Bayesian belief networks to analyse trade-offs among ecosystem services at the regional scale

Knowledge on trade-offs and synergies among ecosystem services is crucial for the design of land use strategies that optimize ecosystem service delivery. Correlation coefficients, obtained through pairwise comparison of ecosystem service provision maps, have been put forward as suitable indicators to quantify these interactions. However, for more in depth analyses of trade-offs and synergies where driving forces of interactions need to be determined, more sophisticated methods are needed. Although Bayesian belief networks have been frequently mentioned as promising tools to investigate interactions among ecosystem services, up till now, no structured approaches to do so have been suggested. This paper presents a way to analyse trade-offs and synergies among ecosystem services together with their driving forces. Joint probability distributions of ecosystem service pairs, which can be calculated by using Bayesian belief network models, are used to quantify interactions. The paper demonstrates the approach by quantifying trade-offs and synergies among several ecosystem services in Flanders, Belgium. Our analysis identifies two bundles of ecosystem services which react synergistically. Wood production and several regulating services on the one hand and food production and soil formation on the other hand. Trade-offs are identified among food production and most of the other services that were included into the analysis. In addition to these general findings, the analysis shows that the identified interactions may change depending on the considered environmental conditions, specified through soil type, land cover and land use.     

The mangrove-based coastal and nearshore fisheries of Bangladesh: ecology,exploitation and management

The mangrove forest of Bangladesh, the largest continuous mangrove forest of the world, is one of the most important coastal features of the country. The existence of the mangrove has increased the values of other coastal and marine resources such as the coastal and marine fisheries by increasing productivity and supporting a wide biological diversity. The artisanal fishery, which is highly influenced by mangroves, has been contributing 85–95% of the total coastal and marine catch of Bangladesh. The mangrove also supports offshore and deep sea fisheries by playing a significant role as nursery ground for many deep sea fishes and shrimps including the giant tiger shrimp (Penaeus monodon) which is the major species of the industrial bottom trawl fishery of Bangladesh. The mangrove also contributes significantly in shrimp farming which has been the most significant export-oriented industry since the 1970s. However, the mangrove fisheries have been under intensive pressure from deleterious fishing activities and deliberate aquaculture development by destructing mangrove habitats. The impacts of mangrove have been reflected in the contribution of artisanal fishery catch that has been in a continuous decline since the 1980s. Shrimp farming has been the most destructive contributor to mangrove destruction with a corresponding loss of biological resources particularly the wild shrimp fishery. This paper reviews different aspects of the mangrove fisheries of Bangladesh and discusses the impacts of different fisheries. The paper identifies the importance of reviewing, amending and/or replacing the traditional management approaches by the new management techniques such as habitat restoration and stock enhancement in the natural environment; the paper also identifies the need for research findings in formulating and implementing new management approaches.     

桑沟湾海洋生态系统的服务价值

对我国黄海内的典型集约化浅海养殖区域——桑沟湾的生态系统服务价值进行了评估.结果表明:2003年桑沟湾的总服务价值为6.07×108元,平均单位海域面积的服务价值为4.24×106元.km-2.在总服务价值中,供给服务、调节服务和文化服务分别占51.29%、17.34%和31.37%.在所评估的8项主要和次要生态系统服务中,食品供给服务价值最高(50.45%),其次是旅游和娱乐服务价值(29.89%)及气候调节服务价值(9.18%),最低的是有害生物与疾病的生物调节与控制服务价值(0.0017%).桑沟湾的养殖活动对当地社会经济、环境调节与社会文化均有较大贡献.海水养殖活动,特别是大型藻类的养殖对于维持和提升海洋生态系统的服务具有重要意义.     

