Chrissie P.N. Kaponda

Health-seeking patterns for AIDS in Malawi

Health-seeking practices in Malawi are not well understood and it is not clear where people go for help to manage AIDS symptoms and to receive treatment for AIDS- defining illness. This qualitative study examines the health-seeking practices of families affected by AIDS in rural Malawi. Semi-structured interviews were conducted with family caregivers (N=26) and patients with AIDS symptoms (N=20). Health seeking progressed in three stages: traditional care and treatment by family were used first, followed by remedies from traditional healers. When traditional methods fail and symptoms continue modern treatments from hospitals or clinics were used as a last alternative. We discuss the cultural context of health seeking for HIV/AIDS in Malawi and suggest ways in which traditional practices can be integrated into interventions to improve the quality of care and treatment for people living with AIDS.

A primary health care intervention to mobilize health workers for HIV prevention in Malawi

For the last 4 years we have implemented a model to mobilize rural health workers as leaders for HIV prevention in Malawi. We use a conceptual framework that integrates the World Health Organization’s (WHO) primary health care (PHC) model, the social‐ cognitive model of behavioural change, and contextual tailoring of the intervention. Health workers are potential rural HIV prevention leaders because they have community trust and respect. However, their leadership potential has been limited by both health system barriers such as inadequate workers, supplies, and training and personal barriers such as risky occupational and personal behaviours. In the first phase of the project, we developed collaborative relationships and conducted qualitative research to adapt a peer group intervention for rural health workers and community members. In the ongoing second phase, we trained the health workers, who then volunteered and provided the intervention to adults in the communities their health centres serve. The intervention was adapted for young people through a community participatory process. Currently the adapted intervention is being offered to young people. As a guide to replication, we discuss barriers encountered in implementing this collaborative project and how we overcame them. This project demonstrates that health workers can be effective leaders for community AIDS prevention in African countries. The primary health care model offers a feasible, cost-effective and sustainable approach to maximizing health worker-community collaboration to reduce the spread of HIV.

CenteringPregnancy-Africa: a pilot of group antenatal care to address Millennium Development Goals.

BACKGROUND severe health worker shortages and resource limitations negatively affect quality of antenatal care (ANC) throughout sub-Saharan Africa. Group ANC, specifically CenteringPregnancy (CP), may offer an innovative approach to enable midwives to offer higher quality ANC. OBJECTIVE our overarching goal was to prepare to conduct a clinical trial of CenteringPregnancy-Africa (CP-Africa) in Malawi and Tanzania. In Phase 1, our goal was to determine the acceptability of CP as a model for ANC in both countries. In Phase 2, our objective was to develop CP-Africa session content consistent with the Essential Elements of CP model and with national standards in both Malawi and Tanzania. In Phase 3, our objective was to pilot CP-Africa in Malawi to determine whether sessions could be conducted with fidelity to the Centering process. SETTING Phases 1 and 2 took place in Malawi and Tanzania. Phase 3, the piloting of two sessions of CP-Africa, occurred at two sites in Malawi: a district hospital and a small clinic. DESIGN we used an Action Research approach to promote partnerships among university researchers, the Centering Healthcare Institute, health care administrators, health professionals and women attending ANC to develop CP-Africa session content and pilot this model of group ANC. PARTICIPANTS for Phases 1 and 2, members of the Ministries of Health, health professionals and pregnant women in Malawi and Tanzania were introduced to and interviewed about CP. In Phase 2, we finalised CP-Africa content and trained 13 health professionals in the Centering Healthcare model. In Phase 3, we conducted a small pilot with 24 pregnant women (12 at each site). MEASUREMENTS AND FINDINGS participants enthusiastically embraced CP-Africa as an acceptable model of ANC health care delivery. The CP-Africa content met both CP and national standards. The pilot established that the CP model could be implemented with process fidelity to the 13 Essential Elements. Several implementation challenges and strategies to address these challenges were identified. KEY CONCLUSIONS preliminary data suggest that CP-Africa is feasible in resource-constrained, low-literacy, high-HIV settings in sub-Saharan Africa. By improving the quality of ANC delivery, midwives have an opportunity to make a contribution towards Millennium Development Goals (MDG) targeting improvements in child, maternal and HIV-related health outcomes (MDGs 4, 5 and 6). A clinical trial is needed to establish efficacy. IMPLICATIONS FOR PRACTICE CP-Africa also has the potential to reduce job-related stress and enhance job satisfaction for midwives in low income countries. If CP can be transferred with fidelity to process in sub-Saharan Africa and retain similar results to those reported in clinical trials, it has the potential to benefit pregnant women and their infants and could make a positive contribution to MGDs 4, 5 and 6.

