Tracy Morse

Incidence of cryptosporidiosis species in paediatric patients in Malawi

We determined the incidence of cryptosporidiosis in children aged <5 years presenting with diarrhoea in an urban and rural hospital-based setting in Malawi. Stools were collected over a 22-month period during both rainy and dry seasons. A range of microscopic methods were used to determine the presence of Cryptosporidium spp. oocysts. Species determination was by polymerase chain reaction–restriction fragment length polymorphism (PCR–RFLP) of oocyst-extracted DNA using 18S rRNA and COWP gene loci. Cryptosporidium spp. oocysts were seen in 5.9% (50/848) of samples, of which 43 amplified by PCR–RFLP indicated the following species: C. hominis, C. parvum, C. hominis/C. parvum, C. meleagridis and C. andersoni. Seven samples could not be amplified by PCR. Wider species diversity was found in the rural setting, and may be a result of increased malnutrition and zoonotic exposure in this area. Improvements in water, sanitation, household hygiene and animal control are required to reduce the incidence of infection in this population.

Household and community variations and nested risk factors for diarrhoea prevalence in southern Malawi: a binary logistic multi-level analysis.

This paper examines household and community-level influences on diarrhoeal prevalence in southern Malawi. A Bayesian multi-level modelling technique is used in the estimation of hierarchically built data from a survey of individuals nested within households nested within communities. Households have strong unobserved influence on diarrhoeal illness ( = 4.476; 95% CI: 2.081, 6.871). A joint Wald test of significance shows that an individuals age [ ] and school [ ] have strong influence on an individuals diarrhoeal prevalence. An individuals history of malarial-like illness also has a strong positive relationship with diarrhoeal prevalence [β = 0.606, p = 0.000]. Household factors that influence diarrhoea include employment status of head of household [β = −0.619, p < 0.021], maternal age [β = −0.013, p < 0.003], and size of household [β = −0.669, p = 0.000]. The positive relationship between diarrhoea and malaria-like episodes highlights common risk factors hence the need for common approaches to combat the diseases. Significant household effects underline the importance of household considerations in policy issues.

Pattern of Maternal Knowledge and Its Implications for Diarrhoea Control in Southern Malawi: Multilevel Thresholds of Change Analysis

A survey was conducted in Southern Malawi to examine the pattern of mothers’ knowledge on diarrhoea. Diarrhoea morbidity in the district is estimated at 24.4%, statistically higher than the national average at 17%. Using hierarchically built data from a survey, a multilevel threshold of change analysis was used to determine predictors of knowledge about diarrhoeal aetiology, clinical features, and prevention. The results show a strong hierarchical structured pattern in overall maternal knowledge revealing differences between communities. Responsible mothers with primary or secondary school education were more likely to give more correct answers on diarrhoea knowledge than those without any formal education. Responsible mothers from communities without a health surveillance assistant were less likely to give more correct answers. The results show that differences in diarrhoeal knowledge do exist between communities and demonstrate that basic formal education is important in responsible mother’s understanding of diseases. The results also reveal the positive impact health surveillance assistants have in rural communities.

Knowledge, awareness and practice of the importance of hand-washing amongst children attending state run primary schools in rural Malawi

A study was undertaken to determine the efficacy of hygiene practices in 2 primary schools in Malawi. The study determined: (1) presence of Escherichia coli on the hands of 126 primary school pupils, (2) knowledge, awareness and hygiene practices amongst pupils and teachers and (3) the school environment through observation. Pupil appreciation of hygiene issues was reasonable; however, the high percentage presence of E. coli on hands (71%) and the evidence of large-scale open defaecation in school grounds revealed that apparent knowledge was not put into practice. The standard of facilities for sanitation and hygiene did not significantly impact on the level of knowledge or percentage of school children’s hands harbouring faecal bacteria. Evidence from pupils and teachers indicated a poor understanding of principles of disease transmission. Latrines and hand-washing facilities constructed were not child friendly. This study identifies a multidisciplinary approach to improve sanitation and hygiene practices within schools.

