimization from bullying is prevalent among in-school adolescents in grades 7 to 10 in Zambia, and interventions to curtail it should consider the factors that have been identified in this study.
doi:10.5249/jivr.v4i1.84
PMCID: PMC3291278  PMID: 21502789
18.  Prevalence of hypertension and its correlates in Lusaka urban district of Zambia: a population based survey 
Background
Hypertension is a leading cause for ill-health, premature mortality and disability. The objective of the study was to determine the prevalence and associated factors for hypertension in Lusaka, Zambia.
Methods
A cross sectional study was conducted. Odds ratios and their 95% confidence intervals were calculated to assess relationships between hypertension and explanatory variables.
Results
A total of 1928 individuals participated in the survey, of which 33.0% were males. About a third of the respondents had attained secondary level education (35.8%), and 20.6% of males and 48.6% of females were overweight or obese. The prevalence for hypertension was 34.8% (38.0% of males and 33.3% of females). In multivariate analysis, factors independently associated with hypertension were: age, sex, body mass index, alcohol consumption, sedentary lifestyle, and fasting blood glucose level.
Conclusions
Health education and structural interventions to promote healthier lifestyles should be encouraged taking into account the observed associations of the modifiable risk factors.
doi:10.1186/1755-7682-4-34
PMCID: PMC3195701  PMID: 21974840
Hypertension; BMI; alcohol consumption; sedentary behaviour; fasting blood glucose level; Lusaka; Zambia
19.  Prevalence and socio-demographic correlates for serious injury among adolescents participating in the Djibouti 2007 Global School-based Health Survey 
BMC Research Notes  2011;4:372.
Background
Mental health and injury are neglected public health issues especially in low-income nations. The objective of the study was to determine the prevalence and socio-demographic correlates for serious injury in the last 12 months.
Findings
The study used data of the 2007 Djibouti Global School-based Health Survey. Logistic regression analysis was used to establish associations. Of the 1, 777 respondents, 61.1% (63.2% males and 57.8% females) reported having sustained serious injury (SSI). Compared to participants who were not bullied, those who reported being bullied 3-9 days per month were more likely to have sustained serious injury in the last 12 months (AOR = 1.27; 95% CI [1.06, 1.52] for 3-5 days of bullying victimization per month, and AOR = 3.19; 95% CI [2.28, 4.47] for 6-9 days per month. Adolescents who were engaged in physical fighting were 47% (AOR = 1.47, 95% CI [1.40, 1.55] more likely to have sustained serious injury compared to those who were not engaged in the fighting. Meanwhile, adolescents who used substances (cigarettes, other forms of tobacco or drugs) were 30% (AOR = 1.30, 95% CI [1.19, 1.42]) more likely to have sustained serious injury compared to those who did not use substances.
Conclusions
Serious injury is common among adolescents in Djibouti, and we suggest that health workers attending to injured adolescents explore the patients' psycho-social environment. Further, we suggest longitudinal studies where reduction of substance use and bullying may be assessed if they have an impact in reducing serious injury among adolescents.
doi:10.1186/1756-0500-4-372
PMCID: PMC3189130  PMID: 21951721
20.  Self-reported poor oral hygiene among in-school adolescents in Zambia 
BMC Research Notes  2011;4:255.
Background
Dental health is a neglected aspect of adolescent health globally but more so in low-income countries. Secondary analysis using the 2004 Zambia Global School-Based Health Survey (GSHS) was conducted in which we estimated frequencies of relevant socio-demographic variables and explored associations between selected explanatory variables and self-reported poor oral hygiene (not cleaning or brushing teeth) within the last 30 days of the completion of questionnaire.
Findings
Most of the 2257 respondents were males (53.9%) and went hungry (82.5%). More than 4 in 10 respondents drank alcohol (42.2%) while 37.2% smoked cannabis. Overall 10.0% of the respondents reported to have poor oral hygiene. Male respondents were 7% less likely to report to have poor oral hygiene compared to females. Compared to respondents who never drank alcohol, those who drank alcohol were 27% more likely to report to have poor oral hygiene. Respondents who smoked cannabis were 4% more likely to report to have poor oral hygiene compared to those who did not smoke cannabis. Finally, respondents who went hungry were 35% more likely to report to have poor oral hygiene compared to those who did not go hungry.
