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1. THE IMPACT OF YOUTH FRIENDLY HEALTH SERVICES ON PREGNANCY RISK AMONG ADOLESCENT GIRLS AND YOUNG WOMEN IN LILONGWE, MALAWI

Creator:
Graybill, Lauren
Date of publication:
2023
Abstract:
In 2020, approximately 22 million adolescent girls and young women aged 15-24 (AGYW) in sub-Saharan Africa (SSA) became pregnant, 45% of which were unintended. Interventions that enhance contraceptive use in this population may reduce risk of early and unintended pregnancy. Using rigorous epidemiologic methods, we investigated if—and how—access to youth-friendly health services (YFHS) shaped pregnancy risk among participants in the Girl Power study. In 2016, Girl Power assigned four government-run health clinics in Lilongwe, Malawi, to offer either standard of care (SOC; n=1) or YFHS (n=3). Each clinic enrolled 250 AGYW and followed them for 12 months. In Aim 1, we used longitudinal data on sexual activity and contraceptive use to evaluate the impact of YFHS on the probability of sustained pregnancy protection. Sustained pregnancy protection, defined as sustained use of contraception or abstinence over 12 months, was more common under YFHS than under SOC (45.7% vs 38.5%; RD: 7.2%, 95% CI: -2.6%, 17.0%). The effect of YFHS was concentrated among participants who were married and those with children, and was driven by greater sustained use of non-barrier methods of contraception among participants with access to YFHS than those in the SOC. In Aim 2, we leveraged longitudinal data on pregnancy (based self-report and results from urine pregnancy tests) to evaluate the impact of YFHS on the 12-month probability of pregnancy among study participants. Because of missing pregnancy test results, we used multiple imputation to correct for outcome misclassification in self-reported pregnancy status. After correcting for outcome misclassification, the probability of pregnancy was lower under the YFHS model of service delivery than under the SOC (15.8% vs. 23.2%; RD: -7.3%, 95% CI: -15.5%, 0.8%). Pregnancies were concentrated among participants who did not sustain pregnancy protection over the 12-month study period. Overall, our findings suggest that YFHS can improve contraceptive behaviors and decrease pregnancy risk, supporting ongoing efforts to introduce and expand access to YFHS in SSA. Future research is needed to identify interventions that enhance demand for contraception among unmarried and nulliparous AGYW, and to identify effective strategies for bringing YFHS to scale in SSA.
Resource type:
Dissertation

2. THREE ESSAYS ON SCHOOLING, LABOR ALLOCATION, AND GRADUATION OUT OF POVERTY: EVIDENCE FROM A CASH TRANSFER PROGRAM IN MALAWI

Creator:
Sirma, Paul
Date of publication:
2023
Abstract:
This dissertation deepens our understanding of the short- and long-term impacts of a national cash transfer program in Africa. In three chapters, I summarize the effects of the Government of Malawi’s most extensive poverty alleviation program—the Malawi Social Cash Transfer Program (SCTP)—which provides unconditional cash transfers (UCT) to the poorest eight percent of the population in rural Malawi. In the first chapter, I follow children of the SCTP beneficiaries over eight years to show how cash transfers affected their school enrollment and grade attainment. The second chapter extensively analyzes the impacts of the UCT in Malawi on agricultural production. In this chapter, I show how transfers caused households to change their labor allocation and how these adjustments impacted their agricultural productivity. Finally, in the third chapter, I grapple with the ‘graduation’ question—precisely, whether the UCT in Malawi can move households out of poverty.
Resource type:
Dissertation