Assessment of implementation of the health management information system at the district level in southern Malawi

Background Despite Malawis introduction of a health management information system (HMIS) in 1999, the countrys health sector still lacks accurate, reliable, complete, consistent and timely health data to inform effective planning and resource management. Methods A cross-sectional survey was conducted wherein qualitative and quantitative data were collected through in-depth interviews, document review, and focus group discussions. Study participants comprised 10 HMIS officers and 10 district health managers from 10 districts in the Southern Region of Malawi. The study was conducted from March to April 2012. Quantitative data were analysed using Microsoft Excel and qualitative data were summarised and analysed using thematic analysis. Results The study established that, based on the Ministry of Healths minimum requirements, 1 out of 10 HMIS officers was qualified for the post. The HMIS officers stated that HMIS data collectors from the district hospital, health facilities, and the community included medical assistants, nurse-midwives, statistical clerks, and health surveillance assistants. Challenges with the system included inadequate resources, knowledge gaps, inadequacy of staff, and lack of training and refresher courses, which collectively contribute to unreliable information and therefore poorly informed decision-making, according to the respondents. The HMIS officers further commented that missing values arose from incomplete registers and data gaps. Furthermore, improper comprehension of some terms by health surveillance assistants (HSAs) and statistical clerks led to incorrectly recorded data. Conclusions The inadequate qualifications among the diverse group of data collectors, along with the varying availability and utilisation different data collection tools, contributed to data inaccuracies. Nevertheless, HMIS was useful for the development of District Implementation Plans (DIPs) and planning for other projects. To reduce data inconsistencies, HMIS indicators should be revised and data collection tools should be harmonised.

Transdisciplinarity as an emergent property in an agricultural research-for-development project on the East India Plateau

Transdisciplinary Research and Practice for Sustainability Outcomes examines the role of transdisciplinarity in the transformations needed for a sustainable world. After an historical overview of transdisciplinarity, Part 1 focuses on tools and frameworks to achieve sustainability outcomes in practice and Part 2 consolidates work by a number of scholars on supporting transdisciplinary researchers and practitioners.Part 3 is a series of case studies including several international examples that demonstrate the challenges and rewards of transdisciplinary work. The concluding chapter proposes a future research pathway for understanding the human factors that underpin successful transdisciplinary research.

Care-seeking behaviour and implications for malaria control in southern Malawi

Although malaria is a controllable and preventable disease, it remains among the leading causes of mortality and morbidity in southern Malawi. The importance of early diagnosis and prompt treatment with hospital prescribed drugs and effective home management to control malaria is well established; however, these in part depend on how households make their decisions when family members have suffered from malaria. This study examines the behaviour of households with regard to decisions they make in managing malaria illness. Using hierarchically built data from a survey of 1,400 mothers nested within 33 communities, a series of two-level logistic regression models with Bayesian estimation was used to determine predictors of care-seeking behaviour towards malaria when a family member or a child was perceived to have malaria. The results show that most families normally visit or use medication prescribed at health facilities for both adult (80%) and child (86%) members when they are perceived to have malaria. The main obstacle to accessing the nearest health facility was distance and transport costs (73%) and the main problems encountered at health facilities were long waiting time or absence of health workers (73%) and shortage of drugs (35%). Among the main predictor variables for choices of treatment for childhood malaria was the absence of a health surveillance assistant for those that visited hospitals [β=0.56; 95% CI:-0.86,-0.26]; bought medication from open markets [β=0.51; 95% CI:0.20,0.82]; and those that used other traditional methods or did nothing [β=0.70; 95% CI:-0.04,1.44; p=0.06].. The results have an important role to play in the control and prevention of malaria in Malawi. The results reveal the need for increased awareness about the dangers of purchasing drugs from non-medical and/or uncertified private institutions and sources such as those found in open markets. They also show the important role of community health workers in the delivery of health systems. The study recommends empowerment of community health workers through rigorous and relevant health promotion programmes to update both their knowledge and their skills in communication and counselling.

