“I Need to Be the First One with a Different Approach and to Make a Difference to the People”: A Mixed Methods Pilot Study on Non-Physician Clinicians Training in Malawi

**Background:** Malawi faces a critical shortage of skilled healthcare workers, with only 26% of health facilities in rural areas where over 80% of the population lives. To address this, the Ministry of Health introduced Clinical Officers (COs), a mid-level Non-Physician Clinician cadre, and later a three-year specialist Bachelor of Science in Paediatrics and Child Health (BSc PCH) training program for COs in 2012. However, challenges including lack of professional recognition, low remuneration, and difficult working conditions affected CO motivation. The German Society of Tropical Paediatrics & International Child Health partnered with the College of Medicine, Campus Lilongwe, to support the BSc PCH CO training from September 2017 to December 2019, adding upgraded bloc courses, intensive supervision, and mentoring by national and international teachers.

**Methods:** This mixed-methods pilot study included all 17 enrolled students across three intake years (2016/17: 8 students; 2017/18: 5 students; 2018/19: 4 students). Quantitative data collection (January 2018–June 2019) used: (1) post-self-assessment bloc course surveys (5-point Likert scale; 15 of 17 students returned questionnaires; 12 of 15 bloc courses analyzed); (2) Research Self-Efficacy Scale (RSES; 10-point scale; n=10 students conducting research); and (3) Stages of Change (SOC) model (4-point scale; n=10). Qualitative data collection (April 1–10, 2019) included three focus group discussions (one per intake year) and five in-depth interviews (two with students, three with key informant supervisors). Analysis used modified grounded theory with thematic approach using NVivo.

**Key Results:** Quantitative findings showed: 92% of students rated bloc courses "At my level", 70.5% rated teaching quality as "Good quality", and 61% found topics "Very important/relevant" to daily clinical work. The courses impacted patient management skills "Every time" (55%) or "Almost every time" (43%). Teamwork improvement was rated "Strongly agree" (55%) and "Agree" (39%). Stress coping improved (51% "Agree", 49% "Strongly agree"). The mean RSES score was 9.10 (SD 0.91) out of 10. SOC scores showed 100% "Strongly agree" for attitudes about research importance, with lower action scores: 80% would suggest colleagues do research, 80% would talk in formal meetings to increase research, 70% would increase research use at workplace. Qualitative themes revealed: improved clinical reasoning and confidence; holistic disease management approach considering socioeconomic and psychological factors; enhanced communication and networking skills including use of WhatsApp for case discussions; appreciation of international teachers providing global perspective; and feeling prepared for leadership roles. Students expressed concerns about cadre recognition, salary increases, and opportunities for Master's degree progression.

**Clinical Implications:** The partnership training formats appear to have improved both clinical and non-clinical skills among BSc PCH CO students, potentially addressing the need for skilled child healthcare workers in rural Malawi. Students developed research self-efficacy (mean 9.10/10) and reported feeling autonomous to make evidence-based decisions. The study suggests that combining classroom teaching with bedside clinical supervision, adding structured research projects, and incorporating leadership and communication training can foster transformative learning. However, sustainability challenges include the need for ongoing supervision, mentoring, continuous professional development, adequate remuneration, and career progression pathways. The small sample size (n=17), absence of a control group, and cross-sectional design limit generalizability. The authors recommend adopting the additions as regular curriculum components and establishing monitoring and evaluation of long-term effects on quality of care.