Deborah Nyirenda

Background: Early detection and treatment of childhood infections are crucial for preventing disease progression and reducing mortality among children under five years of age. However, evidence shows that only about 46% of Malawian caregivers seek prompt medical care for childhood illnesses such as diarrhoea. This study explored the factors influencing caregivers’ care-seeking behaviour for children under five with diarrhoea at Bangwe Health Centre in Blantyre, Malawi. Methods: A qualitative study was conducted using 15 in-depth interviews with caregivers of children affected by diarrhoea. The interviews were conducted in Chichewa, audio-recorded with participants’ consent, transcribed verbatim, translated into English, and analysed thematically. Sampling continued until thematic saturation was reached. Results: Four main themes were identified. Individual factors, particularly the child’s health status, encouraged early care-seeking, whereas limited awareness of the importance of early treatment contributed to delays. Health system barriers, including staff shortages, negative attitudes of healthcare providers, limited availability of medicines, and long waiting times, further delayed access to care. Economic and geographical barriers, including travel costs and reliance on home remedies, also negatively affected care-seeking for childhood diarrhoea. Conclusions: Improving the early diagnosis and treatment of childhood diarrhoea requires a holistic approach. Interventions should strengthen caregiver health literacy, improve health service delivery by addressing workforce and medicine shortages, and reduce geographical barriers through improved infrastructure and community-based services. These efforts are essential to improving child health outcomes in Malawi.

Inappropriate antibiotics use due to low public knowledge and awareness contributes to the growing Antimicrobial Resistance (AMR) burden, especially in low- and middle-income countries (LMICs). The aim of Responsive Dialogues (RDs) is to engage communities and key stakeholders to share information, galvanize action and create local solutions to reduce the burden of AMR. RDs promote collaborative problem-solving and have been identified as a potential tool for engaging diverse stakeholders in addressing AMR. However, RDs were only recently developed, and empirical evidence about their utility and feasibility in LMICs is currently limited. We piloted RDs with poultry farmers, government and private pharmacists or prescribers, and male caregivers in Malawi. Using 13 semi-structured interviews and three focus groups, we assessed feasibility of this participatory approach to influence inclusive local AMR policies and solutions. The participatory nature of RDs promoted inclusive decision-making and facilitated participants’ capacity to co-create locally relevant AMR solutions. Information shared during RDs improved AMR awareness, prompting participants to recognize and reconsider antibiotic practices and co-create solutions including community education on responsible use, local stewardship committees, and integrating AMR education into existing health programs. Implementation barriers varied: farmers and private prescribers expressed concerns about economic losses from reduced antibiotic use, while male caregivers reported difficulties educating others without tangible resources. Considerations for AMR-RDs scale-up include resource allocation, integration with existing health systems, and further research on long-term impact across different low resource settings. Despite these challenges, this pilot demonstrates that RDs offer a valuable participatory approach for co-creating contextually relevant AMR solutions in resource-limited settings. Sustained impact requires addressing structural barriers, establishing feedback mechanisms, and integrating RDs outputs within existing health system structures and national AMR action plans.

Low public awareness and inappropriate antibiotic use contribute to the growing Antimicrobial Resistance (AMR) burden, especially in low- and middle-income countries (LMICs). The aim of Responsive Dialogues is to engage communities and key stakeholders to share information, galvanize action and create local solutions to reduce the burden of AMR. RDs promote collaborative problem-solving and have been identified as a potential tool for engaging diverse stakeholders in addressing AMR. However, RDs were only recently developed, and empirical evidence about their utility and feasibility in LMICs is currently limited. We piloted Responsive Dialogues (RDs) with poultry farmers, government and private pharmacists or prescribers, and male caregivers in Malawi. Using 13 semi-structured interviews and three focus groups analyzed thematically, we assessed feasibility of this participatory approach to influence inclusive local AMR policies and solutions. The participatory nature of RDs promoted inclusive decision-making and facilitated participants’ capacity to co-create locally relevant AMR solutions. Information shared during RDs improved AMR awareness, prompting participants to recognize and reconsider antibiotic practices and co-create solutions including community education on responsible use, local stewardship committees, and integrating AMR education into existing health programs. Implementation barriers varied: farmers and private prescribers expressed concerns about economic losses from reduced antibiotic use, while male caregivers reported difficulties educating others without tangible materials or resources. Considerations for AMR-RDs scale-up include resource allocation, integration with existing health systems, and further research on long-term impact across different low resource settings. Despite these challenges, this pilot demonstrates that RDs offer a feasible participatory approach for co-creating contextually relevant AMR solutions in resource-limited settings, showing promise for engaging diverse stakeholders though sustained impact requires addressing identified barriers and health system integration.

