In total, 192 of the 280 eligible PLWDs above 18 years old were screened for hypertension, with 9% (n = 17) referred for follow-up for blood pressures greater than 160 mmHg systolic or 110 mmHg diastolic. An additional 274 and 371 PLWDs were screened for malnutrition and tuberculosis, respectively. Six per cent (n = 18) of those screened for malnutrition were referred to care, as were 2% (n = 10) of those screened for tuberculosis.
As Malawi is struggling with a double burden of HIV and non-communicable diseases, programmatic approaches are needed to reach key populations where they live (Malawi Government). Because of a shortage of health workers, it may not be possible to use formally trained professionals to provide household-based screening. Limited information describing the use of task shifting to identify PLWDs and provide household screening exists in Malawi. Household-based studies report on disability identification and linkage to care by CHWs and/or non-clinical staff (Mulwafu et al.; Tataryn et al.). We could not find any programme that employed task shifting to provide integrated household screening, including hypertension screening, for PLWDs.
Secondly, the programme demonstrated the feasibility and acceptability of combining screening for HIV and other conditions, including hypertension, in a household setting: a high proportion of PLWDs accepted the services. However, few family members accepted to be screened. The screening team focused screening the PLWDs and it may be the reason that influenced lower uptake, but we were not able to collect information on why family members and some PLWDs refused some of the screening. This could be addressed in programmes similar to this case study.
Thirdly, this project provided one approach for household-based targeted disease screening, specifically for HIV, to a vulnerable population. People living with disabilities were targeted because of their limited access to services. Up to 10% of the PLWDs were referred for services. A large majority of the PLWDs had never before had an HIV test, which is striking given the considerable investments on HIV programme in Malawi. We hypothesise that this could be the result of stigma and difficulty accessing available services related to disability (Mcbain et al.). Further efforts will be required to ensure that patients who tested negative remain negative; this will be addressed through continued preventive services by the CHWs. After the pilot, we could not roll out the programme to the whole district because of limited funding; however, with funding, this could be scaled up to other settings, and considering the specific needs of PLWDs is a component of ongoing exploration in Neno for the optimisation of integrated home visits.
There are a few notable limitations to this programme. Firstly, the disability identification tool we used mainly identified self-reported functional disability. Additionally, this identifies the most common disabilities and may miss 'invisible disabilities', such as mental health disorders. We also could not measure the severity of the disabilities. Secondly, the programme was carried out with a small population in a remote area of Malawi, making it difficult to generalise to Neno and other district of Malawi. Thirdly, we were not able to cost this programme that would give more information in whether scale-up would be recommended. Fourthly, we referred patients to the nearest health facilities but were not able to ascertain if all PLWDs were successfully linked to care.
Future programmes would consider the following steps to improve on our limitations: (1) expand household screening to other common chronic condition such as diabetes as they are also common in low- and middle-income countries, (2) cover a larger population to identify more PLWDs who can benefit from the screening, (3) design efforts that can be made to ensure that many family members of PLWDs are screened and document reasons of refusals for both PLWDs and family members, (4) measure costs to help other programme managers to plan and implement this programme and (5) design strategies to ensure that referred PLWDs receive the care at the facility as they may either not go to facilities or face other barriers once they arrive at the facility.
NB: The disability-associated questions were designed by United Nations Washington Group on Disability Statistics (http://www.washingtongroup-disability.com). They were translated to local language by bilingual speaker (both English and Chichewa speaker [local language of Malawi]) and were pre-tested in the initial survey conducted in 2014. The people screened were classified as either having disability (if they have a score 2 or above) or no disability if they score 1. The type of disability was also recorded.