BackgroundIntegrated Disease Surveillance and Response (IDSR) are crucial for strengthening public health systems in Africa but faces implementation challenges. Despite the growing utility of implementation theories, models, and frameworks in assessing the determinants of innovation implementation, no implementation research theories have examined the determinants of IDSR implementation. This systematic review aimed to identify the barriers and facilitators of IDSR implementation in Africa using a Consolidated Framework for Implementation Research (CFIR).MethodsWe systematically searched four databases, EMBASE, PUBMED, CINAHL, and Scopus, for studies on IDSR assessments in Africa published between 2010 and 2025. Data on barriers and facilitators were extracted and mapped to CFIR domains and constructs and analyzed deductively using content analysis and inductively using thematic analysis. The quality of the included studies was assessed using the Johns Hopkins Nursing Evidence Appraisal Tool. The review was reported in alignment with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).ResultsThirty-seven studies were included in this analysis. Six CFIR domains and 24 constructs explained the determinants of IDSR implementation. The key barriers identified were limited resources, inadequate access to knowledge/information, and structural constraints in the inner-setting domain. Individual domain factors, such as low motivation and capability, also emerged as crucial barriers. Facilitators included structural characteristics, improved access to knowledge, and adequate resources in the inner setting domain as well as positive innovation outcomes in the outcome domain.ConclusionThe implementation of IDSR encounters complex barriers and opportunities within health facilities. Comprehensive strategies addressing both organizational and individual factors of healthcare facilities are needed. The CFIR framework, alongside the CFIR-ERIC matching tool, provides a foundation for identifying context-specific implementation strategies that lead to improved innovation performance.Systematic Review RegistrationPROSPERO https://www.crd.york.ac.uk/PROSPERO/view/CRD42024571576, identifier CRD42024571576.

Introduction The WHO cut-offs to define anaemia among children (haemoglobin, Hb <105 g/L in 6–23 months and <110 g/L in 24–59 months) are based on the distribution of Hb concentrations in a healthy population. Our objective was to identify Hb values that best discriminate functional outcomes among children aged 6–30 months.Methods We used previously compiled datasets from an individual participant data meta-analysis of effects of small quantity lipid-based nutrient supplements. Participants were eligible for this pooled analysis if they had Hb measured at 6–30 months and data on at least one functional outcome of interest, which included physical activity and sleep patterns, and language, socioemotional and motor development. We stratified the datasets by child age in 3-month intervals and analysed associations of Hb with both concurrent and subsequently measured (longitudinal) outcomes. If Hb significantly discriminated the 25th, 50th or 75th percentile of the outcome based on the pooled area under the receiver operating characteristic curve (AUC), we identified the Hb value with the highest concordance probability as the best discriminatory threshold.Results 11 datasets from 8 countries including 27 626 children were analysed. Hb significantly discriminated 21 of 47 concurrent and 11 of 32 longitudinal Hb-outcome associations. Best Hb discriminatory thresholds ranged from 102 to 111 g/L for concurrent physical activity outcomes, 103–116 g/L for concurrent developmental outcomes, and 109–117 g/L for longitudinal developmental outcomes. The I2 for the pooled AUC analysis indicated generally low to moderate heterogeneity across studies.Conclusions The current WHO cut-offs to define anaemia among children are in the middle to upper range of Hb values that best discriminate concurrent physical activity and development, and are in the lower range of values that best discriminate subsequent child development. Along with other types of evidence, this study provides additional evidence to inform Hb cut-offs to define anaemia among young children.

