There is limited research describing survivors of gender-based violence (GBV) in Malawi. This study examined characteristics, medical management, and outcomes of GBV survivors presenting at health facilities in Neno district, Malawi. We conducted a retrospective cross-sectional study, using facility-based GBV registers at 14 health facilities in Neno district, Malawi. We categorized all variables and used frequencies and percentages. We used Chi-square and Fisher exact to test the association between sexual abuse and other variables. Of 465 GBV survivors, 59.1

Adolescent contraception is important in reducing sexually transmitted infections and teenage pregnancies. However its uptake remains low at 10% in Neno district, despite various interventions promoting free access. A phenomenological qualitative study was carried out in the district to explore the barriers, facilitators and preferences for the uptake of contraceptive methods among adolescents aged 15-19. Five focus group discussions and 18 in depth interviews were carried out with adolescents, parents, healthcare workers, community leaders and youth volunteers. Data was collected in Chichewa, translated into English, and analysed using thematic analysis. Three key themes appeared: 1) a climate of restriction: stigma, misinformation, and systemic barriers; 2) agency and support: navigating pathways to contraceptive uptake; and 3) the paradox of acknowledged risk and sustained resistance. Adolescents in Neno faced socio- cultural barriers, health facility limitations and informational gaps, alongside individual and external facilitators like education and peer influence. Adolescent choices were shaped by ease of use, sexual desires and economic hardships. Therefore, an integrated approach involving healthcare workers, policymakers, and non-governmental organisations (NGOs) is crucial to improving contraceptive uptake in Neno.

OBJECTIVES:Severe chronic non-communicable diseases (NCDs) place a significant burden on low- and middle-income countries (LMICs), where overburdened and underprepared health systems lead to misdiagnosis, treatment delays and poor outcomes. While prior research has examined health system gaps, little is known about patient experiences navigating care. This study examines the experiences of inpatients living with severe chronic NCDs in Neno District, Malawi, identifying triggers for care, mapping pathways to diagnosis and patient experience navigating care. METHODS:We conducted a cross-sectional study among inpatients admitted for severe chronic NCDs at two rural hospitals. Participants were asked about their journey to diagnosis, associated costs of illness and treatment, barriers encountered along their journey, decisions around seeking care and termination of care. Data collection included clinical record reviews and structured surveys documenting patient demographics and detailed clinical timelines (symptoms and careseeking) and costs, followed by open-ended fieldnotes capturing patient narratives. RESULTS:Fifty-two patients were recruited, representing 51% of eligible admissions over the study period. Ages ranged from 2 to 80 years (median: 43.5, IQR: 23.5-62). Diagnoses included heart disease, Type 1 and insulin-dependent Type 2 diabetes, kidney and liver disease, epilepsy and schizophrenia, with nearly half of patients admitted for cardiac conditions. Among paediatric patients, common conditions included congenital heart disease, sickle cell disease and epilepsy. One-third sought care within 3 days of recognizing symptoms, and 60% were admitted with new diagnoses. Time from symptom onset to diagnosis varied widely: Type 1 diabetes was diagnosed within 2 months of initial symptoms, and sickle cell disease often took years. Financial burdens were substantial; 77% of patients reported out-of-pocket costs, and 71% borrowed money for care. CONCLUSION:Gaps in diagnostic tools and provider expertise contribute to delays in diagnosis and treatment, exacerbating health and financial burdens. Our findings emphasize the need to ensure ongoing patient engagement and to enhance providers' ability to recognize patients who would benefit from the services.

