Continuing Professional Development (CPD) is a fundamental component of nursing practice, facilitating the ongoing acquisition of knowledge and skills beyond initial training. It serves as a mechanism for nurses to remain abreast of current advancements, fostering their professional development and ultimately enhancing the delivery of quality patient care. However, in low-resource settings like Malawi, limited evidence exists regarding nurses’ perspectives on CPD, particularly, alignment of CPD programmes with nurses’ clinical needs and practice realities. The study aimed at exploring nurses’ perspectives on CPD at Zomba Central Hospital (ZCH), Malawi. The specific objectives of the study were to; explore nurses’ perceived CPD needs, examine the congruency of nurses’ needs and their participation in CPD programmes, explore nurses’ experiences of CPD programme delivery, and asses the factors that influence participation in CPD programmes. This study employed a qualitative interpretive design. Using purposive sampling, 15 nurses were interviewed. Data were collected through interview guide and analyzed using thematic analysis. Coding and theme development were conducted to enhance consistency and credibility. Five themes were identified. Nurses actively identify their learning needs through self-assessment and clinical practice often with inadequate institutional coordination. CPD was perceived as important for professional development contributing to improved knowledge, clinical skills, confidence and patient care. There is a perceived misalignment between CPD programmes and nurses’ needs, particularly in practical skill development. Current CPD set up lack post-training mentorship and support thereby constraining the application of learning in practice. Some CPD sessions are relevant to departmental needs, but many lack practical applicability and fail to address the knowledge gaps. Diverse interactive learning resources are highly valued. Most CPD facilitators lack expertise and proficiency in teaching skills. Barriers to CPD participation include scheduling conflicts, workload pressures, and financial obstacles such as limited access to data bundles and transportation costs. Exploring nurses’ perspectives on CPD at Zomba Central Hospital assisted in determining the relationship between nurses’ actual needs and the CPD programmes in which they engage. CPD is valued by nurses but is not often aligned with their clinical needs. Strengthening needs-based and practice-oriented CPD, institutional coordination and mentorship, and addressing structural barriers may enhance participation and translate learning into practice.

Task shifting in healthcare delivery, the redistribution of activities from one cadre to another (with mostly fewer qualifications), has been a central policy of health systems across the world. Policy on task shifting is particularly important in countries with health systems that suffer from a profound lack of investment and has been well described in the literature. Informal task shifting has not received the same attention. It is rarely described or theorised and, as a consequence, debate about its impact on equity, safety and quality of services is lacking. In this paper, drawing on participant observation and in-depth interviews, the multiple manifestations of informal task shifting in Malawi are described and analysed to show their dynamics in relation to the health system. The paper identifies two dominant practices that were carried out by staff formally employed to clean the facility, care for the gardens and provide security services surrounding areas: first, the cleaning and suturing of wounds, and second, the dispensing of medication. Both practices were found to be connected to wider forms of informality, including informal payments and the theft of medicines and consumables. This was mostly, but not always, sanctioned by health professional staff. In some health centres the practice was so entrenched that medical staff concerned about its impact on patient safety and care felt unable to intervene. The discussion reflects on how Malawi may reduce its reliance on untrained and unskilled personnel working in government health centres.

In Malawi, health services are officially free at the point of use, but patients often make informal payments to access services or obtain medicines. These payments undermine equity and trust in the health system. This study examined for the first time the prevalence, types, and determinants of informal payments among Malawians who had recently used health services. We conducted a multidistrict cross-sectional household survey in four districts chosen to reflect urban and rural Malawi. Households containing someone who had been hospitalized in the previous 6 months were interviewed using a structured questionnaire. Descriptive analyses identified the types and prevalence of informal payment, while multivariable logistic regressions identified factors associated with informal payments. Overall, 17% of respondents reported paying for services that are officially free. Informal payments are most often for medicines (52%), consumables (24%), and consultations (24%). Female respondents and those living in urban areas were significantly more likely to report giving informal payments, while those with higher levels of education were less likely. Participants with a good or very good financial situation were more likely to make such payments. Significant geographical variations were observed, with higher probabilities in Mchinji and Mzimba than in the Blantyre district. Nearly one in five Malawians reported making informal payments to access health services, questioning the formal policy that these are free. These findings highlight the need for governance reforms, greater accountability, and community awareness to reduce informal payments and promote equitable access to care.