3. Assessing the role of depression-related stigma in depression care in Malawi

Creator:
Dussault, Josée
Date of publication:
2022
Abstract:
Globally, depression is prevalent and burdensome. People with depression that hold stigmatizing beliefs related to their condition are at higher risk of never seeking treatment and/or falling out of treatment after initial engagement, posing significant risks to depression recovery. Research in the U.S. found a reduction in stigma after patients engaged in supportive counseling compared to other treatment methods for depression. There has not been much research on mental health stigma in Malawi. Therefore, using data from the Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity Building scale-up trial, this dissertation expands upon ongoing depression-related implementation science research efforts in the region by exploring the role of stigma during depression care. Patients in the cohort (N=743) were largely treatment-naïve and had depressive symptoms indicated by the Patient Health Questionnaire-9. This dissertation aimed to 1) estimate the effect of baseline anticipated treatment-related stigma on the 3-month probability of depression remission and 2) estimate the association between referral to clinically appropriate problem-solving based therapy and internalized depression stigma three months later. We found that the probability of achieving depression remission at the 3-month interview among participants with high anticipated treatment-related stigma (0.31; 95% Confidence Interval [CI]: 0.23, 0.39)) was 10 percentage points lower than among patients who had low or neutral levels of anticipated treatment-related stigma (risk: 0.41; 95% CI: 0.36, 0.45; RD: -0.10; 95% CI: -0.19, -0.003). In our analysis of the effect of counseling referral on 3-month probability of having high internalized depression stigma, we found that the probability of high internalized stigma was 33 percentage points greater (95% Confidence Interval [CI]: 0.16, 0.50) among patients who were referred to counseling (0.43; 95% CI: 0.32, 0.55) compared to those who were not referred to counseling (0.10; 95% CI: -0.10, 0.30). Taken together, the results from this dissertation highlight 1) the critical role that treatment-related stigma plays in the path to depression recovery, 2) the lack of adequate solutions currently being implemented to address internalized stigma during depression treatment, and 3) the potential impact of an intervention targeting depression-related stigma among patients receiving depression care in Malawi.
Resource type:
Dissertation

4. DISABILITY, CAREGIVER ABILITY, AND THE IMPACT OF CASH TRANSFER PROGRAMS ON CHILD-LEVEL OUTCOMES

Creator:
Silverstein, Hannah
Date of publication:
2022
Abstract:
About 15% of the global population have disabilities, roughly equal to one billion people.1 Cash transfer (CT) programs aim to interrupt cycles of poverty and often explicitly include people with disabilities (PWD), but there is little research investigating how CT impacts may vary depending on ability and limitations. Therefore, this dissertation strives to answer this overarching question: Is there heterogeneity in CT impacts on children that vary depending on the abilities of the members in their households? The first analysis explores how CT impacts on child physical health and access to material needs are differentiated by household disability status in both the Malawi’s Social Cash Transfer (SCT) program and Zambia’s Child Grant Program (CGP). I use differences-in-differences-in-differences models to estimate disability-differential impacts of both programs on child health, access to material needs, and nutritional status. Results show that CTs reduce the prevalence of illness more among children living in households of people with disabilities compared to children living in households without disabilities. The programs similarly and significantly improve access to material needs among children living in households with and without disabilities.The second analysis takes a more in-depth look at how the relationship between caregiver cognitive skills and child cognitive development might be changed by the Zambia CGP. Using multiple statistical strategies, I find that the CT improves cognitive development for children of caregivers with lower scores at the 24-month follow-up survey, particularly among children who have not yet attended school. Likely because of measurement and score estimation challenges at later survey waves, as well as increasing school attendance, results do not indicate CT impacts on child development were sustained long term. Together, both analyses suggest that children who live in households with disabilities or who have caregivers who experience more limitations are most impacted by CTs in terms of health and developmental outcomes. This research fills a gap in the CT literature and could be used to inform the targeting of social protection policy to maximize benefits to children.
Resource type:
Dissertation

5. The Effect of Incentive Spirometry on Postoperative Pulmonary Function Following Laparotomy: A Randomized Clinical Trial

Creator:
Cairns, Bruce A., Tyson, Anna F., Kendig, Claire E., Mabedi, Charles, and Charles, Anthony G.
Date of publication:
2015
Abstract:
IMPORTANCE: Changes in pulmonary dynamics following laparotomy are well documented. Deep breathing exercises, with or without incentive spirometry, may help counteract postoperative decreased vital capacity; however, the evidence for the role of incentive spirometry in the prevention of postoperative atelectasis is inconclusive. Furthermore, data are scarce regarding the prevention of postoperative atelectasis in sub-Saharan Africa. OBJECTIVE: To determine the effect of the use of incentive spirometry on pulmonary function following exploratory laparotomy as measured by forced vital capacity (FVC). DESIGN, SETTING, AND PARTICIPANTS: This was a single-center, randomized clinical trial performed at Kamuzu Central Hospital, Lilongwe, Malawi. Study participants were adult patients who underwent exploratory laparotomy and were randomized into the intervention or control groups (standard of care) from February 1 to November 30, 2013. All patients received routine postoperative care, including instructions for deep breathing and early ambulation. We used bivariate analysis to compare outcomes between the intervention and control groups. INTERVENTION: Adult patients who underwent exploratory laparotomy participated in postoperative deep breathing exercises. Patients in the intervention group received incentive spirometers. MAIN OUTCOMES AND MEASURES: We assessed pulmonary function using a peak flow meter to measure FVC in both groups of patients. Secondary outcomes, such as hospital length of stay and mortality, were obtained from the medical records. RESULTS: A total of 150 patients were randomized (75 in each arm). The median age in the intervention and control groups was 35 years (interquartile range, 28-53 years) and 33 years (interquartile range, 23-46 years), respectively. Men predominated in both groups, and most patients underwent emergency procedures (78.7% in the intervention group and 84.0% in the control group). Mean initial FVC did not differ significantly between the intervention and control groups (0.92 and 0.90 L, respectively; P=.82 [95% CI, 0.52-2.29]). Although patients in the intervention group tended to have higher final FVC measurements, the change between the first and last measured FVC was not statistically significant (0.29 and 0.25 L, respectively; P=.68 [95% CI, 0.65-1.95]). Likewise, hospital length of stay did not differ significantly between groups. Overall postoperative mortality was 6.0%, with a higher mortality rate in the control group compared with the intervention group (10.7% and 1.3%, respectively; P=.02 [95% CI, 0.01-0.92]). CONCLUSIONS AND RELEVANCE: Education and provision of incentive spirometry for unmonitored patient use does not result in statistically significant improvement in pulmonary dynamics following laparotomy. We would not recommend the addition of incentive spirometry to the current standard of care in this resource-constrained environment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01789177.
Resource type:
Article

