BACKGROUND: Active case finding (ACF) for tuberculosis (TB) can reduce transmission, yet efficient targeting requires high-quality surveillance data. We investigated the potential costs and impact of targeted ACF, guided by local estimates of the annual risk of TB infection (ARTI) derived from Mycobacterium tuberculosis (Mtb) immunoreactivity survey data in children aged <5 years. METHODS AND FINDINGS: Using mathematical models parameterized with local data, we compared three case-finding approaches across 33 urban neighborhoods in Blantyre, Malawi: passive case finding (PCF) only; PCF with untargeted ACF; and PCF with ARTI-guided targeted ACF. Health outcomes (life expectancy, disability-adjusted life years [DALYs]) and costs were estimated using a Markov microsimulation model. Costs were assessed from health system and societal perspectives. Results were calculated for different assumptions about the relationship between ARTI and true TB prevalence. Compared to PCF-only, untargeted ACF was estimated to improve life expectancy by 3.3 years (95% credible interval (CrI) [1.7, 5.4]) for individuals with TB disease, but at high cost. Targeted ACF covering half of the study population was estimated to identify 80% of all individuals with TB and achieved a lower cost per DALY averted (US$400, 95% CrI [20,1,000]) than untargeted ACF (US$700, 95% CrI [100, 1,500]). In the main analysis, these cost-effectiveness ratios exceeded available cost-effectiveness thresholds for Malawi, although cost-effectiveness improved under assumptions of higher TB prevalence or greater transmission reduction. The findings are based on mathematical modeling and are subject to several limitations, including assumptions regarding the relationship between ARTI and TB prevalence, which remains uncertain. CONCLUSIONS: Targeting ACF using Mtb immunoreactivity survey data could substantially improve health impact and cost-effectiveness compared to untargeted approaches. However, low-cost approaches for collecting these data are needed for wider adoption.
Sun Kim, Melike Hazal Can, Hannah M. Rickman et al.
This article examines how teenage girls in rural KwaZulu-Natal, South Africa, navigate heterosexual relationships shaped by emotional dependency, patriarchal moralities, and intersecting structural inequalities. Drawing on focus groups and interviews with 48 school-going girls, and framed through intersectional Afro-feminist perspectives, the article shows that sexual risk-taking among rural teenage girls is rooted not in ignorance but in affective economies that equate love with sacrifice, trust with compliance, and loyalty with endurance. The findings reveal how girls’ emotional labour, such as sustaining relationships, tolerating infidelity, and avoiding conflict, becomes a key mechanism through which heteropatriarchal power is reproduced in intimate life. By foregrounding emotion as a site of political regulation and negotiation, the paper advances a relational understanding of teenage sexuality and calls for interventions that centre emotional justice, feminist relational ethics, and structural transformation. The study contributes to gender studies and, in particular, African feminist scholarship by illuminating how Black rural girls’ affective worlds expose both the vulnerabilities and the subtle resistances embedded in the everyday politics of love and survival.
The Malawi Economic Monitor (MEM) provides an analysis of economic and structural developmentissues in Malawi. This edition was published in November 2018. It follows seven previous editions of the MEM and is part of an ongoing series, with future editions to follow twice each year.The aim of the publication is to foster better-informed policy analysis and debate regarding the key challenges that Malawi faces in its endeavor to achieve high rates of stable, inclusive andsustainable economic growth. The MEM consists of two parts: Part 1 presents a review of recent economic developments and a macroeconomic outlook. Part 2 focuses on a special topic relevant to Malawi’s development prospects. In this edition, the special topic focuses on ending child marriages and early childbearing as well as improving girls’ level of educational attainment.Despite substantial progress over the last two decades, girls still have lower average levels ofeducational attainment than boys at the secondary level in many countries. This is also the case inMalawi, partly because many girls marry or have children before the age of 18, often before they are physically and emotionally ready to become wives and mothers. Educating girls, ending child marriage, and preventing early childbearing are all essential to ensure that girls have agency, not only as future wives and mothers, but also as productive citizens in a wide range of roles. These are also enablers for countries to achieve their full development potential, which requires the full participation of all citizens to the degree to which they are capable. The failure to empower women to participate therefore represents a lost opportunity. This MEM documents trends in child marriage, early childbearing and girls’ low average levels of educational attainment, with an examination of their impacts on a wide range of development outcomes. It includes estimations of the economic costs of child marriage and proposes a range of policy options to improve opportunities for adolescent girls. (Malawi)