Ecosystem approach to inland fisheries: research needs and implementation strategies

Inland fisheries are a vital component in the livelihoods and food security of people throughout the world, as well as contributing huge recreational and economic benefits. These valuable assets are jeopardized by lack of research-based understanding of the impacts of fisheries on inland ecosystems, and similarly the impact of human activities associated with inland waters on fisheries and aquatic biodiversity. To explore this topic, an international workshop was organized in order to examine strategies to incorporate fisheries into ecosystem approaches for management of inland waters. To achieve this goal, a new research agenda is needed that focuses on: quantifying the ecosystem services provided by fresh waters; quantifying the economic, social and nutritional benefits of inland fisheries; improving assessments designed to evaluate fisheries exploitation potential; and examining feedbacks between fisheries, ecosystem productivity and aquatic biodiversity. Accomplishing these objectives will require merging natural and social science approaches to address coupled social-ecological system dynamics.     

Habitat Fragmentation Intensifies Trade-Offs between Biodiversity and Ecosystem Services in a Heathland Ecosystem in Southern England

While habitat fragmentation represents a major threat to global biodiversity, its impacts on provision of ecosystem services are largely unknown. We analysed biodiversity value and provision of multiple ecosystem services in 110 fragments of lowland heathland ecosystems in southern England, in which vegetation dynamics have been monitored for over 30 years. Decreasing fragment size was found to be associated with a decrease in biodiversity and recreational values, but an increase in relative carbon storage, aesthetic value and timber value. The trade-off between either biodiversity or recreational values with the other ecosystem services therefore became more pronounced as heathland size decreased. This was attributed to a higher rate of woody succession in smaller heathland fragments over the past three decades, and contrasting values of different successional vegetation types for biodiversity and provision of ecosystem services. These results suggest that habitat fragmentation can reduce the potential for developing “win win” solutions that contribute to biodiversity conservation while also supporting socio-economic development. Approaches to multi-purpose management of fragmented landscapes should therefore consider the potential trade-offs in ecosystem services and biodiversity associated with fragmentation, in order to make an effective contribution to sustainable development.     

INTEGRATING SEAWEEDS INTO MARINE AQUACULTURE SYSTEMS: A KEY TOWARD SUSTAINABILITY

The rapid development of intensive fed aquaculture (e.g. finfish and shrimp) throughout the world is associated with concerns about the environmental impacts of such often monospecific practices, especially where activities are highly geographically concentrated or located in suboptimal sites whose assimilative capacity is poorly understood and, consequently, prone to being exceeded. One of the main environmental issues is the direct discharge of significant nutrient loads into coastal waters from open-water systems and with the effluents from land-based systems. In its search for best management practices, the aquaculture industry should develop innovative and responsible practices that optimize its efficiency and create diversification, while ensuring the remediation of the consequences of its activities to maintain the health of coastal waters. To avoid pronounced shifts in coastal processes, conversion, not dilution, is a common-sense solution, used for centuries in Asian countries. By integrating fed aquaculture (finfish, shrimp) with inorganic and organic extractive aquaculture (seaweed and shellfish), the wastes of one resource user become a resource (fertilizer or food) for the others. Such a balanced ecosystem approach provides nutrient bioremediation capability, mutual benefits to the cocultured organisms, economic diversification by producing other value-added marine crops, and increased profitability per cultivation unit for the aquaculture industry. Moreover, as guidelines and regulations on aquaculture effluents are forthcoming in several countries, using appropriately selected seaweeds as renewable biological nutrient scrubbers represents a cost-effective means for reaching compliance by reducing the internalization of the total environmental costs. By adopting integrated polytrophic practices, the aquaculture industry should find increasing environmental, economic, and social acceptability and become a full and sustainable partner within the development of integrated coastal management frameworks.     