Background Supportive supervision (SS) is a systematic approach used to assess health facilities' preparedness to provide quality healthcare service and support healthcare providers to identify and address barriers to the provision of quality health services. There is, however, inconclusive evidence of the full benefit and influence of SS on performance in different settings of primary health care (PHC). Additionally, not much is known about what constitutes an effective SS approach that can successfully improve service provision by influencing better problem solving. This review synthesised evidence on the effectiveness of mechanisms of SS in PHC in low- and middle-income countries (LMIC). Methods Search strategy: The first search was done in five relevant databases, then in the remaining database and finalised with a search in the reference list. Selection criteria: Selection criteria were guided by population (primary health care providers), intervention (mechanism of supportive supervision) and outcomes (positive or negative) in the context of low- and middle-income countries. Selection was based initially on title and abstract, then full-text articles. Data extraction and analysis: A data extraction tool was used to extract the relevant information to answer the review question. Studies were analysed through frequency counting of articles. And qualitative content analysis was used, and synthesised results were reported narratively. Results: A total of 29 studies were identified, ranging from 2013 to 2023. Methodologies identified included 6 cluster randomised control trials, 15 quasi-experimental studies, 5 qualitative studies, 5 analytical cross-sectional studies and 3 cohort studies. The studies were from the following: Egypt, Ethiopia, Pakistan, India, Kenya, Zambia, Nigeria, Mozambique, Tanzania and Malawi. Study results found multiple mechanisms used when conducting SS in PHC in LMIC. SS was either effective 69% (n=20), ineffective 3.5% (n=1) or had inconclusive 28% (n=8) results. The role of SS in primary care performance included improved attitudinal behaviour, knowledge, skills and practice, and health and patient outcomes. Conclusion: There are multiple approaches to conducting SS, and the mechanisms yielded both positive, negative and inconclusive results, supporting evidence of inconsistencies in what constitutes an effective mechanism of SS. Multiple external factors such as incentive, training and transport logistics were seen to influence the role of SS in PHC. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The Norwegian Programme for Capacity Development in Higher Education and Research for Development (NORHED) scholarship was the source of funding for this study. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

This review examined methodologies used to cost the impact of antimicrobial resistance (AMR) infections in humans from household and health system perspectives. Although extensive research has been conducted on the clinical AMR burden in low- and middle-income countries (LMICs) in terms of prevalence and other drivers of antimicrobial resistance, there is increased misuse and overuse of antibiotics which increases the risk of AMR infections compared to high-income countries. Lack of comprehensive estimates on economic costs of AMR in LMICs due to lack of standard methodologies that incorporate time biases and inference for instance, may negatively affect accuracy and robustness of results needed for reliable and actionable policies. We conducted a systematic review of studies searched in PubMed and other electronic databases. Only studies from LMICs were included. Data were extracted via a modified Covidence template and a Joanna Briggs Institute (JBI) assessment tool for economic evaluations to assess the quality of the papers. Using PRISMA, 2542 papers were screened at the title and abstract levels, of which 148 were retrieved for full-text review. Of these, 62 articles met the inclusion criteria. The articles had a quality assessment score averaging 85

Background Multimorbidity is a growing global concern, affecting patient outcomes and healthcare costs. In low- and middle-income countries, data on multimorbidity in primary care beyond prevalence is limited. Our study explored the demographic and clinical characteristics of multimorbidity among older people attending primary health care in Malawi. Methods We conducted a cross-sectional analysis on medical records from 15,009 older patients aged ≥50 years across three hospitals in Malawi (one tertiary, two district). Data from 2019-2021 was analyzed using R statistical software to examine patterns of multimorbidity (two or more chronic conditions). Outcome estimates were adjusted for sex, age, location, and year of clinic visit. Results The overall prevalence of multimorbidity, defined across 17 recorded chronic conditions, was 19.6%. Among the 2,941 cases of multimorbidity, 2,708 (92.0%) involved two chronic conditions, while 233 (8.0%) involved three. While most conditions increased steadily in prevalence with age, diabetes followed a different pattern, with higher prevalence among individuals aged 50–59 years (53.9%) and 60–69 years (52.4%) compared to those 70 years and older (40.3%). After adjusting for clinic visit year, gender, and study location, individuals aged 70 years and older were significantly less likely to have multimorbidity compared to those aged 50–59 years (AOR = 0.57, 95% CI: 0.52–0.62, p < 0.001). Conclusion The study revealed a wide range of multimorbidity combinations among older people attending primary health care. Strategies to address multimorbidity in older people should include efforts to identify other, less common clusters of chronic conditions.

