Protocols

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Assessing nursing students’ approaches to learning in selected nursing schools in Malawi
(Kamuzu University of Health Sciences, 2021-01-13) Zolowere, Dalitso
Study type: This will be a quantitative cross-section study. Problem to be studied: Students’ approaches to learning are vital in nursing education. This is because nursing is a profession where classroom learning leads to clinical performance. Literature recognizes the student’s approaches to learning as a significant aspect affecting the quality of student’s learning. A student’s adopted approach to learning affects the student’s ability to acquire critical thinking, problem solving and lifelong learning which in turn aids nursing students and nurses to tackle various challenges in diverse clinical settings. Consequently, it affects positive health outcomes in health care consumers. In Malawi, nursing and midwifery technicians are a largest nursing workforce, however, there is scarcity of empirical data on learning approaches that Malawian nursing and midwifery technician students in nursing colleges employ. This study therefore, seeks to establish learning approaches that Malawian nursing and midwifery technician students employ. Study objective: The main objective of this study is to assess the different approaches to learning among nursing and midwifery technician students in selected Malawian nursing colleges. It will specifically identify approaches to learning adopted by nursing and midwifery technician students in selected nursing colleges in Malawi. It will also measure the association between demographic characteristics of the nursing and midwifery technician students and their adopted approaches to learning in selected nursing colleges in Malawi. The study will further specifically assess the association between the assessment the nursing and midwifery technician students pass through and the adopted approaches to learning in selected nursing colleges in Malawi. Methodology: This will be a cross- sectional study that will employ quantitative methods. The target population is nursing and midwifery technician students in year one, two and three from Nkhoma College of Nursing, Ekwendeni College of Health Sciences and Malawi College of Health Sciences. A total of 253 students will be sampled from the three nursing colleges. Data will be collected through a self-administered questionnaire and will be analyzed using SPSS version 22.0. To ensure adherence to ethical standards the research proposal will be submitted to COMREC for ethical approval. Furthermore, throughout the process of conducting the research, confidentiality, beneficence, respect for human dignity and justice will be strictly observed. Dissemination of results: The findings from this study will be disseminated at the selected colleges. In addition, the findings will be submitted to Kamuzu College of Nursing and COMREC in form of a report (thesis) and further be published in peer reviewed journals after authorization. Furthermore, the thesis will be shared with KCN libraries for both campuses so that it can be used for educational purposes.
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Assessing the knowledge and attitudes of University of Malawi female undergraduate students on cervical cancer screening
(Kamuzu University of Health Sciences, 2021-01-05) Matola, Esmy; Kachitsamba, Yamikani; Katengeza, Kholiwe
Cervical cancer is the 4th most common cancer among women worldwide[1]. Once diagnosed, about 80% of the women die prematurely. This is mostly because they present to the hospital very late when the cancer is in its advanced stage when there is nothing much that medical practitioners can do. These are deaths that could be avoided if women went for cervical cancer screening. There are so many reasons why women do not go for cervical cancer screening one of which is lack of knowledge about cervical cancer and screening. University female undergraduate students are at a risk of developing cervical cancer later on in their lives due to the various risk factors that they are exposed to. Some of them being multiple sexual partners and early sexual debut. College education in Malawi does not offer a greater access to health education specifically about cervical cancer to the female students. Therefore, there is little knowledge about cervical cancer which may have an impact on cervical cancer screening. This study aims to assess the knowledge and attitudes that these female university students have about cervical cancer and screening. This is going to be a cross sectional quantitative study targeting female undergraduate students in the University of Malawi (College of Medicine, Kamuzu College of nursing, Polytechnic and Chancellor College) aged 21 to 29. Data will be collected using self-administered questionnaires where the participants will fill and resubmit to the researchers. The expectation is that this study will reveal the different levels of knowledge that these university female undergraduate students have on cervical cancer , and screening. The reasons for the variation in the levels of knowledge will be fully understood during data analysis. Data will be presented in tables, pie charts and graphs.