The development objective of the Investing in Early Years for Growth and Productivity Project for Malawi is to improve coverage and utilization of early childhood development services with focus on nutrition, stimulation and early learning from conception to 59 months in selected districts of Malawi.It has four components. First component, Community-based nutrition and early stimulation interventions to consolidate and scale up the delivery of a comprehensive set of high impact and cost-effective nutrition and early stimulation interventions; Second component, Center-based early learning, nutrition and health interventions to improve the coverage and quality of preschool education and reproductive, maternal, and adolescent health services; Third component, Multisectoral coordination, capacity and system strengthening is to support capacity-building activities from national to district levels to strengthen management, coordination and implementation of nutrition, and early stimulation and early learning interventions; enhance systems and service delivery at all levels; and improve citizen engagement; Fourth component, Contingent emergency response component will allow for rapid reallocation of project proceeds in the event of a future natural or man-made disaster or crisis that has caused or is likely to imminently cause a major adverse economic and/or social impact during the life ofthe project. (Malawi)
Background Despite improvements in maternal, newborn, and child health (MNCH) service coverage in Malawi, completion of the continuum of care (CoC) remains low and unequally distributed across socioeconomic groups. This study quantified socioeconomic inequality in MNCH CoC completion and its determinants. Methods We analyzed pooled data from the 2010, 2015–16, and 2024 Malawi Demographic and Health Surveys, including 18,741 women with a live birth; analytic samples were 15,552 women for maternal CoC and 7,625 children aged 12–23 months for full CoC. Wealth-related inequality was assessed using Erreygers concentration indices. Multivariable and multilevel logistic regression identified determinants of CoC completion, while Wagstaff, Oaxaca–Blinder, Fairlie, and inequality-of-opportunity decompositions identified inequality contributors. Results Full CoC completion rose from 1.4% (2010) to 6.8% (2024); maternal CoC rose from 4.9% to 17.4%. Women completed an average of 8.3 of 11 interventions. Pro-rich inequality persisted for maternal CoC (Erreygers index = 0.036, p < 0.001); inequality in full CoC was smaller and not statistically significant (0.004, p = 0.497). Women's education, particularly higher education, was the strongest and most consistent predictor of completion (adjusted OR: 3.42 maternal, 3.45 full CoC, pooled). Contributors varied by method: education, wealth, and rural residence dominated the Wagstaff decomposition, while education, age, and parity contributed more consistently in the Oaxaca–Blinder and Fairlie decompositions. Circumstance variables reproduced the entirety of observed maternal CoC inequality, falling to 78.7% when wealth was excluded. Conclusions Although MNCH CoC coverage improved substantially in Malawi, socioeconomic inequalities persisted, particularly for maternal CoC, and were closely linked to structural circumstances. Policies improving geographic access, expanding girls’ and women's education, and addressing structural barriers may support more equitable progress toward Sustainable Development Goal 3.
Microbiological diagnosis of childhood pulmonary tuberculosis can be challenging. We investigated the accuracy of Xpert MTB/RIF Ultra on the induced sputum, focused on high-risk groups (infants, malnourished children, and those living with HIV), where data is limited. Children (under 15 years) investigated for pulmonary tuberculosis at Dora Nginza Hospital, South Africa, were prospectively enrolled between January 2018 and January 2024, and followed up for 12 months. Induced sputa were tested with liquid culture and Xpert MTB/RIF Ultra (Ultra). Children were categorized with confirmed, unconfirmed, or unlikely tuberculosis, according to NIH consensus definitions. Ultra diagnostic accuracy was calculated against culture, with analysis by high-risk subgroups. Of 636 children (median age, 27.4 (IQR 11.8-61.6) months), 173 (27.2%) were classified with confirmed TB, 384 (60.4%) with unconfirmed TB, and 79 (12.4%) with unlikely TB. There were 223 (37.8%) children underweight-for-age, 168 (26.5%) living with HIV, and 163 (25.6%) infants. Of 557 children with TB, 145 (26.0%) were confirmed on induced sputa; with 137/557 (24.6%) confirmed on Ultra (46.0%; 63/137, of which were "trace positive"), and 88/557 (15.8%), on culture. Of those confirmed, 57/145 (39.3%) were Ultra positive, culture negative - contributing 10.2% to the overall yield. Ultra performed better in children over 5 years and with weight-for-height Z-scores < -3. Overall, Ultra sensitivity was 90.9% (95%CI 82.9-96.0) and specificity, 89.6% (95%CI 86.7-92.0), with high accuracy across high-risk groups. Mortality amongst children treated for PTB was 4.9% (27/557) with aRR highest for stunted children (7.3; 95% CI, 2.2-24.2), followed by children with HIV (3.5; 95% CI, 1.6-7.5), and infants (3.3; 95% CI, 1.6-6.7). Ultra on induced sputum was feasible, with high yield and diagnostic accuracy for high-risk children.