Introduction: Mental health conditions, particularly depression and anxiety, are common among individuals with life-limiting illnesses and significantly affect their quality of life. However, little is known about their burden in palliative care in rural Malawi. Objective: This study assessed the prevalence and factors associated with depression and anxiety among adult patients enrolled in the palliative care program in Neno District, Malawi. Methodology: A cross-sectional study was conducted across nine health facilities from January to June 2024. Using simple random sampling, 152 adult participants were selected from the Neno district palliative care database. Quantitative data was collected using the PHQ-9 and GAD-7 as screening tools for depression and anxiety. The analysis used descriptive statistics and multivariable ordered logistic regression to identify factors associated with depression and anxiety, with results reported as adjusted odds ratios and 95% confidence intervals. Results: Of 152 eligible patients, 151 completed the study (99% response rate). The mean age was 67 years (SD = 16.3); 78% (n = 117) were female, and 66% (n = 99) were unmarried. Depression was present in 72% (95% CI: 65.0%-79.4%, n = 109) and anxiety in 70% (95% CI: 62.1%-77.0%, n = 105). Suicidal ideation was reported by 3% (n = 4) of participants. Depression and anxiety were strongly associated (depression model: aOR = 1.490, p < 0.001; anxiety model: aOR = 1.506, p < 0.001). Older age was associated with higher anxiety severity (aOR = 1.027, p = 0.016). No other sociodemographic variables were significantly associated with either outcome. Conclusion: The study findings underscore the high burden of depression and anxiety among patients under a palliative care program in Neno District, age-trailed mental health in chronic ill patients, and integration of mental health services and palliative care programs. Future research should examine how depression and anxiety develop in older adults to tailor interventions for this population.

Non-communicable diseases (NCDs) account for nearly 74% of global deaths, with 86% of premature NCD mortality occurring in low- and middle-income countries. In Malawi, hypertension, diabetes mellitus, and asthma contribute substantially to morbidity and mortality. Integrated service delivery models such as the Integrated Chronic Care Clinics (IC3) in Neno District aim to improve chronic disease management; however, evidence on disease control within these models remains limited. This study assessed disease control and associated correlates among patients receiving care in IC3 clinics in rural Malawi. We conducted a mixed-methods retrospective cross-sectional study at Neno District Hospital and Lisungwi Community Hospital. Quantitative data were extracted from OpenMRS electronic medical records for 1,790 patients diagnosed with hypertension, diabetes, or asthma. Disease control was defined as blood pressure <140/90 mmHg (<130/80 mmHg for hypertensive diabetics), HbA1c < 7% for diabetes, and symptom-based criteria for asthma. Associations between disease control and demographic or clinical variables were assessed using chi-square tests and logistic regression. Qualitative data were collected through 17 focus group discussions and 56 in-depth interviews with patients and healthcare providers. Hypertension control was achieved in 55% of patients, asthma control in 87%, and diabetes control in 32%. Males had lower odds of hypertension control than females (aOR 0.70, 95% CI 0.55-0.90). Overweight patients and those receiving more than two antihypertensive medications also had lower odds of hypertension control. Asthma control was associated with inhaled corticosteroid use, while glycaemic control was associated with the number of prescribed medications. Qualitative findings identified health literacy, medication adherence, patient-provider communication, and access to care as key influences on disease management. Disease control varied across conditions within integrated chronic care clinics in rural Malawi and was influenced by demographic, treatment-related, and contextual factors.

Background:Snakebite envenoming is a neglected public health problem in many tropical countries, resulting in over 100 000 deaths and 400 000 disabilities worldwide each year. In Gabon, where venomous snakes are abundant, studies on the epidemiology and treatment of snakebites are lacking. Methods:Between October 2022 and June 2023, we conducted a cross-sectional community survey in the department of Ogooué et des Lacs in central Gabon to estimate the snakebite incidence, describe clinical presentations and treatment-seeking behaviours, and describe the burden of snakebites to animal populations in rural and urban communities. We also surveyed health facilities in the department to describe treatment practices and the availability of antivenom. Results:The standardised annual incidence rate was 246 snakebite cases per 100 000 person-years (95% confidence interval (CI) = 138-438). Of the 175 snakebite cases reported in the five years prior to the survey, 18% showed signs of envenomation, predominantly with cytotoxic signs. The mortality among the bitten population was 3%. Snakebite treatment was first sought at a formal health facility in 55% of cases, from traditional healers in 22%, and with self-treatment or no treatment in the remaining 23%. Of snakebite patients treated at a formal health facility in the five years prior to the survey, 81% received antivenom, 41% received antibiotics, and 51% received corticosteroids. Almost one in six households reported animal deaths due to snakebites in the previous 12 months. Conclusions:This study provides the first robust epidemiological estimates of the burden of snakebites in Gabon and highlights the importance of community-based surveys in accurately assessing this high burden. Training health care workers, developing treatment guidelines, and ensuring the availability of effective and affordable antivenom are important steps to improving the outcome for snakebite victims.