Care-Seeking for Diarrhoea in Southern Malawi: Attitudes, Practices and Implications for Diarrhoea Control

This paper examined care-seeking behaviour and its associated risk factors when a family member had diarrhoea. Data was obtained from a survey conducted in Chikwawa, a district in Southern Malawi. Chikwawa is faced with a number of environmental and socioeconomic problems and currently diarrhoea morbidity in the district is estimated at 24.4%, statistically higher than the national average of 17%. Using hierarchically built data from a survey of 1403 households nested within 33 communities, a series of two level binary logistic regression models with Bayesian estimation were used to determine predictors of care-seeking behaviour. The results show that 68% of mothers used oral rehydration solutions (ORS) the last time a child in their family had diarrhoea. However, when asked on the action they take when a member of their household has diarrhoea two thirds of the mothers said they visit a health facility. Most respondents (73%) mentioned distance and transport costs as the main obstacles to accessing their nearest health facility and the same proportion of respondents mentioned prolonged waiting time and absence of health workers as the main obstacles encountered at the health facilities. The main predictor variables when a member of the family had diarrhoea were maternal age, distance to the nearest health facility, school level, and relative wealth, household diarrhoea endemicity, and household size while the main predictor variables when a child had diarrhoea were existence of a village health committee (VHC), distance to the nearest health facility, and maternal age. Most households use ORS for the treatment of diarrhoea and village health committees and health surveillance assistants (HSAs) are important factors in this choice of treatment. Health education messages on the use and efficacy of ORS to ensure proper and prescribed handling are important. There is need for a comprehensive concept addressing several dimensions of management and proper coordination of delivery of resources and services; availability of adequate healthcare workers at all levels; affordability to accessibility of healthcare resources and services to all communities; acceptability and quality of care; intensification of health education messages on the use and management of ORS, and prompt and timely treatment of diarrhoeal illness.

The Pattern of Variation between Diarrhea and Malaria Coexistence with Corresponding Risk Factors in, Chikhwawa, Malawi: A Bivariate Multilevel Analysis

Developing countries face a huge burden of infectious diseases, a number of which co-exist. This paper estimates the pattern and variation of malaria and diarrhea coexistence in Chikhwawa, a district in Southern Malawi using bivariate multilevel modelling with Bayesian estimation. A probit link was employed to examine hierarchically built data from a survey of individuals (n = 6,727) nested within households (n = 1,380) nested within communities (n = 33). Results show significant malaria [σu12=0.901 (95% CI:0.746,1.056)] and diarrhea [σu22=1.009 (95% CI:0.860,1.158)] variations with a strong correlation between them [ru(1,2)=0.565] at household level. There are significant malaria [σv12=0.053(95% CI:0.018,0.088)] and diarrhea [σv22=0.099(95% CI:0.030,0.168)] variations at community level but with a small correlation [rv(1,2)=0.124] between them. There is also significant correlation between malaria and diarrhea at individual level [re(1,2)=0.241]. These results suggest a close association between reported malaria-like illness and diarrheal illness especially at household and individual levels in Southern Malawi.

Social capital insights from Healthy Settings needs assessment in Malawi

Despite global health improvements, substantial challenges in social determinants of health and poverty remain in rural communities in low-income countries. Public health theorists suggest that communities with high social capital are less vulnerable to such challenges and more likely to participate in community development. This research examines levels of social capital amongst rural communities in southern Malawi through data gathered as part of a participatory needs assessment for a Healthy Settings project, and discusses the potential benefits of having access to such data before project implementation. Social capital data was collected during 108 focus group discussions in 18 communities (split by gender, age, status) by adapting an existing mixed methods measurement tool, the Schutte tool. Five indicators were measured: sense of belonging, friendship, reliance, ability to work together and influence. Mean results showed all 18 communities had medium-high levels of social capital. Means from each group in the 18 communities highlighted the lowest social capital among the youth groups and the highest with the leaders. A more detailed breakdown highlighted that all groups had a strong sense of belonging to the community, while youth and women had lower social capital levels in terms of influence over local decisions and ability to rely on other community members. Incorporating social capital tools into community health needs assessments in low-income settings provides a valuable overview of community dynamics before project implementation, and Monitoring & Evaluation indicators which allow changes in social capital to be measured at different stages of the project.