Juaneta Luiz, Lesley Jean Workman, Cynthia B. Whitman et al.
Recently, Early Childhood Care and Learning has become a central point in the South African education spectrum. Unfortunately, this sector faces challenges, especially in economically challenged societies. Practitioners are not receiving sufficient professional development from relevant government departments, and they also struggle to find teaching and learning resources due to the prevalent socio-economic issues in the societies where their centres are located. This interpretive project, which is premised on Participatory Action Learning and Action Research as a research design, was conceptualised to support early childhood practitioners and parents in creating diverse teaching media, using recyclable materials. Engagements with practitioners after the implementation stage indicate the following: children enjoy manipulating recyclable material, practitioners value recyclable material; practitioners appreciate new pedagogical strategies; activities involving recyclable material improve children’s vocabulary significantly; the activities cement schemata; interaction in literacy classrooms improves critical skills such as critical thinking, effective listening, following instructions, speaking, problem-solving, and communication. The project concludes that literacy instruction using recyclable materials in early childhood learning may sustainably improve literacy.
Introduction: Violence against women (VAW) and violence against children (VAC) interconnect in a variety of important ways. Parenting programmes may offer promise for preventing both forms of violence, through supporting co-parenting as an avenue for reducing inter-parental conflict, and for engaging men without stigma. Method: This paper presents results from a pilot study with 50 families of the new Co-parenting Sinovuyo Caring Families Programme for Parents and Teens, which took place in rural Manicaland, Zimbabwe. It is a version of the Parenting for Lifelong Health (PLH) Teen programme, adapted to include a more explicit focus on preventing VAW and the engagement of fathers for the Zimbabwean context. A mixed methods embedded intervention design was used to assess changes in VAW and VAC from baseline to endline. Qualitative data included discussions with participant advisory boards before the pilot, individual interviews with participants at the endline, and a focus group discussion with all parenting group facilitators at the endline. Quantitative data included assessments at the endline and baseline with the primary outcome of intimate partner violence (IPV). Results: This programme led to significant reductions in reported physical IPV, co-parenting struggles, harsh parenting, parenting stress, and teen behaviour problems, but not in emotional IPV, teen-reported IPV, or attitudes to harsh punishment of children. There were significant increases in positive parenting and equitable gender attitudes. These quantitative findings are supported by the qualitative findings with participants and facilitators highlighting improved relationships between themselves and their community, families doing things together and less conflict in the home. Conclusion: This programme is promising for the prevention of VAW and VAC simultaneously.
<p dir="ltr">Background: Violence against children undermines children's rights and their development into autonomous people. Public health agendas must prioritise our understanding of this preventable health threat and inform its prevention. The Sub-Saharan African (SSA) region has some of the highest prevalences of child violence-related injuries globally. Yet, knowledge of its burden and prevention is scarce in the region, including in Mozambique.</p><p dir="ltr">Aim: The thesis aims are twofold: to increase knowledge of the burden of violence- related injuries among children in the SSA region and Mozambique and to shed light on whether the prerequisites are in place for Mozambican stakeholders to engage and succeed in the prevention of all forms of violence against children. Each aim is addressed by two complementary studies.</p><p dir="ltr">Methods: The first two papers are register-based, and the following two are based on primary data gathered through interviews. Paper I is a cross-country (SSA region), ecological study based on data from the Global Burden of Disease 2019 study (latest data available at the time of the study). The outcome was the trend in child violence-related death and DALYs and its correlation with risk factors. Descriptive statistics compiled trends over the past 30 years and Spearman's rank correlation test for the association with alcohol consumption per capita. Paper II was cross-sectional and hospital-based. Outcomes were forms of child violence-related injuries presented at the paediatric emergency and forensic unit of