Background/Objectives: Self-care experiences and understanding of coronary heart disease (CHD) play a pivotal role in the management of CHD and can contribute to positive health outcomes. This qualitative study aimed to explore the views and experiences of CHD patients, their families, and Indigenous leaders about self-care practices of CHD. Methods: A qualitative design employing semi-structured interviews and a focus group discussion was used. Employing purposive sampling, 49 respondents, comprising 30 patients, 10 family members, and 9 Indigenous leaders, were recruited and interviewed from April to September 2022. The data were analyzed using content analysis. Results: Five major categories were constructed: (1) inadequate knowledge and early symptom identification; (2) self-care activities for physical, psychosocial, and spiritual needs; (3) family and kinship support for self-care efforts; (4) barriers to self-care including physical, psychological, and access issues; and (5) health improvement expectations based on culturally sensitive health education. Conclusions: The study reveals significant gaps in knowledge about CHD and the identification of early symptoms among patients, families, and Indigenous leaders. Despite efforts to meet physical, psychosocial, and spiritual needs, self-care is hindered by various barriers, including limited access to healthcare and entrenched habits. The support from family and kinship systems is crucial for self-care. Participants expressed a strong desire for culturally tailored health education and better health control to improve heart health outcomes.

Background Sepsis is a significant global health problem, particularly in low- and middle-income countries. Sepsis is a life-threatening condition that requires prompt identification and early definitive medical intervention. Globally, sepsis is common, with estimated 31.5 million cases per year. Sepsis accounts for a significant in-hospital mortality rate of 17% in high-income countries while in Malawi, it ranges from 17–50%. For Malawi, the trend can be reversed with improvements in patient referral system within the healthcare system. The study set out to establish the referral pathway of patients with sepsis from primary healthcare to tertiary hospitals and to understand healthcare workers and patients’ perspectives on barriers associated with delayed referral of patients with sepsis from primary to tertiary healthcare. Methods A qualitative descriptive study in six health centres within Blantyre District health office included 22 face-to-face semi-structured interviews with purposively selected patients recovering from sepsis and with healthcare workers. Results The study revealed that the main referral pathways for patients with sepsis include community-to-facility and facility-to-facility referrals. Ambulances and personal transport are common transportation mode used during referrals. Primary care facilities face several challenges that delay referrals from primary to tertiary health facility of patients with sepsis, such as lack of referral transport, poor communication, poor road network, shortage of skilled healthcare workers, patient preferences, delayed treatment-seeking action, and ambulances prioritising maternal conditions. Conclusions Patients’ delay and failure to access prompt and timely referral services result from the healthcare system’s lack of transport, communication problems, bad road networks and shortage of well-trained personnel. Referral delays have deleterious effects on patient-care outcomes.

BACKGROUND:The survival of children with Burkitt lymphoma (BL) in sub-Saharan Africa is disproportionately low compared to high-income countries. In Malawi, many of these children are diagnosed in advanced stages. Early and accurate diagnosis is critical to survival of children with BL. This qualitative study evaluates factors influencing health-seeking decisions of guardians of children with BL in Northern and Central Malawi. METHODS:We conducted in-depth interviews of guardians of children (<18 years) diagnosed with BL and admitted to the Pediatric Oncology Unit at Kamuzu Central Hospital, in Lilongwe, Malawi, from February to April 2023. Participants were identified using purposive sampling. Data were analyzed using thematic content analysis. RESULTS:Twenty guardians participated in the interviews. The median age of the respondents was 41 years, and 65% were females. Four main themes emerged as factors influencing health-seeking behaviors as guardians of children with BL navigated the Malawi health system. These included personal, economic, access to healthcare, and social factors. Financial status consistently emerged as a crucial determinant in the health-seeking behaviors of guardians, but thematic analysis also revealed knowledge and awareness, geographical accessibility, and symptom interpretation as key factors shaping health-seeking behaviors for guardians of children with BL. Symptom interpretation was influenced by the limited knowledge of the disease, and the lack of general awareness about childhood cancer. CONCLUSION:We identified financial and non-monetary barriers affecting health-seeking behavior among guardians of children with BL in Malawi. Targeted initiatives to alleviate the economic burden of cancer on affected families and increased awareness campaigns in the community are critical to improving BL outcomes in Malawi and other low-resourced settings.