Mangroves and brackishwater pond culture in the Philippines

Around 50% of mangrove loss in the Philippines can be traced to brackishwater pond construction. The decrease in mangroves from 450 000 ha in 1920 to 132 500 ha in 1990 has been accompanied by expansion of culture ponds to 223 000 ha in 1990. The history of fishpond development in the country includes a government-sponsored fishpond boom in the 1950-g and 1960s, the proconservation decade of the 1970s followed by a shrimp fever in the 1980s. Production from brackisshwater ponds has increased from 15 900 mt worth P7.6 million in 1938 to 267 000 mt valued at P6.5 billion in 1990. On the other hand, the maximum valuation of over $11 000 ha^–1 yr^–1 for unmanaged and managed mangrove forests makes them economically on par with the most profitable pond farming systems. The loss of mangrove systems and their varied goods and services is the single most important consequence of brackishwater pond culture in the Philippines. Moreover, intensive shrimp farming is associated with other ecological and socioeconomic effects such as pollution of coastal waters and decline in domestic food crops. New legislation and enforcement of existing laws, conservation of remaining mangroves, massive rehabilitation of denuded mangrove areas, and promotion of sustainable aquaculture and fisheries are recommended.     

The Loss of Species: Mangrove Extinction Risk and Geographic Areas of Global Concern

Mangrove species are uniquely adapted to tropical and subtropical coasts, and although relatively low in number of species, mangrove forests provide at least US $1.6 billion each year in ecosystem services and support coastal livelihoods worldwide. Globally, mangrove areas are declining rapidly as they are cleared for coastal development and aquaculture and logged for timber and fuel production. Little is known about the effects of mangrove area loss on individual mangrove species and local or regional populations. To address this gap, species-specific information on global distribution, population status, life history traits, and major threats were compiled for each of the 70 known species of mangroves. Each species'' probability of extinction was assessed under the Categories and Criteria of the IUCN Red List of Threatened Species. Eleven of the 70 mangrove species (16%) are at elevated threat of extinction. Particular areas of geographical concern include the Atlantic and Pacific coasts of Central America, where as many as 40% of mangroves species present are threatened with extinction. Across the globe, mangrove species found primarily in the high intertidal and upstream estuarine zones, which often have specific freshwater requirements and patchy distributions, are the most threatened because they are often the first cleared for development of aquaculture and agriculture. The loss of mangrove species will have devastating economic and environmental consequences for coastal communities, especially in those areas with low mangrove diversity and high mangrove area or species loss. Several species at high risk of extinction may disappear well before the next decade if existing protective measures are not enforced.     

Charcoal production in the Mopane woodlands of Mozambique: what are the trade-offs with other ecosystem services?

African woodlands form a major part of the tropical grassy biome and support the livelihoods of millions of rural and urban people. Charcoal production in particular is a major economic activity, but its impact on other ecosystem services is little studied. To address this, our study collected biophysical and social datasets, which were combined in ecological production functions, to assess ecosystem service provision and its change under different charcoal production scenarios in Gaza Province, southern Mozambique. We found that villages with longer histories of charcoal production had experienced declines in wood suitable for charcoal, firewood and construction, and tended to have lower perceived availabilities of these services. Scenarios of future charcoal impacts indicated that firewood and woody construction services were likely to trade-off with charcoal production. However, even under the most extreme charcoal scenario, these services were not completely lost. Other provisioning services, such as wild food, medicinal plants and grass, were largely unaffected by charcoal production. To reduce the future impacts of charcoal production, producers must avoid increased intensification of charcoal extraction by avoiding the expansion of species and sizes of trees used for charcoal production. This is a major challenge to land managers and policymakers in the area.This article is part of the themed issue ‘Tropical grassy biomes: linking ecology, human use and conservation’.     

Alcohol Production as an Adaptive Livelihood Strategy for Women Farmers in Tanzania and Its Potential for Unintended Consequences on Women’s Reproductive Health

Background

Although women occupy a central position in agriculture in many developing countries, they face numerous constraints to achieving their full potential including unequal access to assets and limited decision-making authority. We explore the intersection of agricultural livelihoods, food and economic security, and women’s sexual and reproductive health in Iringa Region, Tanzania. Our goal was to understand whether the benefits of supporting women in the agricultural sector might also extend to more distal outcomes, including sexual and reproductive health.

Methods

Using the Sustainable Livelihoods Framework to guide data collection, we conducted 13 focus group discussions (FGD) with female (n = 11) and male farmers (n = 2) and 20 in-depth interviews with agricultural extension officers (n = 10) and village agro-dealers (n = 10).