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Burden and associated factors among caregivers of people with mental illness receiving treatment at Saint John of God Hospitaller Lilongwe services
(Kamuzu University of Health Sciences, 2021-03-04) Mainjeni, Angella
Background/introduction: Mental, neurological and substance use disorders are major contributors to morbidity and premature mortality throughout the world. Over 10% of the global burden of disease, measured in terms of years of healthy life lost, can be attributed to these disorders. Family members play an important role in providing care to their relatives with mental illness. Family caregivers are responsible for adopting certain duties and responsibilities that are in excess of those normally associated with a family role at a particular stage of life hence this might be burdensome. Burden of caregiving is any unwanted or negative consequences experienced by caregivers of people with mental illness (PWMI) as a result of taking care of and the responsibility for PWMI. Studies have shown there is relationship between providing care to people with mental illness and experiences of different forms burden as a result of caregiving. Problem: severe and chronic mental illness has negative impact on the client himself and his family members. The longer the care giving the more burdensome it becomes and this might contribute to a lot of frustrations to those who are providing care to the mentally ill patients and this affect the care and recovery of mentally ill patients. Objectives: This study will determine the magnitude of the caregiver’s burden and establish the association of social demographic, clinical and personal characteristic associated with burden among caregivers of patients with mental illness receiving treatment at St John of God Hospitaller Lilongwe service in Malawi. Methodology: This will be cross sectional study recruiting 323 caregivers aged 18 years and above of patients receiving outpatient management for different kinds of mental illnesses at St John of God Hospitaller Lilongwe Service. Screening for caregiver burden will be done using involvement evaluation questionnaire (IEQ). 2.5 Constraints: Time may not be adequate for the researcher to collect the required data hence this may limit the study. Because of smaller sample size, it would be difficult for the findings to be generalized to other settings since the study will only be done at one facility. Participants may not be honest enough when responding to questions in fear of offending their ill relation hence this may affect study results. Expected findings: The study will establish if severe and chronic mental illness contribute to caregiver burden and also establish factors that associated with caregiver burden. Dissemination: Research findings will be disseminated to COMREC research dissemination conferences, St John of God Journal Presentations, annual Malawi -Scotland mental health conference, and will also be submitted for publishing in appropriate journals.
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Effectiveness of midwife led continuity of care (MLCC) caseload model: An interventional explanatory sequential mixed methods study at Mchinji District Hospital, Malawi
(Kamuzu University of Health Sciences, 2021-03-17) Zileni, Barbara Debra
Type of study: An interventional explanatory sequential mixed methods study that will utilize both quantitative and qualitative data collection methods and analysis. The problem: Worldwide, maternal and neonatal morbidity and mortality remain a public health concern and improving maternal and neonatal health is a key focus in most countries. The World Health Organisation (WHO) reports that in 2017 there were 295,000 women across the globe who died as a result of pregnancy related complications representing a maternal mortality ratio (MMR) of 211 deaths/100,000 live births. Similarly, 2.5 million neonates died, and the majority of these neonatal deaths were due to preterm birth (PTB) complications. Most of the maternal (66%) and neonatal (41%) deaths occurred in sub-Saharan Africa alone. Similar to other countries in sub-Saharan Africa, Malawi has high maternal and neonatal mortality ratios (439 deaths/100,000 live births and 27 deaths/1,000 live births respectively). In response, United Nations (UN) developed the 2030 Sustainable Development Goals (SDGs), to work with countries across the globe to improve development outcomes including maternal and neonatal outcomes. The SDG target 3.1 and 3.2 aim towards reducing global maternal deaths to 70 per 100,000 live births and neonatal deaths to 12 per 1000 live births by the year 2030. Similarly, the Malawi government developed strategies to improve maternal and neonatal health, however, barriers to accessing, utilising, and financing maternity services poses a challenge to improving these outcomes. To achieve these targets and end avoidable maternal and neonatal deaths, country specific interventions are needed. The antenatal period provides a first entry point within the childbirth