Background Acute malnutrition remains a major public health challenge among children under five in Malawi due to undetected and untreated cases. While several policies and programmes are in place, they face significant resource input and implementation constraints. In this study, we evaluate the potential health impact and cost-effectiveness of three interventions designed to address constraints along the care pathway in childhood acute malnutrition management. These include improving early recognition of symptoms by caregivers, increasing attendance at routine growth monitoring visits through community outreach, and scaling up the availability of therapeutic food supplements. Methods and Findings We use a newly developed model representing the natural history and management of acute malnutrition, implemented within the Thanzi La Onse (TLO) dynamic individual-based simulation framework, which captures the public health system in Malawi. Each of the three interventions is assessed both individually and in combination, translated into seven scenarios which we evaluate in comparison to the status quo. The optimal strategy combines two interventions, improved caregiver awareness of early symptoms with increased availability of therapeutic food supplements. Over five years, this strategy is predicted to avert 840,470 (95% CI: 682,057–998,883) DALYs with total incremental costs of $34 million. This corresponds to an annual health expenditure increase of $0.32 per capita. At a cost-effectiveness threshold of $76 per DALY averted, the strategy results in an incremental net health benefit of 394,252 (95% CI: 235,839–552,665) DALYs averted. Conclusions The cost-effective strategy for addressing constraints in childhood acute malnutrition management is simultaneously improving caregiver recognition of early symptoms and expanding therapeutic food supplement availability. Out of the seven scenarios evaluated, this integrated approach was found to be the optimal strategy within the Malawian public health system, yielding substantial health at modest costs. These findings provide critical evidence to inform national policy and guide investment prioritisation for the management of childhood acute malnutrition. ### Competing Interest Statement SM reports grants from National Institutes of Health (NIH), grants from Global Institute for Disease Elimination, outside the submitted work. TC has received funding in the last 5 years to his institution (UCL) from the Wellcome Trust, UK Medical Research Council, US National Institutes for Health, the Save the Children UK ? GSK partnership, and The Global Fund to Fight AIDS, Tuberculosis and Malaria. TC also reports being the chair of a Trial Steering Committee for a trial in Nepal on adolescent mental health. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Thanzi La Onse project received ethical approval from the College of Medicine Malawi Research Ethics Committee (COMREC, P.10/19/2820) in Malawi. Only publicly available anonymised secondary data is used in the Thanzi La Onse modelling framework therefore, individual informed consent was not required. 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 The Thanzi La Onse modelling framework is open source and available for review and usage at https://github.com/UCL/TLOmodel. In particular, the outputs analysed in this study can be reproduced from the tag accessible at https://github.com/UCL/TLOmodel/releases/tag/Janouskova\_etal2026\_wasting\_intervs\_v0.1, using the scenario files from src/scripts/wasting\_analyses/scenarios/100K. The scripts used to generate the plots in the manuscript and the appendix (heatmaps\_cons\_wast.py, calib\_analysis\_wasting.py, run\_interventions\_analysis\_wasting.py) can be found in the src/scripts/wasting_analyses directory. [https://github.com/UCL/TLOmodel/releases/tag/Janouskova\_etal2026\_wasting\_intervs\_v0.1][1] [1]: https://github.com/UCL/TLOmodel/releases/tag/Janouskova_etal2026_wasting_intervs_v0.1

Undernutrition in early childhood causes stunted growth, cognitive delays, and anemia, with effects often magnified among children from the poorest households. Small-quantity lipid-based nutrient supplements (SQ-LNS) are effective in addressing undernutrition and improving child development. As momentum builds to scale up SQ-LNS for children aged 6-24 months in the Global South, a key concern is achieving equity in its distribution and outcomes. We performed equity analysis of individual participant data from 14 randomized controlled trials in nine countries (N=37,707 children) to assess SQ-LNS effects on child growth, development, and anemia across levels of an international wealth index. Benefits of SQ-LNS were consistent across the wealth spectrum, leading to similar improvements in child growth, development, and anemia regardless of wealth. However, such equal benefits of SQ-LNS did not erase large inequities in child growth and development between the poorest and wealthier households.

