Assessing stakeholder perceptions and contextual factors in implementing post-discharge malaria chemoprevention in children with severe anaemia in Malawi

Severe anaemia poses a significant threat to children under five in sub-Saharan Africa, serving as one of the leading causes of hospitalisation and mortality in Malawi. In endemic regions, malaria complicates recovery in children admitted with severe anaemia and increases relapse risk. The World Health Organization (WHO) recommends post-discharge malaria chemoprevention (PDMC) in moderate to high malaria transmission areas to reduce post-discharge mortality and readmissions. Still, it offers limited guidance on its implementation. This formative research study aimed to assess stakeholders’ perceptions of the WHO recommendation on PDMC and considerations for its practical implementation in Malawi. This exploratory qualitative study, conducted in May 2024, employed in-depth and key informant interviews across various stakeholder levels in Malawi. We purposively sampled 31 participants. Interviews were audio-recorded, transcribed verbatim, and thematically analysed using inductive coding in NVivo 14. Stakeholders revealed a continued high burden of malaria and anaemia, with significant gaps in knowledge among Health Surveillance Assistants and follow-up care. Caregivers faced numerous barriers to timely healthcare access, including traditional beliefs, financial constraints, and logistical challenges. Four broad themes emerged from the data: (i) understanding the dual challenge of malaria and anaemia in Malawian children, (ii) barriers to timely healthcare access, (iii) stakeholder perspectives on strategies to improve caregiver adherence to the PDMC regimen, and (iv) PDMC implementation considerations. Findings underscore operational challenges such as logistical constraints, medication supply issues, and targeted health worker training. It emphasises the importance of community engagement, strengthening supply chains, and integrating PDMC into health systems. Effective implementation will require collaboration among government agencies, health organisations, and local communities to foster sustainable practices, improve caregiver support, and ensure equitable access. These insights advance implementation science by illustrating how interventions like PDMC can be adapted and scaled in low-resource, high-burden settings to reduce childhood malaria and anaemia-related morbidity and mortality.