continuum, to implement effective interventions aimed at improving maternal and neonatal health, through prevention, detection, and management of obstetric complications. Timely implementation of antenatal care (ANC) services could reduce maternal and neonatal deaths, however, statistics for sub-Saharan Africa, including Malawi, show underutilization and low attendance for ANC services. Of the 95% women who attend at least one ANC contact in Malawi, only 51% attend four or more ANC contacts, and only 24% attend the initial ANC contact during the first trimester of pregnancy. The low utilization of ANC services especially in regions with high maternal and neonatal deaths puts women at increased risk of adverse outcomes such as preterm births. The WHO developed recommendations on antenatal care for a positive pregnancy experience to help countries implement evidence-based interventions to improve maternal and neonatal health. One of the recommendation relevant to this study, is the WHO’s recommendation of Midwife Led Continuity of Care (MLCC) during pregnancy. In MLCC models women receive care from the same caregiver (caseload) or a small group of midwives (team) during the childbirth continuum. Use of MLCC models has been associated with improved ANC utilization and childbirth outcomes. Antenatal care in Malawi is based on a fragmented Standard Antenatal Care (SANC) model with care provision from different midwives and doctors. Evidence indicates that most of the current strategies, employed by Malawi in the SANC model, may not be optimal and there is a need to adopt and evaluate strategies that have worked effectively in other countries. A new modified service delivery model, the MLCC caseload model recommended by WHO, could be one strategy worth implementing and evaluating in Malawi. Although the MLCC caseload model is acceptable and effective in developed countries, no country in Africa has adopted this model to date. There is a lack of literature on the effectiveness of caseload model in developing countries and a thorough search of the literature did not return any study on caseload model in sub-Saharan Africa. Studies conducted in sub-Saharan Africa including Malawi on ANC models have concentrated on ‘group’ ANC model, a model different from WHO’s recommended caseload model. A thorough search of the literature could not find any study on caseload model in Malawi and sub-Saharan Africa. Aim and specific objectives: The main aim of the proposed study is to examine effectiveness of the caseload model in improving childbirth outcomes and explore experiences of midwives working in the model. The following specific objectives will be addressed: 1. Describe socio-demographic and obstetric characteristics of women who receive care through the caseload model with women who receive care through SANC model. 2. Examine whether a caseload model decreases rate of PTB among women when compared with SANC model 3. Compare women’s satisfaction with ANC in caseload model versus SANC model 4. Compare maternal outcomes (ANC attendance, admission to ANC ward, place of birth, labour onset, mode of birth, anaemia, malaria, antepartum haemorrhage, postpartum haemorrhage, hypertensive disorders of pregnancy, maternal death) of women who receive care in the caseload model with women who receive care in SANC model. 5. Compare other neonatal outcomes (birth weight, fetal and neonatal loss, Apgar score, admission to neonatal ward, initiation of breast feeding, initiation of skin-to-skin contact) among women who receive care in the caseload model and SANC model. 6. Explore midwives’ experiences of working in a caseload model. Methodology: An interventional explanatory sequential mixed methods study will be conducted at Mchinji District Hospital (MDH) in Malawi in two phases. In phase one, a post-test only parallel randomised clinical trial (RCT) will be conducted to test the intervention (caseload model). A sample of 1206 pregnant women aged 18 and above with a gestation of less than 20 weeks at initial ANC contact will be randomly allocated to caseload or SANC model. Data will be collected on primary and secondary outcome variables and analysed using descriptive and inferential statistical tests in Statistical Package for the Social Sciences (SPSS) version 26. Reporting of the data will follow the CONsolidated Standards of Reporting Trials (CONSORT) guidelines for reporting of RCT’s. In phase two, a qualitative descriptive design will be used to explore midwives’ experiences of working in the caseload model. All six midwives working in the caseload model will be asked to participate in individual in-depth interviews on completion of the study. NVivo software version 12 will be used to organise data using thematic analysis by identifying codes and common themes emerging. Ethical considerations such as privacy, anonymity, voluntary participation, doing no harm will be observed throughout the study period. The first ethics approval has been obtained from Curtin Human Research Ethics Committee (HRE2020-0752) and the second ethics approval will