the Maputo Central Hospital in Mozambique. Data were extracted from medical records (2019) using a standardised Case Report Form. Descriptive analysis and chi-square tests were performed. Paper III addressed community readiness to prevent child maltreatment based on the WHO Readiness Assessment for the Prevention of Child Maltreatment-Individual questionnaire with stakeholders from national agencies and in Maputo. The questionnaire-specific scoring system and descriptive analysis were performed. Paper IV was qualitative descriptive research exploring frontline practitioners' experiences with the implementation and enforcement of child protection laws in local services in Maputo City. An inductive approach and thematic analysis by Braun and Clarke were used.</p><p dir="ltr">Results: The SSA region registered a decline in child violence-related deaths and DALYs rates between 1990 and 2019, 22.5% and 22.3%, respectively. In Mozambique, death and DALYs rates declined 22.7% and 25.3%, respectively, that the country in 2019 to match the regional average rates in 2019. A significant correlation was seen between alcohol consumption and child interpersonal violence for both death and DALYs in 2019 (r=0.446, p<0.001 and r=0.435, p<0.001, respectively) (Paper I). Among the 321 cases of child violence-related injuries treated at the hospital over one year, sexual violence was the most common form (59.5%), followed by physical violence (40.5%). While girls were the most common victims of the former (female-to-male ratio of 6.35), boys were of the latter (male- to-female ratio of 1.95). Children of both sexes sustained multiple injuries but not severe injuries due to physical violence, mainly bruises to the head or upper limbs. Girls who were victims of sexual violence suffered more serious injuries, of the kind that required surgery or intensive care (Paper II). Mozambique is at the preparation stage of prevention of child maltreatment, with a total average score of readiness of 5.4 (for a maximum of 10) according to information from professionals in the child protection sector at national and local levels. Low scores were observed in resources, scientific data, and programmes (Paper III). Through interviews with frontline practitioners, two themes were identified. The first related to barriers encountered in the implementation and enforcement of child protection laws: limited resources, a weak organisational system, legal gaps and constraints, and norms and attitudes. The second theme concerned the facilitators: resourceful support from NGOs and a favourable working environment (Paper IV).</p><p dir="ltr">Conclusion: Findings from this thesis indicate that, albeit declining, the rates of child violence-related injuries remain higher both in SSA and in Mozambique than the global average, despite the significant reduction in death and DALYs rates in the past three decades. Sexual violence, typically sustained by girls, was the most frequent form of violence among child victims seeking hospital care in Maputo Central Hospital. Mozambique is in early stages of readiness to prevent child maltreatment. Child protection services in Maputo lack the capacity to implement and enforce child protection laws to protect children from violence, mainly at the local level.</p><h3>List of scientific papers</h3><p dir="ltr">I. Trends and demographic differences in interpersonal violence against children in sub-Saharan Africa: findings from the 1990-2019 Global Burden of Disease Study. <b>Sergio Nhassengo</b>, Lucie Laflamme, Mathilde Sengoelge, GBD 2019 SSA Child Interpersonal Violence. BMJ Open. 2025;15:e083070. <a href="https://doi.org/10.1136/bmjopen-2023-083070">https://doi.org/10.1136/bmjopen-2023-083070</a></p><p dir="ltr">II. Circumstances and Consequences of Violence-Related Injuries Presenting at Hospital. A Study at the Pediatric Emergency and Forensic Medicine Units of Maputo Central Hospital, Mozambique. <b>Sérgio Keita </b><b>Nhassengo</b>, Stela Ocuane Matsinhe, Eunice Jethá and Lucie Laflamme. Int. J. Environ. Res. Public Health. 2021, 18, 12125. <a href="https://doi.org/10.3390/ijerph182212125">https://doi.org/10.3390/ijerph182212125</a></p><p dir="ltr">III. Community readiness to prevent child maltreatment in Mozambique: An investigation among key informants at country level and from Maputo city. <b>Sergio Nhassengo</b>, Lucie Laflamme, Mathilde Sengoelge. Children and Youth Services Review. 176 (2025) 108400. <a href="https://doi.org/10.1016/j.childyouth.2025.108400">https://doi.org/10.1016/j.childyouth.2025.108400</a></p><p dir="ltr">IV. Frontline practitioners' perspective of the implementation of child protection laws and prevention of violence against children in Maputo, Mozambique. <b>Sergio Nhassengo</b>, Stela Ocuane Matsinhe, Eunice Jetha, Mathilde Sengoelge, Lucie Laflamme and Asli Kulane. [Submitted]</p>