Despite efforts to improve neonatal care worldwide, neonatal mortality rates in sub-Saharan Africa remain high. Adequate space, equipment, and staff are vital to improving mortality rates through high-quality care. We evaluated the impact of a district-level neonatal special care nursery over seven years at Neno District Hospital, Malawi. We conducted a retrospective cohort study to measure the neonatal outcomes in the neonatal special care nursery before nursery establishment (study period I, 2014–2015), following the establishment of a small nursery (study period II, 2016–2018), then with a transition to a larger nursery (study period III, 2019–2021). We extracted data from the neonatal registers and employed descriptive statistics and chi-square tests to compare the overall neonatal outcomes between study periods. We performed logistic regression to isolate factors associated with neonates alive at discharge. Of the 1366 neonates observed over the entire study period, the three primary admission diagnoses were birth asphyxia (30.1 ≤ 1500 g were 69

Objective: Snakebite envenoming remains a public health threat in many tropical countries. While community knowledge of local snakes and snakebite first-aid and prevention are needed to reduce snakebite incidence and improve the outcomes for snakebite patients, it is poor in many communities. We assessed community health workers and community members regarding their knowledge on local snakes, snakebite first-aid and prevention in Neno district, Malawi. Methods: In November 2022, we conducted a cross-sectional survey among 312 community health workers and 379 community members in the Neno District of Malawi to assess their knowledge of snake identification, snakebite first-aid, and prevention. Different questions were asked in these sections and summarised as linear scores ranging from 0% to 100%. Scores of 0%-49%, 50%-70%, and >70% were considered inadequate, fairly adequate, and adequate, respectively. Along with data collected during knowledge assessments, the socio-demographic characteristics of participants were collected. To assess knowledge differences between community health workers and community members, Pearson's chi-square or Fisher's exact tests were used, and linear regression was calculated to investigate possible predictors of knowledge. Results: Overall, 66.6% of participants were females with a median age of 39 (IQR = 30-48) years. Of the 89% (n = 615) who agreed to view snake pictures, only 1.3% had adequate snake identification knowledge. Less than 5% (n = 33) had adequate knowledge of first aid measures, and 14.3% (n = 99) had adequate knowledge of prevention practices. Overall, less than 1% (n = 3) had adequate knowledge across the three assessment sections, with no significant difference between community health workers (n = 1, 0.3%) and community members (n = 2, 0.5%) (p > 0.949). Conclusion: Both community health workers and community members had inadequate knowledge regarding local snake species, first aid for snakebites and prevention measures. The effect of awareness campaigns and other education initiatives could be explored to help improve these gaps.

BACKGROUND:Adolescents in low- and middle-income countries often struggle to access sexual and reproductive health services (SRHS). To address this, the Ministry of Health, with support from Partners In Health, implemented Youth Corners in selected health facilities in Neno District to improve the utilisation of Youth-Friendly Health Services (YFHS). OBJECTIVE:This study examines the role of Youth Corners in enhancing YFHS usage in Neno District, Malawi. METHODS:A descriptive cross-sectional study was conducted by extracting data from Youth Corner registers and DHIS2 from health facilities between October 2022 and September 2023. Population estimates were obtained from the National Statistical Office projections. Descriptive statistics and chi-square tests were used to describe service utilization patterns, and binary logistic regression was used to assess the association between distance and service attendance. RESULTS:During the study period, 1,877 young people aged 10-24 accessed YFHS, with 45% (n = 852) aged 15-19 and 57% (n = 1,063) female. They completed 2,869 visits, all receiving information and counselling. The utilisation rate was 829 visits per 1,000 young people aged 10-24. An association was found between distance, age, and attendance (p < 0.05). Adolescents aged 15-19 were less likely to attend youth corners (OR = 0.57, p = 0.003), and those living more than 10 km from facilities participated less frequently (OR = 0.59, p = 0.011). CONCLUSION:While Youth Corners are highly suggested as a way for improving YFHS uptake among young people, their impact in Neno District was found to be suboptimal.