be obtained from Malawi College of Medicine Research Ethics Committee (COMREC). Permission to conduct the study at MDH has been granted by the Director of Health and Social Services, Mchinji District Health Office and the Director of Reproductive Health Services, Ministry of Health, Malawi. The RCT has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN12621000008820p). Expected findings and dissemination: The study will provide evidence on the effectiveness of the caseload model in improving childbirth outcomes and experiences of midwives working in a caseload model at Mchinji District Hospital, Malawi. Based upon the evidence around caseload model, the anticipated outcomes could include, increased number of antenatal attendances, reduced rates of PTB, reduced prevalence of Low Birth Weight (LBW) neonates, fewer admissions to high risk ANC ward, increased proportion of spontaneous vaginal births, early initiation of breastfeeding within the first hour of birth, reduced admissions to neonatal ward, reduced proportion of fetal and neonatal deaths and greater maternal satisfaction with ANC. The caseload model in this study will provide women with more information and knowledge on pregnancy, birth and postnatal, through antenatal appointments with a known trusted midwife. Furthermore, increased engagement of women with a known midwife may improve the midwife-woman relationship, increasing job satisfaction for midwives. Exploring midwives’ experiences and views could also inform policy makers in Malawi on how the model can be adapted and expanded to other settings. Study results and findings will be disseminated through publication in journals, research conference presentations and dissertation publication at Curtin University online Library.
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Exploring lived experiences of male partners’ in the care of preterm newborns: A qualitative study
(Kamuzu University of Health Sciences, 2021-02-21) Mhango, Patani
Executive Summary Type of Study: This will be a phenomenological qualitative study which will use qualitative data collection methods. Background: Every year, it is estimated that 15 million preterm births occur globally contributing 3.1% of global disability-adjusted life years (DALYs) through 1.1 million deaths and long-term loss of human potential amongst survivors. The greatest risk of death is during the neonatal period (0-28 days of life). Malawi has the highest rate of preterm births in the world, estimated to be between 18%26% of live births causing almost 36% of neonatal deaths. Birth of a child in the family presents a new challenge into parenthood and comes with it a great change, responsibility and transition. However, for the fathers of preterm newborns, the transition is disrupted by the unexpected birth of the child, uncertainty about the baby’s survival and life to follow. Fathers have been for so long considered traditionally as the breadwinners of the family, providing the family with all the necessary support it requires and the mothers were responsible of caring for the children and the household. In the recent years, these roles have changed in several ways as men and women have become more equal. Fathers spend more time with their children and have better experience in taking care of their children. Male involvement has been advocated as a key to improve maternal and child health because fathers play a vital role in decision-making in the households. However, fathers’ thoughts, feelings, fears and experiences in the care of preterm newborns are not adequately explored. In Malawi, there is lack of literature despite having highest preterm birth rate globally. As such, there is need to explore the lived experiences of the fathers, which is critical to their involvement in the care of the preterm newborns. Objectives: The broad objective of the study is to explore lived experiences of male partners’ in the care of preterm newborns in Balaka District. Specific objectives are a. To identify practices male partners are involved in provision of care to preterm infants b. To assess perceptions of men on their involvement in the care of the preterm infants c. To explore barriers to male involvement in the care of the preterm infants d. To explore facilitators to male involvement in the care of the preterm infants Study design, population, sample size and sampling strategy: The study will use the phenomenological qualitative research design guided by the Theory of Planned Behaviour because its versatility will allow exploration of the dynamic and complex nature of male involvement. The proposed study will be conducted amongst fathers of hospitalised preterm neonates aged 7-28 day. Twenty participants will take part in the study. The number resonates with methodological literature on saturation of qualitative data. Participants will be sampled purposively using maximum variation technique to ensure rich data is collected. Study Site, Study period and data collection: The study will be conducted in Balaka district at Balaka District hospital, which is