Diarrhoeal diseases are a leading cause of morbidity and mortality among children under five years in low- and middle-income countries (LMICs) with Shigella and Enterotoxigenic Escherichia coli (ETEC), both targets of ongoing vaccine development, playing major roles. To inform the introduction of vaccines against these pathogens in Ethiopia, Kenya, and Malawi, we assessed evidence needs for technical policy decisions and community engagement in national policy development processes. Using qualitative methods, we conducted 27 in-depth interviews (IDIs) with institutional stakeholders (ministries of health, researchers, and partners) and one focus group discussions (FGDs) in each country with community representatives. Data were collected between May 2023 to September 2024 and analysed thematically. Institutional stakeholders emphasised the need for robust, localised evidence on disease burden, vaccine efficacy, safety, cost-effectiveness, programmatic feasibility, alongside structured mechanisms to integrate evidence into policy. They noted the absence of diarrhoeal disease-specific technical working groups in their countries and advocated for their establishment. Meanwhile, community representatives expressed vaccine acceptance but stressed the importance of clear communication of information delivered by trusted health workers and leaders. They highlighted the need for comprehensive information on new vaccines, particularly regarding their safety and potential side effects. While community involvement in national policy-making processes was deemed low, participants highlighted the value of meaningful engagement to ensure ownership and uptake. The findings highlight the importance of robust evidence generation, effective communication, and inclusive community engagement to facilitate the successful introduction of Shigella and ETEC vaccines. Addressing these gaps can accelerate adoption, improve readiness, and foster trust in vaccination programmes.

Diarrhoea due to rotavirus remains a significant cause of child mortality in developing regions. Caregivers’ perspectives on the social determinants of gastroenteritis and childhood vaccination, including the rotavirus vaccine, were explored through focus group discussions in Ethiopia (n = 6), Kenya (n = 14), and Malawi (n = 10), using a combination of thematic and framework analysis approaches. The results show that diarrhoea was perceived to be a burden in all three countries, particularly among infants, due to challenges in WASH (water, sanitation, and hygiene) infrastructures and poverty. Prevention strategies mentioned by the caregivers focussed on enhancing WASH interventions without mention of vaccination. Participants however expressed a lack of agency to address WASH at community level in informal settlements where the studies were conducted. Antibiotics were seen as “strong medications” and often purchased without prescription for treatment of diarrhoea, raising concerns on Anti-Microbial Resistance (AMR), while home remedies such as rice porridge were used for less severe diarrhoea symptoms. Perceived or experiential benefits and safety of previous vaccines promoted vaccine uptake in all three countries. On the other hand, limited understanding of vaccines, concerns about side effects, perceived excessive vaccination, mistrust of vaccines or suspicions of existing vaccines undermined individuals’ willingness to vaccinate children. Our results highlight that a lack of attention to socio-determinants of poor health in contexts where there are several vaccines and yet a high incidence of vaccine-preventable diseases may undermine vaccine confidence. Multi-sectoral interventions to tackle social determinants of diarrhoea and improve community understanding of vaccines are required to improve overall community health outcomes.

In 2018, The Lancet reported that Brazilian researchers had successfully performed a groundbreaking uterus transplantation (UTx) from a deceased donor, leading to the birth of a healthy baby. This procedure involved removing a uterus from a 45-year-old deceased donor and transplanting it into a 32-year-old recipient, who was born without a uterus due to a congenital disorder.1 Since this pioneering achievement, UTx from deceased donors has gained global traction, offering a posthumous gift of life and fertility. By 2023, approximately 90 UTx procedures had been performed worldwide—both from deceased and living donors—with a growing number of using deceased donors, leading to over 45 successful births.2 For individuals affected by absolute uterine factor infertility—approximately 1 in 500 women of childbearing age globally2—UTx from deceased donors represents a vital reproductive option, particularly for those unable to pursue surrogacy or adoption due to religious, ethical, financial or legal constraints.2 3