Results

Despite providing the majority of agricultural labor, women have limited control over land and earned income and have little bargaining power. In response to these constraints, women adopt adaptive livelihood strategies, such as alcohol production, that allow them to retain control over income and support their households. However, women’s central role in alcohol production, in concert with the ubiquitous nature of alcohol consumption, places them at risk by enhancing their vulnerability to unsafe or transactional sex. This represents a dangerous confluence of risk for female farmers, in which alcohol plays an important role in income generation and also facilitates high-risk sexual behavior.

Conclusions

Alcohol production and consumption has the potential to both directly and indirectly place women at risk for undesirable sexual and reproductive health outcomes. Group formation, better access to finance, and engaging with agricultural extension officers were identified as potential interventions for supporting women farmers and challenging harmful gender norms. In addition, joint, multi-sectoral approaches from health and agriculture and alternative income-generating strategies for women might better address the complexities of achieving safe and sustainable livelihoods for women in this context.     

Mangroves as filters of shrimp pond effluent: predictions and biogeochemical research needs

Preliminary estimates of the ratio of mangrove forest: shrimp pond area necessary to remove nutrients from shrimp pond effluent are made using budgets of nitrogen and phosphorus output for semi-intensive and intensive shrimp ponds combined with estimates of total net primary production in Rhizophora-dominated mangrove forests in tropical coastal areas. If effluent is delivered directly to mangrove forest plots, it is estimated that, depending on shrimp pond management, between 2 and 22 hectares of forest are required to filter the nitrogen and phosphorus loads from effluent produced by a 1 hectare pond. While such ratios may apply to small scale, integrated shrimp aquaculture — mangrove forestry farming systems, the variability in mangrove hydrodynamics makes it difficult to apply such ratios at a regional scale. Before mangroves can be used to strip shrimp pond effluent more research is required on the effects that high ammonia and particulate organic matter loads in pond effluent have on nutrient transformations in mangrove sediments and on forest growth.     

Review of the ecosystem service implications of mangrove encroachment into salt marshes

Salt marsh and mangrove have been recognized as being among the most valuable ecosystem types globally in terms of their supply of ecosystem services and support for human livelihoods. These coastal ecosystems are also susceptible to the impacts of climate change and rising sea levels, with evidence of global shifts in the distribution of mangroves, including encroachment into salt marshes. The encroachment of woody mangrove shrubs and trees into herbaceous salt marshes may represent a substantial change in ecosystem structure, although resulting impacts on ecosystem functions and service provisions are largely unknown. In this review, we assess changes in ecosystem services associated with mangrove encroachment. While there is quantitative evidence to suggest that mangrove encroachment may enhance carbon storage and the capacity of a wetland to increase surface elevation in response to sea‐level rise, for most services there has been no direct assessment of encroachment impact. On the basis of current understanding of ecosystem structure and function, we theorize that mangrove encroachment may increase nutrient storage and improve storm protection, but cause declines in habitat availability for fauna requiring open vegetation structure (such as migratory birds and foraging bats) as well as the recreational and cultural activities associated with this fauna (e.g., birdwatching and/or hunting). Changes to provisional services such as fisheries productivity and cultural services are likely to be site specific and dependent on the species involved. We discuss the need for explicit experimental testing of the effects of encroachment on ecosystem services in order to address key knowledge gaps, and present an overview of the options available to coastal resource managers during a time of environmental change.     