the referral hospital in the district. It is expected that this study will run for one year from July 2020 to June 2021. In-depth interviews will be used to collect data Data management and analyses: Data collection and analysis will partly be done concurrently and audio-recorded interviews will be translated and transcribed verbatim by trained transcribers. Before analysis, transcripts will be anonymised. Data will be analyzed using qualitative thematic analysis methods. Analysis will use a hybrid of the deductive and inductive approach Dissemination Plans: Findings from the study will be compiled in a comprehensive that will be submitted to the University of Malawi (UNIMA), College of Medicine (COM) for marking. Copies will be submitted to College of Medicine Research and Ethics Committee, College of Medicine Library, and other research institutions. Furthermore, feedback will be given to Balaka District Hospital. The results will also be presented at relevant regional and international conferences and published in relevant peer-reviewed journals. Anticipated challenges: Firstly, to most families, premature birth comes unexpectedly and brings with it a lot of stress and fathers may not be willing to share their experiences with the researcher. Secondly, due to the COVID-19, recruitment challenges are anticipated considering that visits to hospitals are restricted. Furthermore, some potential participants may have travelled long distances using various means and may wish to be travelling back as soon as they can. This may affect their willingness to participate in the study. Potential use of results: It is believed that findings from this study will help in developing interventions to increase male involvement in the care of preterm newborns, which is critical to the infants’ survival and development. The study will also help inform health care providers the need to encourage and welcome male partners in the care of preterm newborns, as they are in a key position to be influential to the infant’s health.
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Implementation research on the appropriateness, feasibility, acceptability, and effectiveness of delivery of comprehensive sexuality education to Young people with disabilities and young people living with HIV out-of-school.
(Kamuzu University of Health Sciences, 2021-03-04) Chipeta, Effie
Type of study: This is an implementation science research study that will employ different methods to test the appropriateness, feasibility, acceptability and effectiveness of approaches to train and support facilitators to deliver CSE in out-of-school settings to young people with disabilities (YPWDs) and young people living with HIV (YPLHIV) in Malawi. Background and rationale: In January 2018, six UN agencies launched a revised edition of the International technical guidance on sexuality education, which provides guidance on designing and delivering comprehensive sexuality education (CSE) to support young people’s (10-24 years) health and well-being. Through UNFPA HQ and regional offices, the 3-year initiative titled “Reaching those most left behind through CSE for out-of-school young people,” is being implemented in Malawi and other four countries. The program in Malawi focuses on delivering CSE in out-of-school contexts to young people with disabilities and young people living with HIV. Objectives: The overall objective of the implementation research is to determine whether the activities used to train and support the facilitators are feasible, appropriate, acceptable, and effective in enabling the facilitators to engage YPWD and YPLHIV, deliver CSE to them in the out-of-school context, and assist them in obtaining relevant services. The specific objectives of the implementation research are: 1. To determine whether the activities used to train and support facilitators were appropriate for the delivery of comprehensive sexuality education to young people with disabilities and young people living with HIV. 2. To determine whether the plan for training and supporting the facilitators was feasible and whether it was implemented with fidelity. 3. To determine whether the training and support provided to the facilitators was effective in improving their competencies and attitudes. 4. To determine whether the facilitators: a. perceived that the training and support they received adequately enabled them to carry out their roles and responsibilities. b. effectively carried out their roles and responsibilities. 