Background Cholera-like diarrheal disease (CLDD) outbreaks are complex and influenced by environmental factors, socioeconomic conditions, and population dynamics, leading to limitations in traditional surveillance methods. In Malawi, cholera is considered an endemic disease. Its epidemiological profile is characterized by seasonal patterns, often coinciding with the rainy season when contamination of water sources is more likely. However, the outbreak that began in March 2022 has extended to the dry season, with deaths reported in all 29 districts. It is considered the worst outbreak in the past 10 years. Objective This study aims to evaluate the feasibility and outcomes of participatory surveillance (PS) using interactive voice response (IVR) technology for the early detection of CLDD outbreaks in Malawi. Methods This longitudinal cohort study followed 740 households in rural settings in Malawi for 24 weeks. The survey tool was designed to have 10 symptom questions collected every week. The proxies’ rationale was related to exanthematic, ictero-hemorragica for endemic diseases or events, diarrhea and respiratory/targeting acute diseases or events, and diarrhea and respiratory/targeting seasonal diseases or events. This work will focus only on the CLDD as a proxy for gastroenteritis and cholera. In this study, CLDD was defined as cases where reports indicated diarrhea combined with either fever or vomiting/nausea. Results During the study period, our data comprised 16,280 observations, with an average weekly participation rate of 35%. Maganga TA had the highest average of completed calls, at 144.83 (SD 10.587), while Ndindi TA had an average of 123.66 (SD 13.176) completed calls. Our findings demonstrate that this method might be effective in identifying CLDD with a notable and consistent signal captured over time (R2=0.681404). Participation rates were slightly higher at the beginning of the study and decreased over time, thanks to the sensitization activities rolled out at the CBCCs level. In terms of the attack rates for CLDD, we observed similar rates between Maganga TA and Ndindi TA, at 16% and 15%, respectively. Conclusions PS has proven to be valuable for the early detection of epidemics. IVR technology is a promising approach for disease surveillance in rural villages in Africa, where access to health care and traditional disease surveillance methods may be limited. This study highlights the feasibility and potential of IVR technology for the timely and comprehensive reporting of disease incidence, symptoms, and behaviors in resource-limited settings.

The World Health Organisation (WHO) recommends that severe wasting and/or oedema should be treated with ready-to-use therapeutic food (RUTF) at a dose of 150–220 kcal/kg/day for 6–8 weeks. Emerging evidence suggests that variations of RUTF dosing regimens from the WHO recommendation are not inferior. We aimed to assess the comparative efficacy and effectiveness of different RUTF doses and durations in comparison with the current WHO RUTF dose recommendation for treating severe wasting and/or oedema among 6–59-month-old children. A systematic literature search identified three studies for inclusion, and the outcomes of interest included anthropometric recovery, anthropometric measures and indices, non-response, time to recovery, readmission, sustained recovery, and mortality. The study was registered with PROSPERO, CRD 42021276757. Only three studies were eligible for analysis. There was an overall high risk of bias for two of the studies and some concerns for the third study. Overall, there were no differences between the reduced and standard RUTF dose groups in all outcomes of interest. Despite the finding of no differences between reduced and standard-dose RUTF, the studies are too few to conclusively declare that reduced RUTF dose was more efficacious than standard RUTF.

Background Rectal artesunate (RAS) is a World Health Organization (WHO) recommended intervention that can save lives of children 6 years and younger suffering from severe malaria and living in remote areas. Access to RAS and a referral system that ensures continuity of care remains a challenge in low resource countries, raising concerns around the value of this intervention. The objective of this study was to inform RAS programming, using practical tools to enhance severe malaria continuum of care when encountered at community level. Methods A single country two-arm-controlled study was conducted in Malawi, where pre-referral interventions are provided by community health workers (CHWs). The study populations consisted of 9 and 14 village health clinics (VHCs) respectively, including all households with children 5 years and younger. CHWs in the intervention arm were trained using a field-tested toolkit and the community had access to information, education, and communication (IEC) mounted throughout the zone. The community in the control arm had access to routine care only. Both study arms were provided with a dedicated referral booklet for danger signs, as a standard of care. Results The study identified five continuum of care criteria (5 CoC Framework) to reinforce RAS programming: (1) care transitions emerged as to be dependent on a strong cue to action and proximity to an operational VHC with a resident CHWs; (2) consistency of supplies assured the population of the VHC’s functionality for severe danger signs management; (3) comprehensiveness care ensured correct assessment and dosing; (4) connectivity of care between all tiers using the referral slip was feasible and perceived positively by caregivers and CHWs and (5) communication between providers from different points of care. Compliance was high throughout but optimized when administered by a sensitized CHW. Over 93% experienced a rapid improvement in the status of their child post RAS. Conclusion RAS cannot operate within a vacuum. The impact of this lifesaving intervention can be easily lost, unless administered as part of a system-based approach. Taken together, the 5CC Framework, identified in this study, provides a structure for future RAS practice guidelines. Trial registration number and date of registration PACTR201906720882512- June 20, 2019.