Impacts of large‐scale forest restoration on socioeconomic status and local livelihoods: what we know and do not know

Forests are sources of wood, non‐timber forest products and ecosystems services and goods that benefit society as a whole, and are especially important to rural livelihoods. Forest landscape restoration (FLR) has been proposed as a way to counteract deforestation and reconcile the production of ecosystem services and goods with conservation and development goals. But limited evidence indicates how large‐scale forest restoration could contribute to improving local livelihoods. Here, we present a conceptual framework to analyze the effects of large‐scale restoration on local livelihoods, and use it to review the scientific literature and reduce this knowledge gap. Most of the literature referred to case studies (89%), largely concentrated in China (49%). The main theme explored was income, followed by livelihoods diversification, off‐farm employment opportunities, poverty reduction, equity and the provision of timber and energy as ecosystem services. Nearly 60 percent of the papers discussed the importance of governance systems to socioeconomic outcomes. The reforestation/restoration programs and policies investigated in the studies had mixed socioeconomic effects on local livelihoods depending on other variables, such as availability of off‐farm jobs, household characteristics, land productivity, land tenure, and markets for forest products and ecosystem services. We conclude that the effects of large‐scale restoration initiatives on local livelihoods may vary due to several factors and is still not clear for many situations; therefore, monitoring over time with clear indicators is needed.     

Ecological impacts of non-native Pacific oysters (<Emphasis Type="Italic">Crassostrea gigas</Emphasis>) and management measures for protected areas in Europe

Pacific oysters are now one of the most ‘globalised’ marine invertebrates. They dominate bivalve aquaculture production in many regions and wild populations are increasingly becoming established, with potential to displace native species and modify habitats and ecosystems. While some fishing communities may benefit from wild populations, there is now a tension between the continued production of Pacific oysters and risk to biodiversity, which is of particular concern within protected sites. The issue of the Pacific oyster therefore locates at the intersection between two policy areas: one concerning the conservation of protected habitats, the other relating to livelihoods and the socio-economics of coastal aquaculture and fishing communities. To help provide an informed basis for management decisions, we first summarise evidence for ecological impacts of wild Pacific oysters in representative coastal habitats. At local scales, it is clear that establishment of Pacific oysters can significantly alter diversity, community structure and ecosystem processes, with effects varying among habitats and locations and with the density of oysters. Less evidence is available to evaluate regional-scale impacts. A range of management measures have been applied to mitigate negative impacts of wild Pacific oysters and we develop recommendations which are consistent with the scientific evidence and believe compatible with multiple interests. We conclude that all stakeholders must engage in regional decision making to help minimise negative environmental impacts, and promote sustainable industry development.     

A review on the present status and management of mangrove wetland habitat resources in Bangladesh with emphasis on mangrove fisheries and aquaculture

The mangrove forest of Bangladesh, the largest continuous mangrove bulk, is one of the most important features of the coastal area of the country. The existence of the mangrove has increased the values of other coastal and marine resources such as the coastal and marine fisheries by increasing productivity and supporting a wide biological diversity. The deltaic mangrove of Bangladesh is ecologically different from the other, mostly nondeltaic mangroves of the world and is unique also in its floral and faunal assemblage; therefore, a number of endangered plants and animals that are extinct from other parts of the world, are existing in Bangladesh mangrove. However, the mangrove has been under intensive pressure of exploitation for the last few decades which, in addition to direct clearance and conversion have placed the mangrove under extreme threat. Shrimp farming is the most destructive form of resource use the mangrove has been converted to, which contributed significantly to mangrove destruction with a corresponding loss of biological resources. Concerns have been raised among the ecologists, biologists, managers and policy makers since the early 1990s; deliberate destruction of mangrove and unplanned development of coastal aquaculture particularly shrimp aquaculture have been put under extreme criticism and the sustainability has been questioned. The present status of the mangrove resources including mangrove fisheries and aquaculture and management practices have been reviewed in this paper; impacts of different forms of human interventions and resource use have also been discussed. It is suggested that the management options and the policy aspects should be critically reviewed and amended accordingly; beneficiaries and stakeholders at all levels of resource exploitation must take part and contribute to conservation and management. An immediate need for mangrove conservation has been identified.     