5. To determine whether the YPWD and YPLHIV: a. perceived the CSE as accessible, relevant, interesting, and useful. b. gained in terms of knowledge, attitudes, values, and skills related to sexuality and reproduction, and in terms of the use of relevant services. Methods: This is an implementation science research study that will employ different methods to test the appropriateness, feasibility, acceptability and effectiveness of training and supporting facilitators to deliver CSE in out-of-school settings to young people with disabilities and young people living with HIV in Malawi. Data will be collected at different time periods to measure and assess the implementation process and outcomes throughout the course of the intervention. We will use qualitative methods such as focus group discussions and in depth interviews and records review to measure the implementation processes and outcomes. Data management and analysis: The data will be secured. To ensure that the identities of participants are kept confidential, data will be anonymised and random identifiers will be generated for each file. The investigators will also go through audio files and transcripts to ensure quality. Quantitative data will also be cleaned. Qualitative data will be analysed using thematic content analysis approach while we will generate descriptive statistics with quantitative data. The qualitative and quantitative findings will be triangulated. By using various research methods (i.e. records review, qualitative interviews and quantitative data), we will eliminate some biases and shortcomings that may arise with using one method. Where necessary, qualitative data will provide explanations, justifications and validations to the findings from the quantitative data. Possible constraints: We anticipate no major constraints. However, due to the COVID-19 pandemic, study activities may be delayed or paused depending on the status of the pandemic. We will also adhere to all COVID-19 guidelines in conducting our research to ensure the safety of both researchers and study participants. Results To ensure that the research findings support efforts to improve CSE more generally, research findings will be disseminated through key stakeholders, peer reviewed journals, conferences and a copy will be sent to approving ethics committees (e.g. COMREC). Implications of the study: We anticipate that facilitators will become more competent in and more comfortable with delivering CSE in out-of-school settings to the targeted populations, that is, young people with disabilities and young people living with HIV. We anticipate that the facilitators will be acceptable to the young people and that delivery of the CSE will be feasible and more effective.
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Pre-service knowledge, perception and use of emergency contraception among undergraduate medical and nursing students in UNIMA in Blantyre
(Kamuzu University of Health Sciences, 2021-02-16) Munthali, Eddah; Dzunde, Mercy; Kadewere, Lughano
Background: Emergency contraception(EC) is one of the modern methods of preventing unintended pregnancies. It can be conveniently used due to several factors, one of them being the failure of other family planning methods among many others. However, EC is not a replacement of those family planning methods rather a temporary measure. Many health care providers are products of Kamuzu College of Nursing (KCN) and College of Medicine (COM), but little is known of their knowledge, perception and also use when it comes to ECs. Our aim in this study is therefore to explore the knowledge, perception and use of EC among medical and nursing students at those institutions. Objectives and methodologies: The broad objective is to determine the association of knowledge, perception and use of emergency contraception among medical and nursing undergraduate students in College of Medicine and Kamuzu College of Nursing in Blantyre. The specific objectives are; to estimate the knowledge level of medical and nursing students on emergency contraception, to measure the perception towards emergency contraception among medical and nursing students, to quantify the use of emergency contraception among medical and nursing students, to assess the association between knowledge and use of emergency contraception, to assess the association between perceptions and use of emergency contraception. This will be a quantitative cross sectional study. The study population will be MBBS and Pharmacy year 2 students at COM and Bachelor of Midwifery, Bachelor of Adult Health Nursing and Bachelor of Community Health Nursing year 2 students at KCN. The sampling methods purposive sampling and systematic sampling. Data will be collected using self administered questionnaires from 210 students. The sample size was calculated using epi info and was adjusted for refusal and losses. The data collected will be entered in Microsoft excel and will be extracted into and analysed using epi info software. The data will be analysed using descriptive statics and chi square to determine the association between factors associated with awareness and use of EC. Expected findings and dissemination: At the end of this study, we expect to find data on different aspects of knowledge, perception and use of EC and how these aspects relate to one another. This will help to determine if there is a need for provision of additional courses pertaining to family planning especially involving EC. The study findings will be organised and presented at the research dissemination organised by the COMREC in MBBS 4 and submitted for publication in the Malawi Medical Journal.