Advanced HIV disease (AHD) is increasingly becoming a threat to the survival of people living with HIV. Many countries, including Malawi, have adopted and adapted World Health Organization AHD management guidelines to manage the country’s HIV cohort better. However, literature regarding adherence to these guidelines and the treatment outcomes remains limited. Therefore, we describe AHD management and patient outcomes at two rural hospitals in Southern Malawi. We conducted a retrospective cohort study at Neno District and Lisungwi Community Hospitals in Neno District, Malawi. We extracted data from inpatient files, patients’ manual charts referred to as “Mastercards” for outpatients attending Integrated Chronic Care Clinic (IC3) and from Electronic Medical Records (EMR) between January 2022 and December 2022. IC3 is a specialized clinic for people with chronic diseases including HIV, AHD and Non-communicable diseases. We used counts and percentages for all categorical variables and median and Interquartile range (IQR) for all continuous variables. During the study period, 343 HIV patients were hospitalized, of which 9.8

Loss-to-follow-up (LTFU) in the era of test-and-treat remains a universal challenge, especially in rural areas. To mitigate LTFU, the HIV program in Neno District, Malawi, utilizes a preventive default tracking strategy named Tracking for Retention and Client Enrollment (TRACE). We utilized a mixed-methods descriptive study of the TRACE program on patient's re-engagement and retention in care (RiC). In the quantitative arm, we utilized secondary data of HIV-infected patients in the TRACE program from January 2018 to June 2019 and analyzed patients' outcomes at 6-, 12-, and 24-months post-tracking. In the qualitative arm, we analyzed primary data from 25 semi-structured interviews. For the study period, 1028 patients were eligible with median age was 30 years, and 52% were women. We found that after tracking, 982 (96%) of patients with a 6-week missed appointment returned to care. After returning to care, 906 (88%), 864 (84%), and 839 (82%) were retained in care respectively at 6-,12-, and 24-months. In the multivariate analysis, which included all the covariates from the univariate analysis (including gender, BMI, age, and the timing of ART initiation), the results showed that RiC at 6 months was linked to WHO stage IV at the start of treatment (with an adjusted odds ratio (aOR) of 0.18; 95% confidence interval (CI) of 0.06-0.54) and commencing ART after the test-and-treat recommendation (aOR of 0.08; 95% CI: 0.06-0.18). RiC after 12 months was associated with age between 15 and 29 years (aOR = 0.18; 95%CI: 0.03-0.88), WHO stage IV (aOR = 0.12; 95%CI: 0.04-0.16) and initiating ART after test-and-treat recommendations (aOR = 0.08; 95%CI: 0.04-0.16). RiC at 24 months post-tracking was associated with being male (aOR = 0.61; 95%CI: 0.40-0.92) and initiating ART after test-and-treat recommendations (aOR = 0.16; 95%CI:0.10-0.25). The qualitative analysis revealed that clarity of the visit's purpose, TRACE's caring approach changed patient's mindset, enhanced sense of responsibility and motivated patients to resume care. We recommend integrating tracking programs in HIV care as it led to increase patient follow up and patient behavior change.