Conclusions
Results from this study indicate that female gender, alcohol drinking, cannabis smoking, and going hungry were associated with self-reported poor oral hygiene. The identification of these factors should guide the design and implementation of programs aimed to improve oral health among adolescents.
doi:10.1186/1756-0500-4-255
PMCID: PMC3156756  PMID: 21781301
21.  We Are Not Just a “Tiny, Landlocked, Impoverished Sub-Saharan Country with HIV Burden” 
Croatian Medical Journal  2010;51(6):560-562.
doi:10.3325/cmj.2010.51.560
PMCID: PMC3031302  PMID: 21162169
22.  Occupational illnesses in the 2009 Zambian labour force survey 
BMC Research Notes  2010;3:272.
Background
Occupational health has received limited research attention in the Southern African Development Community (SADC). Much of the published data in this region come from South Africa and little has been reported north of the Limpopo. The present study was conducted to estimate the burden of occupational illnesses in Zambia and assess factors associated with their occurrence.
Methods
Data were obtained from the Zambian Labour Force Survey of 2009. Frequencies were used to estimate the prevalence of occupational diseases. Logistic regression analyses were conducted to determine the associations between demographic, social and economic factors and reported illness resulting from occupational exposures. Odds ratios (OR) from bivariate analyses and adjusted odds ratios (AOR) from the multivariate analysis together with their 95% Confidence Intervals (CI) are reported.
Results
Data on 59,118 persons aged 18 years or older were available for analysis, of which 29805 (50.4%) were males. The proportions of the sample that reported to have suffered from an occupational illness were 12.7% among males and 10.4% among females (p < 0.001). Overall the proportions of respondents who reported suffering from fatigue, fever and chest infections were 38.8%, 21.7% and 17.1%, respectively. About two thirds (69.7%) of the study participants had stayed away from work due to the illness suffered at work; there was no sex differences (p = 0.216). Older age, being male, lower education level, married/cohabiting or once married (separated/divorced/widowed), and paid employee or employer/self employed were positively associated with having suffered from illness.
Conclusions
The findings from this study call for urgent effort for specific measures to prevent and mitigate the effects of occupational injuries. These interventions may include: public health campaigns, enforcement or change in work policies and regulations. Special attention may have to be made towards those who were more likely to suffer from occupational illnesses.
doi:10.1186/1756-0500-3-272
PMCID: PMC2987870  PMID: 20979616
23.  “I Can’t Use a Condom, I Am a Christian:” Salvation, Death, and… Naivety in Africa 
Croatian Medical Journal  2010;51(5):468-471.
doi:10.3325/cmj.2010.51.468
PMCID: PMC2969142  PMID: 20960597
24.  Compensation patterns following occupational injuries in Zambia: results from the 2009 Labour Survey 
Background
Occupational injuries have received limited research attention in the Southern African Development Community. Much of the published data come from South Africa and little has been reported elsewhere within the region. The present study was conducted to estimate the prevalence rates of occupational injuries and compensation; and to determine factors associated with occupational injuries and compensation.
Methods
Data were obtained from occupational health and injury questions added to the Zambian Labour Force Survey of 2009 by the Work and Health in Southern Africa programme. Logistic regression analyses were conducted to determine the degree of association between demographic, social and economic factors on one hand and injury and compensation on the other.
Results
Data on 61871 study participants were available for analysis, of whom 4998 (8.1%) reported having been injured (10.0% of males, and 6.2% of females) due to work in the previous 12 months to the survey. Of those injured, 60.5% reported having stayed away from work as a result. The commonest type of injury was "open wound" (81.6%). Male gender, being married or married before, being a paid employee, working for a private company and household were positively associated with serious injuries. Injuries also varied by geographical area. Factors positively associated with receiving compensation for work-related injuries were: male gender, Copperbelt and North-Western provinces, and unpaid family worker. Employer/self employed and having less than 5 employees in a workplace were negatively associated with compensation.
Conclusion
The prevalence of reported injury and its association with a significant level of absence from work, indicate that occupational hazards in Zambia have significant health and economic effects. Female workers should equally be compensated for injuries suffered as their male counterparts.
doi:10.1186/1755-7682-3-19
PMCID: PMC2944123  PMID: 20825646
25.  Goodbye Collaboration, Welcome Partnerships in International Research? 
Croatian Medical Journal  2010;51(4):359-360.
doi:10.3325/cmj.2010.51.359
PMCID: PMC2931443  PMID: 20718091

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