6. What Happens to Contraceptive Use After Injectables Are Introduced? An Analysis of 13 Countries

Creator:
Sutherland, Elizabeth G., Otterness, Conrad, and Janowitz, Barbara
Date of publication:
2011
Abstract:
Although the introduction of a new method is generally hailed as a boon to contraceptive prevalence, uptake of new methods can reduce the use of existing methods. It is important to examine...
Resource type:
Article

7. Plasma Micronutrient Concentrations Are Altered by Antiretroviral Therapy and Lipid-Based Nutrient Supplements in Lactating HIV-Infected Malawian Women

Creator:
Zgambo, Innocent, Ryan, Mairin, Fiscus, Susan, Ahmed, Yusuf, Davis, Nicole L., Spensley, Allison, Musis, Bonface, Waalberg, Esther, Kumwenda, Jacob, Boyle, Nicola, Meme, Joyce, Allen, Lindsay H., Mkomawanthu, Chimwemwe, Zimba, Chifundo, Bramson, Brian, Chome, Lenesi, Albrecht, Sandra, van der Horst, Charles, Marcus, Cheryl, Chikhungu, Norah, Raines, Byron, Mumba, Noel, Sellers, Christopher, Mayers, Douglas, Jordan-Bell, Elizabeth, Duerr, Ann, Tegha, Gerald, Daza, Eric J., Long, Dustin, Hudgens, Michael, Nkhoma, Jacqueline, Kamthunzi, Portia, Thomas, Roshan, Kacheche, Zebrone, Hoffman, Irving, Snowden, Wendy, Chikasema, Maria, Lee, Hana, Majawa, Maganizo, Mndala, Ibrahim, Shahab-Ferdows, Setarah, Fokar, Ali, Bentley, Margaret E., Tohill, Beth, Parker, Megan, Tien, Hsiao Chuan, Dow, Anna, Eron, Joseph, Farr, Sherry, Ellington, Sascha, Msika, Albans, Flax, Valerie L., Hooten, Elizabeth, Soko, Alice, Cole, Anne, Mwansambo, Charles, Kathyola, Damson, Mita, Khama, Mndala, Gertrude, Kashuba, Angela, Msungama, Wezi, Wilfert, Cathy, Kayira, Dumbani, Butera, Sal, Sichali, Dorothy, Tembo, Martin, Kampani, Coxcilly, Kamanga, Esmie, Steens, Jean Marc, Piwoz, Ellen, Chiudzu, Grace, Madhlopa, Victor, Chasela, Charles S., Jamieson, Denise, Sanne, Ian, Heilig, Chad, Hyde, Lisa, Jamieson, Denise J., Luhanga, Misheck, Kourtis, Athena P., Ait-Khaled, Mounir, Joaki, George, Shugars, Diane, Bobrow, Emily, Mayuni, Isabel, Maida, Alice, Krysiak, Robert, Hampel, Daniela, Guay, Laura, Kamanga, Gift, Galvin, Shannon, Rublein, John, Wiyo, Patricia, Chigwenembe, Maggie, Pendame, Richard, Knight, Rodney, van der Horst, Charles M., Adair, Linda S., McDonough, Marita, Mwapasa, Gerald, Bayer, Ronald, Corneli, Amy, King, Caroline C., Chimerang'ambe, Joseph, Mtimuni, Beatrice, Kazembe, Peter, Thoofer, Navdeep, Chilongozi, David, Ramdas, Zane, Corbett, Amanda, Kanyama, Cecilia, Wiener, Jeffrey, Ferguson, Yvonne Owens, Widen, Elizabeth, Loeliger, Edde, Muita, Jane, Bangdiwala, Shrikant, Eliya, Henry, Chavula, Charity, Matiki, Chrissie, Hosseinipour, Mina, Jones, David, Kamwendo, Deborah, Merry, Ceppie, Martinson, Francis, Moses, Agnes, and Hurst, Stacy
Date of publication:
2015
Abstract:
Background: Little is known about the influence of antiretroviral therapy with or without micronutrient supplementation on the micronutrient concentrations of HIV-infected lactating women in resource-constrained settings.
Resource type:
Article