BACKGROUND:Palliative care remains key in assisting patients who have life-threatening conditions. In most low- and middle-income countries, it is often offered through a centralized system with limitations, including Malawi. In 2014, the World Health Organization called for improving palliative care access through primary health care and community models. Malawi and Neno District subsequently decentralized palliative care delivery to local health centers. This qualitative study explored the decentralization of palliative care services in Neno District, Malawi.METHODS:The descriptive qualitative study was conducted between 2021 and 2022 in two conveniently selected health centers providing palliative care in the Neno District. Fourteen healthcare workers were purposefully selected to participate in two focus groups. Fifteen patients were conveniently selected and participated in three focus groups. Data was analyzed using deductive and inductive approaches. Focused group discussions were conducted in Chichewa (Malawi's official local language), audio recorded, transcribed, translated into English, and analyzed thematically.RESULTS:Four main themes emerged from the focus groups. Patients described positive relationships with healthcare workers built on trust and holistic care over time. Accessing care included transport, social support, time constraints, and distance issues. Facilities effectively responded to needs through coordinated care and follow-up. Decentralization was perceived to benefit patients by reducing travel challenges and improving local access to efficient and inclusive palliative care services. However, challenges with resources, distance, and social support remained. Limitations in sampling and missing participant details necessitate further research with broader sampling.CONCLUSION:Overall, the study provides empirical evidence that can optimize palliative care delivery in similar low-resource contexts by informing policies to address barriers through decentralized approaches.

Introduction:Chronic obstructive pulmonary disease (COPD) continues to pose a global public health challenge. However, literature is scarce on the burden of COPD in Malawi. We assessed the prevalence and risk factors for COPD among adults in Neno, Malawi. Methodology:We conducted a population-based analytical cross-sectional study in Neno District between December 2021 and November 2022. Using a multi-stage sampling technique, we included 525 adults aged≥40 years. All participants underwent spirometry according to the American Thoracic Society (ATS) guidelines and were interviewed using the IMPALA questionnaire. For this study, we utilized the definition of COPD as a post-bronchodilator FEV1/FVC <0.70. We collected data using Kobo collect, exported to Microsoft Excel, and analysed using R software. We used descriptive statistics and logistic regression analysis; a p-value of <0.05 was considered statistically significant. Results:Out of 525 participants, 510 participants were included in the final analysis. Fifty-eight percent of the participants were females (n=296), and 62.2% (n=317) were between 40 and 49 years with a median (IQR) age of 46 (40-86). For patient characteristics, 15.1% (n=77) were current smokers, and 4.1% (n=21) had a history of pulmonary tuberculosis (PTB). Cough was the most commonly reported respiratory symptom (n=249, 48.8%). The prevalence of COPD was 10.0% (n=51) and higher (15.0%) among males compared to females (6.4%). Factors significantly associated with COPD were age 60 years and above (adjusted odds ratio [aOR] = 3.27, 95% CI: 1.48-7.34, p<0.004), ever smoked (aOR = 6.17, 95% CI:1.89-18.7, p<0.002), current smoker (aOR = 17.6, 95% CI: 8.47-38.4, p<0.001), and previous PTB (aOR = 4.42, 95% CI: 1.16-15.5, p<0.023). Conclusion:The cross-sectional prevalence of COPD in rural Malawi is high, especially among males. Factors significantly associated were older age (60 years and above), cigarette smoking, and previous PTB. Longitudinal studies are needed to better understand disease etiology and progression in this setting.

