BackgroundYoung people living with perinatally-acquired HIV require age-appropriate support regarding sex and relationships as they progress towards adulthood. HIV affects both genders but evidence suggests that young women are particularly vulnerable to sexual abuse and more prone to engaging in sexual behaviours to meet their daily survival needs. This can result in poor sexual and reproductive health (SRH) outcomes. HIV services in Malawi provide support for young women’s HIV-related clinical needs, but it is unclear whether there is sufficient provision for their SRH needs as they become adults. This paper explores the sex and relationship experiences of young women growing up with perinatally-acquired HIV in order to understand how to improve SRH care and associated outcomes.MethodsA qualitative case study approach was adopted in which each ‘case’ comprised a young woman (15–19 years) with perinatally acquired HIV, a nominated caregiver and service provider. Participants were purposively selected from three multidisciplinary centres providing specialised paediatric/adolescent HIV care in Malawi. Data was collected for 14 cases through in-depth interviews (i.e. a total of 42 participants) and analysed using within-case and cross-case approaches. The interviews with adolescents were based on an innovative visual method known as ‘my story book’ which encouraged open discussion on sensitive topics.ResultsYoung women reported becoming sexually active at an early age for different reasons. Some sought a sense of intimacy, love, acceptance and belonging in these relationships, noting that they lacked this at home and/or within their peer groups. For others, their sexual activity was more functional – related to meeting survival needs. Young women reported having little control over negotiating safer sex or contraception. Their priority was preventing unwanted pregnancies yet several of the sample already had babies, and transfer to antenatal services created major disruptions in their HIV care. In contrast, caregivers and nurses regarded sexual activity from a clinical perspective, fearing onward transmission of HIV and advocating abstinence or condoms where possible. In addition, a cultural silence rooted in dominant religious and traditional norms closed down possibilities for discussion about sexual matters and prevented young women from accessing contraception.ConclusionThe study has shown how young women, caregivers and service providers have contrasting perspectives and priorities around SRH care. Illumination of these differences highlights a need for service improvement. It is suggested that young women themselves are involved in future service improvement initiatives to encourage the development of culturally and socially acceptable pathways of care.Electronic supplementary materialThe online version of this article (10.1186/s12905-017-0485-9) contains supplementary material, which is available to authorized users.

Background Voluntary medical male circumcision (VMMC) is becoming more popular as an important HIV prevention strategy. Malawi, with a high HIV and AIDS prevalence rate of 8.8% and a low male circumcision prevalence rate of 28% in 2016, is one of the priority countries recommended for VMMC scale-up. This paper investigates the attitudes and key challenges to VMMC adoption in a traditionally circumcising community in Malawi where male circumcision is culturally significant. Methods A mixed design study using quantitative and qualitative data collection methods was carried out to determine the attitudes of 262 randomly selected males towards VMMC in a culturally circumcising community in Malawi. Statistical Package for the Social Sciences (SPSS) version 20 was used to analyse the quantitative data. To identify predictors of VMMC uptake, we used logistic regression analysis. To identify the themes, qualitative data were analysed using content analysis. Results The findings indicate that, while more males in this community prefer medical circumcision, traditional circumcision is still practised. Panic (63%) perceived surgical complications (31%), and cost (27%) in accessing VMMC services were some of the barriers to VMMC uptake. Age and culture were found to be statistically significant predictors of voluntary medical male circumcision in the logistic analysis. According to qualitative data analysis, the key challenges to VMMC uptake were the involvement of female health workers in the circumcision team and the incentives provided to traditional circumcisers. Conclusion According to the findings of this study, VMMC services should be provided in a culturally competent manner that respects and considers existing cultural beliefs and practices in the community. Coordination between local leaders and health workers should be encouraged so that VMMC services are provided in traditional settings, allowing for safe outcomes, and increasing VMMC uptake.