8. Measuring Geospatial and Longitudinal Trends in Malaria Using National Health Surveillance Data in Malawi

Creator:
Topazian, Hillary
Date of publication:
2021
Abstract:
Malaria is a significant cause of morbidity and mortality in Malawi, accounting for 30% of outpatient visits. Children report the highest rates of disease, but adults are thought to be an important reservoir to sustained transmission due to persistent asymptomatic infection. However, national malaria measures have been exclusively estimated through Malaria Indicator Surveys which only offer a regional cross-sectional glance at parasite prevalence among children. Malaria is geographically and temporally heterogeneous, making it necessary to understand local and longitudinal transmission patterns before planning targeted interventions. Long-lasting insecticide treated bed nets (LLINs) are integral to Malawi’s malaria prevention efforts and are allocated to households every 3-years through mass distribution campaigns. Evidence suggests that the maximum protective lifespan of LLINs is 1-3-years, but a national longitudinal evaluation has never been conducted in Malawi.The 2015-2016 Malawi Demographic and Health Survey (MDHS) was a nationally representative household survey of asymptomatic individuals ages 15-54. We analyzed 7,393 survey samples, detecting a P. falciparum prevalence of 31.1%. Protective factors included urbanicity, greater wealth, higher education, and lower environmental temperatures, but living in a household with a bed net and sleeping under an LLIN were not protective against infection. To assess clinical malaria over time, we used District Health Information Software 2 (DHIS2) data from January 2018 to June 2020, capturing monthly aggregate reports of confirmed cases from 711 health facilities across Malawi. We found that risk varied at the health facility level and was highest from January to May. Risk decreased one high transmission season following distribution of 10.7 million LLINs and rebounded after two seasons, indicating that LLINs only have a lifespan of 1-2-years. Piperonyl butoxide-treated nets performed better than pyrethroid-treated nets and LLIN effectiveness varied geographically.Our findings demonstrate a high parasite prevalence among adults, highlighting this population as an important reservoir to sustained transmission. LLINs have a 1-2-year lifespan and insecticide type influences effectiveness. Use of molecular surveillance to supplement ongoing passive data collection creates a natural opportunity to track how large-scale changes affect malaria over time and provide valuable insight to the Malawi Ministry of Health as they plan future interventions. 
Resource type:
Dissertation

9. Sex Differences in Interpersonal Violence in Malawi: Analysis of a Hospital-Based Trauma Registry

Creator:
Samuel, Jonathan, Eichelberger, Kacey, Mkwaila, Judith, Escamilla, Veronica, Charles, Anthony, Kiser, Michelle, and Cairns, Bruce
Date of publication:
2013
Abstract:
Although interpersonal violence (“assault”) exists in every society, the World Health Organization (WHO) estimated that 90 % of the exposure burden occurs in low- and middle-income countries. The objectives of this study were to define the incidence of assault-related injuries among subjects presenting for emergency room care secondary to sustained trauma in Lilongwe, Malawi; to measure the impact of sex on incidence, injury type, and care received; and to measure the effect of both sex and geographic location of the injury on time to presentation for medical care.
Resource type:
Article

10. HIV Testing and Epidemiology in a Hospital-Based Surgical Cohort in Malawi

Creator:
Nonsa, Dominic, Matoga, Mitch, LaCourse, Sylvia M., Haac, Bryce E., Hosseinipour, Mina, and Charles, Anthony G.
Date of publication:
2013
Abstract:
Despite the high prevalence of HIV in adults (11 %) in Malawi, testing among surgical patients is not routine. We examined the feasibility of universal opt-out HIV testing and counseling (HTC) on the surgical wards of Kamuzu Central Hospital in Lilongwe, Malawi, and sought to further delineate the role of HIV in surgical presentation and outcome.
Resource type:
Article