Background Quality data is crucial in making informed decisions regarding health services; However, the literature suggests that in many LMICs including Malawi, it remains of poor quality. Data quality is measured in terms of completeness, timeliness and consistency among other parameters. We describe the Ministry of Health's District Health Information System (DHIS2) report completeness and timeliness at three levels: National, South West Zone (SWZ) and Neno district. Further, describe data consistency following data quality assessments (DQA) in Neno district, Malawi. Methods We conducted a descriptive retrospective study by extracting DHIS2 report completeness and timeliness at three levels and used DQA data in Neno district between January 2016 and December 2022. We defined report completeness as the number of reports in DHIS2 against those expected, timeliness as the number of reports entered into DHIS2 before the deadline and consistency as the level of agreement between three sources: register, report and DHIS2 system. We presented the data graphically and calculated yearly median reporting rates for weekly, monthly and quarterly reports against the national target of 85%. We utilized a verification factor (VF) of 0-200% to evaluate consistency between three sources in the Neno district. VF exceeding 100% indicated over-reporting, 100% as a perfect match, and less than 100% as under-reporting, with an acceptable 90-110% range. Results During the study period, we found increased trends in weekly, monthly and quarterly report completeness at all three levels but were below 85%. Neno district surpassed the target from 2020 onward for weekly reports and from 2019 onward for monthly reports. Similar increased trends were observed for report timeliness with below threshold of 85% except for Neno district monthly report from 2021 onward. We found inconsistencies in data entry from the report to DHIS2 (VF: >90% - <110%) in Neno district. Similarly, under and over-reporting occurred between the register and the report (VF: <90% and > 110%) were observed. These findings should be considered when using DHIS2 for decision-making. Conclusion In general, we found increased completeness and timeliness rates at all three levels, however, less than the set target of 85%. We suggest continued support, including routine DQAs and report monitoring, towards improving DHIS2 data quality.

Background: Community health workers (CHWs) bridge the primary health care (PHC) system and communities by providing care in the household. In Malawi, few studies have examined the perspective of users of household -level CHW services, in remote areas, to understand CHW's role in community -based PHC. Aim: To explore perspectives of community and facility stakeholders on the enablers and challenges of the CHW role in community -based PHC in Neno District. Setting: The study was conducted in the Neno District health facilities, namely, Ligowe, Dambe, Chifunga, and Zalewa. Methods: We conducted eight focus group discussions (FGDs) with purposively sampled community members and conveniently sampled facility stakeholders. Data were transcribed and analysed thematically through an adapted COM-B model of behaviour change. Results: Three main themes of perceived behaviour change within the CHW role were identified: (1) capacity - the CHW programme aids health education and promotion within the community; (2) opportunity - the CHW programme facilitates community -based PHC and linkage to the facility; and (3) motivation - the CHW programme enablers and challenges in providing community -based PHC. Conclusion: Community health workers enrich community -based PHC delivery through health education, timely access to care, and linking communities to the facility. Optimising workload and programme support is critical for the help of CHWs. Further studies are required to address programme and cultural challenges to enhance positive health -seeking behaviours. Contribution: This study provides contextual knowledge for further research on bringing together spiritual and formal health practices and considering the cultural background when planning for health interventions in remote areas.

Objectives:Despite global efforts to address antibiotic self-medication, it is still significantly prevalent. This study aimed to investigate the prevalence of antibiotic self-medication and assess knowledge of antibiotic resistance among community members in Neno District, rural Malawi. Methods:A cross-sectional, community-based study was conducted from September to November 2023, using simple random sampling across 169 villages. Participants from two households per village were surveyed using a "drug bag" method, focusing on those who had taken antibiotics within the preceding 6 months. In addition, drug retailers were selected via snowball sampling for interviews. Results:Of the 531 participants and 39 drug retailers, 71.1% reported antibiotic use, with 69.5% self-medicating in the past 6 months, with convenience (31.5%) and confidence (26.7%) being the reasons. Common symptoms prompting self-medication included cough (29.9%), sore throat (28.6%), and aches and pain (28.6%). Amoxicillin (61.1%) and cotrimoxazole (29.6%) were the most used antibiotics. More than half (53.1%) reused leftover antibiotics from health facilities, with employed participants significantly more likely to self-medicate. Awareness of antibiotic resistance was low (16.1%), mainly learned from hospitals. Unlawful antibiotic sales by drug retailers (46.2%) were noted. Conclusions:The study highlights the urgent need for government-led efforts to regulate antibiotic use and increase public awareness to mitigate the impact on public health.