Objectives To boost COVID-19 vaccine uptake, an innovative 'vaccinate my village' (VMV) strategy using door-to-door vaccination by Health Surveillance Assistants (HSA) was adopted. In this study, we assessed the impact of the 'vaccinate my village' strategy on COVID-19 vaccine uptake. Methods This was a cross-sectional review of the data on COVID-19 vaccination obtained from the Ministry of Health, Malawi, from 11 March 2021 to September 2022. Results From March 2021-4 September 2022,091,551 COVID-19 vaccine doses were administered, out of which 2,253,546 were administered over just six months as a part of VMV as compared to 1,838,005 doses were administered over 13 months as a part of other strategies. The proportion of Malawi's population receiving at least one dose of the COVID-19 vaccine increased substantially from 4.66 to 15.4 with the implementation of the VMV strategy (p = 0.0001). District-wise coverage of the COVID-19 vaccine also increased significantly after its implementation (p = 0.0001). Conclusions Door-to-door vaccination involving HSAs benefitted the COVID-19 vaccination program in Malawi by ensuring accessibility, availability, and acceptability.

Background: Owing to their detachment from urban areas, people living in rural areas of Malawi are on the receiving end of health services and socio-economic benefits. The study therefore explored how Malawians living in these areas are adhering to coronavirus disease 2019 (COVID-19) containment measures and the factors that affect the COVID-19 fight amongst this population. Aim: The study investigated how the rural population in Malawi adheres to COVID-19 containment measures. Setting: The study was conducted in two districts in Northern Malawi. Methods: Data were collected from 263 participants. The chi-square ( χ 2 ) test was performed to determine the association between demographic variables and COVID-19 prevention practices and factors affecting the COVID-19 fight. Results: Education was significantly associated with wearing of masks ( p = 0.01), use of sanitisers ( p < 0.01) and practising social distancing ( p = 0.07). Monthly income was associated with the use of sanitisers ( p < 0.01). Women were more exposed to fake news about COVID-19 ( p = 0.09); older people were more likely to disregard COVID-19 containment measures for cultural reasons ( p = 0.07); and monthly income was associated with a lack of resources for following COVID-19 containment measures ( p < 0.01). Conclusion: Findings show that factors affecting the COVID-19 fight are influenced by various socio-economic factors which should therefore be taken into account in policy planning aiming at controlling the pandemic. Contribution: The study provides health stakeholders with a policy direction that enhances better coordination, implementation and monitoring of COVID-19 response and recovery activities in rural areas in Malawi. The findings have implications on controlling current and future communicable diseases; the proposed strategies might be employed in fighting similar current and future pandemics.