Rural Malawians' perceptions of HIV risk behaviors and their sociocultural context.

Abstract Prevention remains key in the fight against HIV/AIDS. However, prevention requires understanding the sociocultural and economic context in which HIV-risk behaviors occur. This qualitative, descriptive study was part of the initial phase of a larger project to adapt and test a community-based HIV-prevention intervention. We conducted individual interviews with rural Malawian community leaders and focus groups with adult community residents to elicit perceptions of both sexual and non-sexual HIV-risk behaviors and their sociocultural context. Interviews and focus groups were conducted in Chichewa, audio-taped, transcribed and translated into English by bilingual co-investigators. Content analysis of transcripts was done collaboratively by US-based and Malawian co-investigators to confirm culturally accurate interpretation of data. Participants identified sexual and non-sexual HIV-risk behaviors and contextual factors that influence these behaviors, including gender relations, cultural practices, economic conditions and religion. Community leaders and residents voiced similar perspectives on risk behaviors, except that community leaders were much less likely than residents to discuss sexual transmission through participation in traditional cultural practices. We incorporated these study results in adapting our HIV-prevention intervention to the sociocultural context of rural Malawi. Study participation enhanced the community leaders and residents interest in the intervention phase of the project.

Outcomes of an HIV Prevention Peer Group Intervention for Rural Adults in Malawi

This study used a quasi-experimental design to evaluate a six-session peer group intervention for HIV prevention among rural adults in Malawi. Two rural districts were randomly assigned to intervention and control conditions. Independent random samples of community adults compared the districts at baseline and at 6 and 18 months postintervention. Using multiple regressions controlling for six demographic factors, intervention district adults had significantly more favorable outcomes at 6- and 18-month evaluations for condom attitudes, self-efficacy for community prevention, self-efficacy for practicing safer sex, partner communication, using condoms ever in the past 2 months, and community prevention activities. Knowledge and hope for controlling the epidemic were significantly higher in the intervention district only at the 6-month evaluation; having a recent HIV test was significantly higher only at 18 months. Levels of stigma and the number of risky sex practices did not decrease when demographic factors were controlled. Expanding peer group intervention for HIV prevention would benefit rural adults.

Process evaluation of HIV prevention peer groups in Malawi: a look inside the black box

This paper reports the process evaluation of a peer group intervention for human immunodeficiency virus (HIV) prevention which had positive outcomes for three target groups in Malawi: rural adults, adolescents and urban hospital workers. The six-session intervention was delivered to small groups of 10-12 participants by 85 trained volunteer peer leaders working in pairs. A descriptive, observational mixed methods design was used with a convenience sample of 294 intervention sessions. Using project records and a conceptually based observation guide, we examined five aspects of the implementation process. The context was favorable, but privacy to discuss sensitive issues was a concern for some groups. In study communities, program reach was 58% of rural adults, 70% of adolescents and nearly all hospital workers. Session records confirmed that all peer groups received the intended six sessions (dose delivered). The dose received was high, as evidenced by high participant engagement in peer group activities. Peer leaders were rated above the median for three indicators of peer group content and process fidelity: session management skills, interpersonal facilitation skills and whether more like a peer group than classroom. Documenting that this HIV prevention peer group intervention was delivered as intended by trained peer volunteers supports widespread dissemination of the intervention.