A Scoping Analysis of Peer-Reviewed Literature About Linkages Between Aquaculture and Determinants of Human Health

For many of the world’s poor, aquatic products are critical for food security and health. Because the global population is increasing as wild aquatic stocks are declining, aquaculture is an increasingly important source of aquatic products. We undertook a scoping review of the English-language peer-reviewed literature to evaluate how the research community has examined the impacts of aquaculture on four key determinants of human health: poverty, food security, food production sustainability, and gender equality. The review returned 156 primary research articles. Most research (75%) was focused in Asia, with limited research from Africa (10%) and South America (2%). Most research (80%) focused on freshwater finfish and shrimp production. We used qualitative content analysis of records which revealed 11 themes: famer income; the common environment; shared resources; integrated farming/ polyculture; employment; extensive vs. intensive production; local vs. distant ownership; food security; income equity; gender equality; and input costs. We used quantitative content analysis of records and full-text publications about freshwater finfish and shrimp aquaculture to record the frequency with which themes were represented and the positive or negative impacts of aquaculture associated with each theme. Scatter plots showed that no theme was identified in more than half of all articles and publications for both production types. Farmer income was a theme that was identified commonly and was positively impacted by both shrimp and fresh water finfish aquaculture. Polyculture, employment, and local ownership were identified less often as themes, but were also associated with positive impacts. The common environment and shared resources were more common themes in shrimp aquaculture than freshwater finfish aquaculture research, while polyculture and local ownership were more common themes in freshwater finfish aquaculture than shrimp aquaculture. Gender equality, employment, and food security were themes found in a lower percentage of records than full-text publications for both production types.     

What Magnitude Are Observed Non-Target Impacts from Weed Biocontrol?

A systematic review focused by plant on non-target impacts from agents deliberately introduced for the biological control of weeds found significant non-target impacts to be rare. The magnitude of direct impact of 43 biocontrol agents on 140 non-target plants was retrospectively categorized using a risk management framework for ecological impacts of invasive species (minimal, minor, moderate, major, massive). The vast majority of agents introduced for classical biological control of weeds (>99% of 512 agents released) have had no known significant adverse effects on non-target plants thus far; major effects suppressing non-target plant populations could be expected to be detectable. Most direct non-target impacts on plants (91.6%) were categorized as minimal or minor in magnitude with no known adverse long-term impact on non-target plant populations, but a few cacti and thistles are affected at moderate (n = 3), major (n = 7) to massive (n = 1) scale. The largest direct impacts are from two agents (Cactoblastis cactorum on native cacti and Rhinocyllus conicus on native thistles), but these introductions would not be permitted today as more balanced attitudes exist to plant biodiversity, driven by both society and the scientific community. Our analysis shows (as far as is known), weed biological control agents have a biosafety track record of >99% of cases avoiding significant non-target impacts on plant populations. Some impacts could have been overlooked, but this seems unlikely to change the basic distribution of very limited adverse effects. Fewer non-target impacts can be expected in future because of improved science and incorporation of wider values. Failure to use biological control represents a significant opportunity cost from the certainty of ongoing adverse impacts from invasive weeds. It is recommended that a simple five-step scale be used to better communicate the risk of consequences from both action (classical biological control) and no action (ongoing impacts from invasive weeds).     

Fine-Scale Variability in Harbor Seal Foraging Behavior

Understanding the variability of foraging behavior within a population of predators is important for determining their role in the ecosystem and how they may respond to future ecosystem changes. However, such variability has seldom been studied in harbor seals on a fine spatial scale (<30 km). We used a combination of standard and Bayesian generalized linear mixed models to explore how environmental variables influenced the dive behavior of harbor seals. Time-depth recorders were deployed on harbor seals from two haul-out sites in the Salish Sea in 2007 (n = 18) and 2008 (n = 11). Three behavioral bout types were classified from six dive types within each bout; however, one of these bout types was related to haul-out activity and was excluded from analyses. Deep foraging bouts (Type I) were the predominant type used throughout the study; however, variation in the use of bout types was observed relative to haul-out site, season, sex, and light (day/night). The proportional use of Type I and Type II (shallow foraging/traveling) bouts differed dramatically between haul-out sites, seasons, sexes, and whether it was day or night; individual variability between seals also contributed to the observed differences. We hypothesize that this variation in dive behavior was related to habitat or prey specialization by seals from different haul-out sites, or individual variability between seals in the study area. The results highlight the potential influence of habitat and specialization on the foraging behavior of harbor seals, and may help explain the variability in diet that is observed between different haul-out site groups in this population.     