Background The B.1.1.529 (Omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in the fourth COVID-19 pandemic wave across the southern African region, including Malawi. The seroprevalence of SARS-CoV-2 antibodies and their association with epidemiological trends of hospitalisations and deaths are needed to aid locally relevant public health policy decisions. Methods We conducted a population-based serosurvey from December 27, 2021 to January 17, 2022, in 7 districts across Malawi to determine the seroprevalence of SARS-CoV-2 antibodies. Serum samples were tested for antibodies against SARS-CoV-2 receptor binding domain using WANTAI SARS-CoV-2 Receptor Binding Domain total antibody commercial enzyme-linked immunosorbent assay (ELISA). We also evaluated COVID-19 epidemiologic trends in Malawi, including cases, hospitalisations and deaths from April 1, 2021 through April 30, 2022, collected using the routine national COVID-19 reporting system. A multivariable logistic regression model was developed to investigate the factors associated with SARS-CoV-2 seropositivity. Findings Serum samples were analysed from 4619 participants (57% female; 60% aged 18-50 years), of whom 878/ 3794 (23%) of vaccine eligible adults had received a single dose of any COVID-19 vaccine. The overall assay-adjusted seroprevalence was 83.7% (95% confidence interval (CI), 79.3%-93.4%). Seroprevalence was lowest among children <13 years of age (66%) and highest among adults 18-50 years of age (82%). Seroprevalence was higher among vaccinated compared to unvaccinated participants (1 dose, 94% vs. 77%, adjusted odds ratio 4.89 [95% CI, 3.43-7.22]; 2 doses, 97% vs. 77%, aOR 6.62 [95% CI, 4.14-11.3]). Urban residents were more likely to be seropositive than those from rural settings (91% vs. 78%, aOR 2.76 [95% CI, 2.16-3.55]). There was at least a two-fold reduction in the proportion of hospitalisations and deaths among the reported cases in the fourth wave compared to the third wave (hospitalisations, 10.7% (95% CI, 10.2-11.3) vs. 4.86% (95% CI, 4.52-5.23), p < 0.0001; deaths, 3.48% (95% CI, 3.18-3.81) vs. 1.15% (95% CI, 1.00-1.34), p < 0.0001). Interpretation We report reduction in proportion of hospitalisations and deaths from SARS-CoV-2 infections during the Omicron variant dominated wave in Malawi, in the context of high SARS-CoV-2 seroprevalence and low COVID-19 vaccination coverage. These findings suggest that COVID-19 vaccination policy in high seroprevalence settings may need to be amended from mass campaigns to targeted vaccination of reported at-risk populations. Copyright (c) 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Early Childhood Development (ECD) programs are currently understood as critical for children’s cognitive and socioemotional development, especially for those from disadvantaged backgrounds or most at risk for poor outcomes. Nevertheless, while the pioneering ECD programs evaluated in the literature have shown large and long-lasting impacts, replicating their successes has proven challenging in more recent years. We characterize this replication crisis and provide perspectives on how wearable technologies could help overcome it.

Objectives: To establish the impact of "Covid-19 Vaccination express" (CVE) on vaccine uptake in Malawi. Design: Retrospective cross-sectional study to compare the daily vaccine administration rate in CVE and routine covid vaccination (RCV). RCV data was collected from March 2021 to October 2021. The data regarding CVE was collected from 5 November 2021 to 31 December 2021. Data was collected regarding (1) the total number and type of vaccine doses administered and (2) Demographic details like age, gender, occupation, presence of comorbidities, the first dose, or the second dose of the people who received a vac-cine.Results: From March-December 2021, a total of 1,866,623 COVID-19 vaccine doses were administered, out of which 1,290,145 doses were administered at a mean daily vaccination rate of 1854 (95 % CI: 1292-2415) doses as a part of RCV, and 576,478 doses were administered at a mean daily vaccination rate of 3312 (95 % CI: 2377-4248) doses as a part of CVE.Comparing the mean daily doses (Astra Zeneca, AZ doses 1 & 2) administered in the CVE and RCV showed that the mean daily doses of AZ vaccine administered were significantly higher in the CVE (p < 0.05).Conclusion: CVE successfully increased the uptake of the Covid-19 vaccine.(c) 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background: Selenium deficiency is widespread in the Malawi population. The selenium concentration in maize, the staple food crop of Malawi, can be increased by applying selenium-enriched fertilizers. It is unknown whether this strategy, called agronomic biofortification, is effective at alleviating selenium deficiency.Objectives: The aim of the Addressing Hidden Hunger with Agronomy (AHHA) trial was to determine whether consumption of maize flour, agronomically-biofortified with selenium, affected the serum selenium concentrations of women, and children in a rural community setting.Design: An individually-randomized, double-blind placebo-controlled trial was conducted in rural Malawi. Participants were randomly allocated in a 1:1 ratio to receive either intervention maize flour biofortified with selenium through application of selenium fertilizer, or control maize flour not biofortified with selenium. Participant households received enough flour to meet the typical consumption of all household members (330 g capita−1 day−1) for a period of 8 weeks. Baseline and endline serum selenium concentration (the primary outcome) was measured by inductively coupled plasma mass spectrometry (ICP-MS).Results: One woman of reproductive age (WRA) and one school-aged child (SAC) from each of 180 households were recruited and households were randomized to each group. The baseline demographic and socioeconomic status of participants were well-balanced between arms. No serious adverse events were reported. In the intervention arm, mean (standard deviation) serum selenium concentration increased over the intervention period from 57.6 (17.0) μg L−1 (n = 88) to 107.9 (16.4) μg L−1 (n = 88) among WRA and from 46.4 (14.8) μg L−1 (n = 86) to 97.1 (16.0) μg L−1 (n = 88) among SAC. There was no evidence of change in serum selenium concentration in the control groups.Conclusion: Consumption of maize flour biofortified through application of selenium-enriched fertilizer increased selenium status in this community providing strong proof of principle that agronomic biofortification could be an effective approach to address selenium deficiency in Malawi and similar settings.Clinical Trial Registration:http://www.isrctn.com/ISRCTN85899451, identifier: ISRCTN85899451.