IMPACT OF A PEER-GROUP INTERVENTION ON OCCUPATION-RELATED BEHAVIORS FOR URBAN HOSPITAL WORKERS IN MALAWI

&NA; Using a pre‐ and posttest design with no control group, the authors evaluated the impact of a peer‐group intervention on work related knowledge and behavior for health workers at an urban hospital in Malawi. The authors surveyed unmatched random samples of health workers, observed workers on the job, and interviewed clients about hospital services at baseline and at 6 months after the intervention. Universal precautions knowledge, reported hand washing, and reported client teaching were significantly higher at the final evaluation. The outcome differences remained robust in multivariate analyses with controls for demographic factors of age, gender, education, food security, and job category. Observations reported consistently greater use of universal precautions, more respectful interactions, and more client teaching at final evaluation. Patient surveys reported more discussion with health workers about HIV at the final evaluation. Peer‐group interventions can prepare health workers in Malawi for HIV prevention and offer a potential model for other African countries.

Short-term effects of a peer group intervention for HIV prevention among trainee teachers in Malawi.

This report describes the implementation and short-term results of a peer group intervention for HIV prevention on the HIV-related attitudes, knowledge and behaviours of primary school teachers in Malawi. The intervention, based on the social-cognitive learning model, took place in 2000 at two teacher training colleges with a distance-learning programme. Primary school teachers attending a final six-week training session before certification volunteered to participate. Group leaders were teachers selected by each group, and after training they facilitated the peer group intervention. The teachers completed a pre-test and post-test questionnaire. The 286 trainee teachers whose pre- and post-test samples could be matched, largely reported positive changes in their HIV-prevention-related knowledge, attitudes, self-efficacy, behaviour change and condom-use intentions. However, at post-test immediately after the intervention they did not show a higher level of perceived-risk, a greater hope that people could change their high-risk sexual behaviour, or greater agreement that persons infected with HIV should be allowed in public places. This research demonstrates the feasibility of an HIV-prevention intervention for primary school teachers during their training. The Malawi Ministry of Education has since made the programme available to over 90 per cent of all trainee teachers through an NGO.

Empowering Peer Group Leaders for HIV Prevention in Malawi

PURPOSE Behavioral change interventions using peer group leaders are effective and widely used, but few studies have examined how being a peer group leader affects the leaders. This study describes how participants felt being a peer group leader affected their lives. DESIGN This descriptive qualitative study interviewed 18 experienced peer group leaders who had conducted a multisession human immunodeficiency virus (HIV) prevention peer group intervention in rural Malawi. METHODS We used inductive content analysis and comparisons within and between cases. FINDINGS Three major themes were identified. All leaders said they experienced personal changes in their knowledge, attitudes, or HIV prevention behaviors. They described interacting with family, neighbors, and friends, and speaking at church or community meetings, to discuss HIV prevention issues. They increased their self-efficacy to engage others in sensitive HIV prevention issues, developed a self-identity as a change agent, and came to be recognized in their community as trustworthy advisors about HIV and acquired immunodeficiency syndrome. These three themes, taken together, form the meta-theme of psychological empowerment. CONCLUSION Being a peer group leader empowered the leaders as change agents for HIV prevention and had impacts in the community after the intervention ended, potentially increasing the long-term effectiveness and cost effectiveness of peer group interventions. CLINICAL RELEVANCE Healthcare workers and community volunteers who led HIV prevention sessions continued HIV prevention activities in the community and workplace after the program ended. Training health workers as volunteer HIV prevention leaders offers a strategy to bring HIV prevention to limited-resource settings, despite health worker shortages.

HIV Risk Reduction Intervention for Rural Adolescents in Malawi

Malawian adolescents are at risk for HIV infection. Using a quasi-experimental two-group research design, we determined the efficacy of Mzake ndi Mzake Kuunikira Achinyamata (MMKA) in enhancing 13- to 19-year-old Malawian males’ and females’ HIV knowledge, attitude about HIV, self-efficacy for condom use and for safer sex, and HIV risk reduction behaviors. The regression analyses revealed that compared with their cohorts in the control community, the adolescents in the MMKA community had significantly better scores on the outcome variables. The intervention had significant benefits for male and 16- to 19-year-old adolescents but not for 13- to 15-year-old female adolescents. Tailored interventions are needed for these females.