景观空间异质性对生态系统服务形成与供给的影响

景观空间异质性与生态系统服务的关系极为密切,适当调整景观空间异质性有助于生态系统服务的持续形成与稳定供给。研究景观空间异质性和生态系统服务形成与供给之间的相互影响作用及响应机制具有重要的理论与现实意义,是保护生物多样性、管理生态系统服务与优化景观空间配置的基础。现有研究大多在不同尺度上探讨了景观格局与生态过程或生态系统服务间的相互影响关系,而缺乏景观格局-生态过程-生态系统服务三者间有效联结等方面的研究。景观空间异质性是怎样直接或间接地作用于生态系统服务形成与供给的,目前还没有一个较为明确的解释。因此,通过分析国内外文献,回顾了景观格局或景观空间异质性与生态系统服务之间关系的研究进展、研究内容和研究方法;从景观组成、景观构型的变化入手,讨论了景观空间异质性对生态系统服务形成与供给的影响及其强度,并认为景观组成异质性变化能够直接影响生态系统服务,而景观构型异质性变化会通过改变生态过程而间接影响生态系统服务;阐述了景观空间异质性在影响生态系统服务形成与供给的同时,也使生态系统服务在空间上产生了异质性分布,并从自然因素和人为因素两个方面对其进行解释;强调了尺度问题在景观空间异质性与生态系统服务研究中的重要性;最后,明确了对生态系统服务形成与供给的景观空间异质性影响研究不仅有助于生态系统服务的维持与调节,也能更深层次地揭示其中的生态学意义。     

Assessing and Responding to Palliative Care Needs in Rural Sub-Saharan Africa: Results from a Model Intervention and Situation Analysis in Malawi

Introduction

Palliative care is rarely accessible in rural sub-Saharan Africa. Partners In Health and the Malawi government established the Neno Palliative Care Program (NPCP) to provide palliative care in rural Neno district. We conducted a situation analysis to evaluate early NPCP outcomes and better understand palliative care needs, knowledge, and preferences.

Methods

Employing rapid evaluation methodology, we collected data from 3 sources: 1) chart review of all adult patients from the NPCP’s first 9 months; 2) structured interviews with patients and caregivers; 3) semi-structured interviews with key stakeholders.

Results

The NPCP enrolled 63 patients in its first 9 months. Frequent diagnoses were cancer (n = 50, 79%) and HIV/AIDS (n = 37 of 61, 61%). Nearly all (n = 31, 84%) patients with HIV/AIDS were on antiretroviral therapy. Providers registered 112 patient encounters, including 22 (20%) home visits. Most (n = 43, 68%) patients had documented pain at baseline, of whom 23 (53%) were treated with morphine. A majority (n = 35, 56%) had ≥1 follow-up encounter. Mean African Palliative Outcome Scale pain score decreased non-significantly between baseline and follow-up (3.0 vs. 2.7, p = 0.5) for patients with baseline pain and complete pain assessment documentation. Providers referred 48 (76%) patients for psychosocial services, including community health worker support, socioeconomic assistance, or both. We interviewed 36 patients referred to the NPCP after the chart review period. Most had cancer (n = 19, 53%) or HIV/AIDS (n = 10, 28%). Patients frequently reported needing income (n = 24, 67%) or food (n = 22, 61%). Stakeholders cited a need to make integrated palliative care widely available.

Conclusions

We identified a high prevalence of pain and psychosocial needs among patients with serious chronic illnesses in rural Malawi. Early NPCP results suggest that comprehensive palliative care can be provided in rural Africa by integrating disease-modifying treatment and palliative care, linking hospital, clinic, and home-based services, and providing psychosocial support that includes socioeconomic assistance.