Perinatal depression contributes significantly to morbidity and mortality of women and children in low- and middle-income countries. However, due to low resources and little evidence on the impact of screening and treatment, few interventions are offered. Our study aims to assess the feasibility and impact of depression symptoms with screening and treatment of women in rural Malawi. Screening for depression was conducted using the Patient Health Questionnaire 2 (PHQ-2) and PHQ-9. Women identified to have moderate and severe depression were treated through a group counselling intervention-WHO Group Problem Management Plus (group PM+). With integration of PHQ-2 into prenatal and antenatal clinic registration, 90.2% of women were screened with PHQ-2 and 12.8% of women screened positive for depression. Seventy-one women were treated with group PM+ over the study period with decreased depressive symptoms after course completion (mean PHQ-9= 12.3 at enrollment and 2.3 after course [p<.05]) and at 6-month follow-up (mean PHQ-9= 1.0 [p<.05]). Our findings suggest that it is feasible to screen and treat women with perinatal depression in rural Malawi and that group counselling through PM+ can lead to improvement of symptoms.

Snakebite envenoming remains a public health threat in many tropical countries including Malawi. Traditional healers (THs) have been consulted by victims of snakebites as primary caregivers for millennia. There are no studies in Malawi to understand this phenomenon, therefore, our study aimed to explore the experiences and practices of THs regarding snakebite treatment and prevention in rural Malawi. Between August and September 2022, we conducted semi-structured interviews with 16 THs who were purposefully selected from various locations across Neno District, Malawi. We analysed the interview data using Dedoose software, where we generated codes and grouped them into themes. Out of the 16 THs interviewed, 68.8% (n = 11) were male, and 43.8% were aged between 40 and 60 years. Our study identified five themes: THs’ knowledge of snakes and treatment, the continuum of care they provide, payment procedures, snakebite prevention, and their relationship with health facilities. They claimed a good understanding of the snakes in their area, including the seasons with more snakebites, and were confident in their ability to provide treatment, however, this was not scientifically proven. They offered a comprehensive care package, including diagnosis, first aid, main treatment, and follow-up care to monitor the victim’s condition and adjust treatment as needed. THs provide free treatment for snakebites or use a “pay later” model of service delivery. All THs claimed a “vaccine” for snakebites that could prevent bites or neutralize the venom. However, no formal relationship existed between THs and Health Care Workers (HCWs). We recommend collaboration between HCWs and THs, establishing clear referral pathways for snakebite victims and educating THs on identifying danger signs requiring prompt referral to healthcare facilities.

Background: Cardiovascular disease (CVD) is a major cause of death in Malawi. In rural districts, heart failure (HF) care is limited and provided by non-physicians. The causes and patient outcomes of HF in rural Africa are largely unknown. In our study, non-physician providers performed focused cardiac ultrasound (FOCUS) for HF diagnosis and longitudinal clinical follow-up in Neno, Malawi. Objectives: We described the clinical characteristics, HF categories, and outcomes of patients presenting with HF in chronic care clinics in Neno, Malawi. Methods: Between November 2018 and March 2021, non-physician providers performed FOCUS for diagnosis and longitudinal follow-up in an outpatient chronic disease clinic in rural Malawi. A retrospective chart review was performed for HF diagnostic categories, change in clinical status between enrollment and follow-up, and clinical outcomes. For study purposes, cardiologists reviewed all available ultrasound images. Results: There were 178 patients with HF, a median age of 67 years (IQR 44 – 75), and 103 (58%) women. During the study period, patients were enrolled for a mean of 11.5 months (IQR 5.1–16.5), after which 139 (78%) were alive and in care. The most common diagnostic categories by cardiac ultrasound were hypertensive heart disease (36%), cardiomyopathy (26%), and rheumatic, valvular or congenital heart disease (12.3%). At follow-up, the proportion of New York Heart Association (NYHA) class I patients increased from 24% to 50% (p < 0.001; 95% CI: 31.5 – 16.4), and symptoms of orthopnea, edema, fatigue, hypervolemia, and bibasilar crackles all decreased (p < 0.05). Conclusion: Hypertensive heart disease and cardiomyopathy are the predominant causes of HF in this elderly cohort in rural Malawi. Trained non-physician providers can successfully manage HF to improve symptoms and clinical outcomes in limited resource areas. Similar care models could improve healthcare access in other rural African settings.