Diarrhoeal diseases are a leading cause of morbidity and mortality among children under five years in low- and middle-income countries (LMICs) with Shigella and Enterotoxigenic Escherichia coli (ETEC), both targets of ongoing vaccine development, playing major roles. To inform the introduction of vaccines against these pathogens in Ethiopia, Kenya, and Malawi, we assessed evidence needs for technical policy decisions and community engagement in national policy development processes. Using in-depth interviews (IDIs) with 27 institutional stakeholders (health ministries, researchers, and partners) and focus group discussions (FGDs) with community representatives (one per country), we collected data from May 2023 to May 2024 and undertook thematic analysis. Institutional stakeholders emphasised the need for robust, localised evidence on disease burden, vaccine efficacy, safety, cost-effectiveness, programmatic feasibility, alongside structured mechanisms to integrate evidence into policy. They noted the absence of diarrhoeal disease-specific technical working groups in their countries and advocated for their establishment. Meanwhile, community representatives expressed vaccine acceptance but stressed the importance of clear communication of information delivered by trusted health workers and leaders. They highlighted the need for comprehensive information on new vaccines, particularly regarding their safety and potential side effects. While community involvement in national policy-making processes was deemed low, participants highlighted the value of meaningful engagement to ensure ownership and uptake. The findings highlight the importance of robust evidence generation, effective communication, and inclusive community engagement to facilitate the successful introduction of Shigella and ETEC vaccines. Addressing these gaps can accelerate adoption, improve readiness, and foster trust in vaccination programmes.

The workshop, Coercing for Health: Transdisciplinary Approaches to the Ethics of Coercive Public Health Policies was held at the University of Oxford on July 3rd and 4th, 2024. This paper provides both a summary of the workshop proceedings and reflections and directions for future research on coercive public health measures. The workshop consisted of four key parts: defining coercion; history and legal analysis of coercion; public health ethics perspectives on coercion; experiences of coercive public health measures. According to our reflections, some important questions remaining for further research include: what is the difference between coercion and enforcement? Who gets to define and address coercion? How do structural factors affect health and experiences of coercion? We encourage others to continue to work on this important area, to ensure the ethically acceptable and thoughtful implementation of any future coercive measures in the sphere of public health.

Providing emergency care in low resource settings relies on delivery by lower cadres of health workers (LCHW). We describe the development, implementation and mixed methods evaluation of a mobile health (mHealth) triage algorithm based on the WHO Emergency, Triage, Assessment, and Treatment (ETAT) for primary-level care. We conducted an observational study design of implementation research. Key stakeholders were engaged throughout implementation. Clinicians and LCHW at eight primary health centres in Blantyre district were trained to use an mHealth algorithm for triage. An mHealth patient surveillance system monitored patients from presentation through referral to tertiary and final outcome. A total of 209,174 children were recorded by ETAT between April 2017 and September 2018, and 155,931 had both recorded mHealth and clinician triage outcome data. Concordance between mHealth triage by lower cadres of HCW and clinician assessment was 81·6% (95% CI [81·4, 81·8]) over all outcomes (kappa: 0·535 (95% CI [0·530, 0·539]). Concordance for mHealth emergency triage was 0.31 with kappa 0.42. The most common mHealth recorded emergency sign was breathing difficulty (74·1% 95% CI [70·1, 77·9]) and priority sign was raised temperature (76·2% (95% CI [75·9, 76·6]). A total of 1,644 referrals out of 3,004 (54·7%) successfully reached the tertiary site. Both providers and carers expressed high levels of satisfaction with the mHealth ETAT pathway. An mHealth triage algorithm can be used by LCHWs with moderate concordance with clinician triage. Implementation of ETAT through an mHealth algorithm documented successful referrals from primary to tertiary, but half of referred patients did not reach the tertiary site. Potential harms of such systems, such as cases requiring referral being missed during triage, require further evaluation. The ASPIRE mHealth primary ETAT approach can be used to prioritise acute illness and support future resource planning within both district and national health system.

Community engagement (CE) is widely accepted as a critical aspect of health research because of its potential to make research more ethical, relevant and well implemented. Although CE activities linked to international health research involving Low and Middle Income Countries (LMICs; see author note) have proliferated and are increasingly described in published literature, there is a lack of conceptual clarity around how engagement is understood to ‘work’.1 Ultimately, the evidence base for CE remains underdeveloped,2 despite increasing scholarship. We conducted a realist review–a theory-driven approach to evidence synthesis—to better understand the causal dynamics of CE practices associated with health research in LMICs.3 We selected large malaria trials as the entry point for the review because there is a well-established tradition of CE in malaria research, and because this area provides a good representation of current CE practice in international biomedical research involving LMICs. In this commentary, we summarise and discuss the key findings and implications of the review.