AbstractSince, the last polio case was in 1992, health authorities in Malawi declared an outbreak of wild poliovirus type 1 (WPV1) on 17 February 2022. A 3‐year‐old girl was diagnosed with WPV1 in the country's capital, Lilongwe, after getting paralyzed by the virus in November 2021. The re‐emergence of polio presents a new public health challenge that Malawi must respond to avoid the further spread of the virus within and outside the country. With an ongoing Coronavirus disease (Covid‐19) pandemic, responding to polio could be a challenge as the healthcare system is already challenged with responding to the pandemic. Frequent cross‐border movement in the region also poses another challenge, particularly in the background of poor vaccination coverage and poor‐quality vaccines. We recommend the development of a risk assessment plan that will guide in implementing vaccination campaigns. Additionally, polio surveillance programmes must be put in place with strong political, stakeholder and community engagement.

Population-level assessment of zinc deficiency remains a challenge due to the lack of suitable biomarkers. Spot urinary zinc concentration (UZC) has the potential to provide information on population zinc status in large-scale surveys, but there is no established cut-off point indicating deficiency. A strong correlation between this biomarker and an established biomarker such as serum zinc concentration (SZC) in paired samples (i.e., from the same individual), could identify the thresholds indicating zinc deficiency. This study, therefore, aimed to regress spot UZC from school-aged children and women from the Malawi micronutrient survey with paired SZC data using a linear mixed-effects model. The nested variance components indicated no linear relationship between the UZC and SZC data, irrespective of adjustments for inflammation and hydration. Thresholds of urinary zinc excretion that have been suggested by expert panels were applied to the spot UZC data, as a post-hoc analysis. The zinc deficiency prevalence estimates derived from these suggested thresholds were not similar to the estimates from the SZC data, and further research is required to understand whether spot UZC can still provide useful information in population zinc assessment.

Abstract The ongoing COVID‐19 pandemic has posed new and has aggravated already existing public health challenges in Malawi and worldwide. Having a better understanding of these challenges can help facilitate the identification of solutions and designing further public health interventions and policies for effective management of the COVID‐19 pandemic. This article presents an overview of the situation of COVID‐19 in Malawi and identifies emerging public health challenges that the country is facing amidst this pandemic. It is based on a review of relevant key policy documents, reports, and publications. Some of the key emerging challenges identified in Malawi are worsening population health and socio‐economic status; health system challenges like inadequate financing and human resources, disruption of essential health services; a rise in mental health conditions and suicide rates; teenage pregnancies and early marriages; and changes in some health policies. The findings point to the need to invest more in strategies for health promotion, health system strengthening and avoiding disruptions and recovery of services. These should include COVID‐19 vaccination promotion campaigns, improvement of the public health surveillance system, strengthening the health workforce, implementation of health financing strategies, procurement of adequate essential medicines and supplies, and strengthening of youth‐friendly reproductive health services, community health services and community engagement. These will ensure that the health system in Malawi is well‐equipped to deliver resilient, sustainable and quality health services amidst and beyond the COVID‐19 pandemic thereby promoting progress toward the achievement of Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs) in Malawi.