Background: Ethical competence in nursing practice helps clinical nurses to think critically, analyse issues, make ethical decisions, solve ethical problems and behave ethically in their daily work. Thus, ethical competence contributes to the promotion of high-quality care. However, studies on ethical competence in Malawi are scanty. Objectives: The aim of this study was to explore ethical competence among clinical nurses in selected hospitals in Malawi. Methodology: A cross-sectional survey was conducted in four selected hospitals in Malawi with a sample of 271 clinical nurses. Data were collected using self-administered questionnaires, which included a Moral Competence Scale for Home Care Nurses. Descriptive statistics and logistic regression were computed for the dataset using STATA version 12.0. Ethical consideration: The study protocol complied with all ethical requirements and was approved by the College of Medicine Research Ethics Committee under the University of Malawi. Results: The clinical nurses in Malawi are ethically competent. However, there is a significantly high number (p < 0.05) of nurses 57% (n = 135) with low ethical competence. There was no significant association between respondents’ demographic variables and level of ethical competence (p > 0.05). Three determinants of high ethical competence level (strong will, judgement skills and recognition of discrepancy of intention) were identified through a reduced model after stepwise logistic regression analysis. Furthermore, results show that indicators of ethical competence include caring, confidentiality and observance of nurses dressing code. The study has also confirmed that the Moral Competence Scale for Home Care Nurses is a reliable tool to assess ethical competence in low-resource settings. Conclusion: The majority of nurses who completed the survey had low ethical competence. However, clinical nurses with high ethical competence level are required to competently manage complex ethical challenges in health facilities. Strategies for enhancing ethical competence such as continuing ethics education, establishment of ethics committees and provision of supportive supervision are recommended to enable nurses in Malawi attain a high level of ethical competence.

Malawi has one of the highest HIV prevalence rates (8.9%), and data suggest 27% pain prevalence among adolescents living with HIV (ALHIV) in Malawi. Pain among ALHIV is often under-reported and pain management is suboptimal. We aimed to explore stakeholders' perspectives and experiences on pain self-management for ALHIV and chronic pain in Malawi. We conducted cross-sectional in-depth qualitative interviews with adolescents/caregiver dyads and healthcare professionals working in HIV clinics. Data were audio-recorded, transcribed verbatim and translated (where applicable) then imported into NVivo version 12 software for framework analysis. We identified three main themes: (1) Experiencing "total pain": adolescents experienced physical, psychosocial, and spiritual pain which impacted their daily life activities.(2) Current self-management approaches: participants prefer group-based self-management approaches facilitated by healthcare professionals or peers at the clinic focussing on selfmanagement of physical, psychosocial, and spiritual pain. (3) Current pain strategies: participants used prescribed drugs, traditional medicine, and non-pharmacological interventions, such as exercises to manage pain. A person-centred care approach to selfmanagement of chronic pain among ALHIV is needed to mitigate the impact of pain on their daily activities. There is a need to integrate self-management approaches within the existing structures such as teen clubs in primary care.

PurposeThe purpose of this systematic review was to explore the benefits and challenges in the implementation of simulation-based education (SBE) in the classroom and clinical settings in sub-Saharan Africa. The objectives of this systematic review were to identify the benefits of utilising SBE in the classroom and clinical practice in sub-Saharan Africa and to assess the challenges in the implementation of SBE in the classroom and clinical practice in sub-Saharan Africa.Design/methodology/approachFive databases were searched for existing English literature (Medline, CINAHL and Science Direct), including grey literature on the subject. Out of 26 eligible studies conducted in sub-Saharan Africa between 2014 and 2021, six studies that used mixed-methods design were included. Hawker et al.’s framework was used to assess the quality of the studies. Quantitative data were presented using descriptive and inferential statistics in the form of means and standard deviations while qualitative data were analysed and presented thematically.FindingsQuantitative findings showed that participants rated SBE highly in terms of teaching (93.2%), learning (91.4%) and skill acquisition (88.6%). SBE improved the clinical skill competency from 30% at baseline to 75% at the end. On the other hand, qualitative findings yielded themes namely: improved confidence and competence; knowledge acquisition and critical thinking; motivation and supervision; independent, self-paced learning; simulation equipment and work schedules; and planning and delivery of simulation activity. Pedagogical skills, competence and confidence are some of the elements that determine the feasibility of implementing SBE in the classroom and clinical settings.Practical implicationsSBE could help to bridge the gap between theory and practice and improve the quality of care provided by nurses. Simulation-based training is effective in improving the clinical skills of midwives and increasing their confidence in providing care. However, SBE trainees require motivation and close supervision in classroom settings if simulation is to be successfully implemented in sub-Saharan Africa. Furthermore, careful planning of scenarios, students briefing and reading of content prior to implementation facilitate effective simulation.Originality/valueWhile there may be a lack of literature on the use of SBE for training nurses and midwives in the developing world, there is growing evidence that it can be an effective way to improve clinical skills and quality of care. However, there are also significant challenges to implementing simulation-based training in resource-limited settings, and more research is needed to understand how best to address these challenges. This study fills this gap in the literature.