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Predictors of vesicovaginal fistula closure outcomes among women following surgery at Bwaila Fistula Care Centre
(Kamuzu University of Health Sciences, 2021-03-04) Chipapa, Smith
The type of research study: This is a quantitative retrospective cross-sectional study which will use data from the case management notes of women with obstetric fistula at the Bwaila fistula care centre from January 2019 to December 2019. The problem to be studied While the goal of repair is to achieve continence in women with obstetric fistula, a significant number of women experience avoidable failed repairs and remain incontinent even after the repair. As a result these women are continuously subjected to psychological, emotional, social and medical trauma from the urine. Information on the reasons for failed repairs of these women is scanty and mostly limited to the patient related factors. Factors that predict repair outcomes are arguably many and not only limited to patient related factors. If these factors can be considered preoperatively to determine the kind of surgery required for a specified fistula, incidences of failed repairs would be greatly minimized hence optimizing the quality of lives of these women. This study therefore seeks to assess predictors of Vesicovaginal fistula closure outcomes in women following surgery at Bwaila Fistula care Centre The objectives This study aims to assess predictors of Vesicovaginal fistula closure outcomes in women following surgery at Bwaila Fistula care Centre. Methodology Case files of women who underwent obstetric fistula repair from January 2019 to December 2019 will be identified from which 174 case notes will be randomly sampled foranalysis. A data abstraction tool will be used to extract labour, patient and hospital related variable information from the case notes which will be used to assess their association with closure outcome. Data will be analyzed using SPSS version 22. Expected findings and their dissemination. We expect to find labour, patient and hospital related factors that can predict repair outcomes of women with Vesicovaginal fistula. Based on the findings on these predictors, recommendations on how a specific fistula characteristic combination should be handled for optimum repair will be developed. The final copy of the findings will be made available at COMREC, Ministry of Health, and the fistula care Centre where the data will be collected. Findings will also be Presented at national and international conferences and the final copy will be published in a peer reviewed academic journal.
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Provision of essential treatments in critical illness (POETIC)
(Kamuzu University of Health Sciences, 2021-03-15) Baker, Tim
of project: This is a pilot of the overall project which includes literature review and secondary analyses of existing datasets, interviews of health-workers and other stakeholders, group discussions, online surveys and hospital walk-throughs. The problem: Approaches to improving quality of emergency and critical care in Malawi have not been previously studies. Objectives: To assess approaches for improving the quality of care for critically ill patients in hospitals in Malawi. Objectives 1. To evaluate the hospital readiness for providing critical care in hospitals in Malawi 2. To describe the current policy environment for critical care in Malawi 3. To explore existing service delivery arrangements for critically ill patients in hospitals in Malawi and the challenges faced in providing good quality care 4. To model the cost-effectiveness of different approaches for the scale-up and provision of critical care. Methodology: Repeated internet-based group discussions with 12-15 participants will be held. In-depth, more open-ended, narrative interviews will be subsequently held with 8-10 key informants including frontline health workers. Data from online discussions, interviews, walk-throughs and process maps will be analysed and used to generate a general description of the hospital journey of critically ill patients and using thematic analysis. Expected findings and dissemination: The knowledge generated will enable evaluations of the quality of context-appropriate emergency and critical care, bottleneck analyses of the weaknesses in service provision and the underlying determinants of these weaknesses, benchmarking of health services, guide the targeting of qualityimprovement interventions, and assessments of the impact of implementation efforts to improve care for critically ill patients. The results will be disseminated to the Ministry of Health, specialty societies, the Wellcome Innovations Critical Care Flagship and other stakeholders and published in open access peer reviewed journals.

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