BACKGROUND Growth failure in sub-Saharan Africa leads to a high prevalence of child stunting starting in infancy, and is attributed to dietary inadequacy, poor hygiene, and morbidity. OBJECTIVES To evaluate the impact of a program in Malawi providing a lipid-based nutrient supplement to infants from 6-23 months of age, accompanied by a social and behavior change communication intervention to optimize caregiver feeding and handwashing practices. METHODS This impact evaluation was a quasi-experimental, longitudinal study with 1 program and 1 comparison district. Infants were enrolled at 6-7 months of age. Anthropometry, child morbidity, and caregiver feeding and handwashing practices were assessed at enrollment and at 6, 12, and 18 month follow-ups (ages 6, 12, 18, and 24 months, respectively). Changes in the length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and midupper arm circumference (MUAC) were compared using mixed-effects models. Program impacts on child stunting (LAZ < -2), wasting (WLZ < -2), morbidity, and feeding and handwashing practices were estimated using difference-in-differences. RESULTS We enrolled 367 infants across the program (n = 176) and comparison (n = 191) districts. The combined prevalences of stunting and wasting at enrollment were 42.1% and 1.4%, respectively, and did not differ by district. At enrollment, the prevalence of severe stunting (LAZ < -3) was higher in the program (15.5%) versus comparison (7.6%) district (P = 0.02), with corresponding lower LAZ scores (-1.9 vs. -1.7, respectively; P = 0.12). Growth velocities favored program children, such that LAZ, WLZ, and MUAC measurements increased by +0.12/y (P = 0.06), +0.12/y (P = 0.04), and +0.24 cm/y (P < 0.001), respectively, leading to comparable LAZ distributions across districts by 24 months of age. Program exposure was associated with 19.8 percentage point (pp) and 13.8 pp reductions in the prevalences of malaria (P = 0.001) and fever (P = 0.02), respectively, at the 18-month follow-up. Improvements of 20 pp (P < 0.01) in minimum dietary diversity and minimum acceptable diet were seen in the program versus comparison district at 18 months of follow-up. CONCLUSIONS The program improved child growth patterns, with benefits to health and diet apparent after 18 months of exposure. This trial was registered at clinicaltrials.gov as NCT02985359.

Background: Positive effects of SQ-LNS on developmental outcomes have been found in some trials, but not others. Objectives: Our objectives were to generate pooled estimates of the effect of SQ-LNS, compared to control groups that received no intervention or an intervention without any nutritional supplement, on developmental outcomes and to identify study-level and individual-level modifiers of these effects. Methods: We conducted a two-stage meta-analysis of individual participant data from 14 intervention versus control group comparisons in 13 randomized trials of SQ-LNS provided to infants and young children age 6 to 24 months in 9 low- or middle-income countries (total n=30,024). Results: In 11-13 intervention versus control group comparisons (n=23,588-24,561), SQ-LNS increased mean language, social-emotional, and motor scores and reduced the prevalence of children in the lowest decile of these scores by 17%, 19%, and 16%, respectively. SQ-LNS also increased the prevalence of children walking without support at 12 months by 9%. Effects of SQ-LNS on language, social-emotional, and motor outcomes were larger among study populations with a higher burden ([≥]35%) of child stunting at 18 months than in populations with lower stunting burden. At the individual level, greater effects of SQ-LNS were found on language among children who were acutely malnourished at baseline; on language, motor, and executive function among children in households with lower socio-economic status; and on motor development among later-born children, children of older mothers, and children of mothers with lower education. Conclusions: SQ-LNS provided daily to children in the range of 6-24 months of age can be expected to result in modest, but potentially important, developmental gains, particularly in populations with high child stunting burden. Certain groups of children who experience higher risk environments, such as those from poor households or with poor baseline nutritional status, have greater potential to benefit from SQ-LNS in developmental outcomes.