Ecological sanitation - Implementation, opportunities and challenges in Chikwawa

Ecological sanitation (EcoSan) in not a new technology but rather a recognition that human excreta is a valuable natural resource (not a waste to be disposed of), containing plant nutrients which after containment and sanitization can be recycled in agriculture to enhance food production, with minimal risk of pollution of the environment and with minimal threat to human health. Various organizations are implementing EcoSan technologies in Malawi. Chikwawa is a rural district that is currently implementing EcoSan initiatives with resources from the Scotland Chikwawa Health Initiative and the US Ambassador’s Self Help Fund. The benefits from EcoSan are clear. For example, EcoSan systems help reduce the risk of spreading diseases by containing and treating human excreta before collecting it; minimising surface and groundwater contamination and recylcing the nutrients found in excreta and returning them to soil to enhance food production. However, EcoSan poses some challenges in its implementation such as a correct utilization, acceptability and sustainability of the concept

Epidemiology of cryptosporidiosis in rural Malawi

A hospital and community based study was conducted in Malawi, within a rural population over a 23 month period, to identify the incidence, causative species and possible determinants for cryptosporidiosis in under fives. 5.9% (25/423) of samples collected were positive for Cryptosporidium oocysts of which 18 amplified by PCR-RFLP indicating the following species: C. hominis, C. parvum, C. meleagridis and C. andersoni. Consenting positive cases were included in a case control study. 96 home interviews were conducted in 24 communities (cases n=24; unmatched controls n=72). A total of 61 risk factors were investigated with a questionnaire, and combined with quantitative data from samples of domesticated animal stools and drinking water. Oocysts were not isolated from domesticated animals or water samples. Multivariate logistic regression of questionnaire data revealed an increased risk of cryptosporidiosis associated with ownership of pigs (OR 7.2, 95%CI 1.9–27.5, p=0.004), presence of diarrhoea in the household (OR 8.8, 95%CI 1.8–53.4, p=0.008), bathing in the river (OR 76.7, 95%CI 1.1–23.8, p=0.037) and no education within the household (OR 3.6, 95%CI 1.1–11.8, p=0.038). Bacteriological results indicating faecal contamination of both drinking water stored within the home (76%), and the surface of guardians’ hands (75%) were indicative of poor hygienic practices and potential sources of infection

Community knowledge variation, bed-net coverage, the role of a district health care system and their implications for malaria control in Southern Malawi

This paper presents data on the pattern of knowledge of caregivers, bed-net coverage and the role of a rural district healthcare system, and their implications for malaria transmission, treatment, prevention and control in Chikhwawa, southern Malawi, using multi-level logistic regression modelling with Bayesian estimation. The majority of caregivers could identify the main symptoms of malaria, that the mosquito was the vector, and that insecticide-treated nets (ITN) could be used to cover beds as an effective preventative measure, although cost was a prohibitive factor. Use of bed nets displayed significant variation between communities. Groups that were more knowledgeable on malaria prevention and symptoms included young mothers, people who had attended school, wealthy individuals, those residing closest to government hospitals and health posts, and communities that had access to a health surveillance assistant (HSA). HSAs should be trained on malaria intervention programmes, and tasked with the responsibility of working with village health committees to develop community-based malaria intervention programmes. These programmes should include appropriate and affordable household improvement methods, identification of high-risk groups, distribution of ITNs and the incorporation of larval control measures, to reduce exposure to the vector and parasite. This would reduce the transmission and prevalence of malaria at community level

Epidemiology of diarrhoeal disease in Malawi - a case study of cryptosporidiosis

A rural community based case control study was conducted in Malawi, over a 23 month period, to identify determinants influencing human cryptosporidiosis in under fives. 96 home interviews were conducted in 24 communities (cases n=24; unmatched controls n=72). 61 risk factors were investigated by questionnaire, combined with quantitative data from drinking water and domesticated animal stool samples. Cryptosporidium oocysts were not detected in either sample type. Multivariate logistic regression of questionnaire data revealed an increased risk of cryptosporidiosis associated with ownership of pigs (OR7.2, 95%CI 1.9–27.5, p=0.004), presence of diarrhoea in the household (OR8.8, 95%CI 1.8–53.4, p=0.008), bathing in the river (OR76.7, 95%CI 1.1–23.8, p=0.037) and no education within the household (OR3.6, 95%CI 1.1–11.8, p=0.038). Bacteriological results indicating faecal contamination of both drinking water stored within the home, and the surface of guardians’ hands were indicative of poor hygienic practices and potential sources of infection

Scotland Chikwawa Health Initiative - improving health from community to hospital

The Scotland Chikwawa Health Initiative is a three year programme funded by the Scottish Executive International Development Fund which aims to achieve measurable reductions in major causes of disease and death in four villages within the Chikwawa District of Malawi alongside improving the hospital environment for the good of both staff and patients. The initiative has developed a holistic approach to health improvements through the provision of infrastructure at both health facilities and within communities, and training of government personnel and community volunteers. Specific areas targeted have included water and sanitation, maternal health, and communicable disease control with provision of training and materials to facilitate interventions and health education. At the end of the second year the programme has already seen reductions in diarrhoeal disease (30% overall in target communities), improved access to safe water, an increase in the uptake of growth monitoring and immunisations in children under the age of five years (15% increase since training volunteers), improved safe delivery of babies within the community (245 babies delivered safely in target communities with 25 referred due to complications) and increased community health activity (training and integration of village health committees, water point committees, traditional birthing attendants and health surveillance assistants). The programme hopes to act as a model for the District to follow in other communities to achieve it’s obligations under the Malawi Ministry of Health Essential Health Package

Care-seeking for diarrhoea in Southern Malawi : attitudes, practices and implications for diarrhoea control

This paper examined care-seeking behaviour and its associated risk factors when a family member had diarrhoea. Data was obtained from a survey conducted in Chikwawa, a district in Southern Malawi. Chikwawa is faced with a number of environmental and socioeconomic problems and currently diarrhoea morbidity in the district is estimated at 24.4% statistically higher than the national average at 17%. Using hierarchically built data from a survey of 1,403 households nested within 33 communities, a series of two level binary logistic regression models with Bayesian estimation were used to determine predictors of care-seeking behaviour. The results show that 68% of mothers used oral rehydration solutions (ORS) last time a child in their family had diarrhoea . However, when asked on the action they take when a member of their household has diarrhoea two thirds of the mothers said they visit a health facility. Most respondents (73%) mentioned distance and transport costs as the main obstacles to accessing their nearest health facility and the same proportion of respondents mentioned prolonged waiting time and absence of health workers as the main obstacles encountered at the health facilities. The main predictor variables when a member of the family had diarrhoea were maternal age, distance to the nearest health facility, school level, and relative wealth, household diarrhoea endemicity, and household size while the main predictor variables when a child had diarrhoea were existence of a village health committee (VHC), distance to the nearest health facility, and maternal age . Most households use ORS for the treatment of diarrhoea and village health committees and health surveillance assistants (HSAs) are important factors in this choice of treatment. Health education messages on the use and efficacy of ORS to ensure proper and prescribed handling are important. There is need for a comprehensive concept addressing several dimensions of management and proper coordination of delivery of resources and services; availability of adequate healthcare workers at all levels; affordability to accessibility of healthcare resources and services to all communities; acceptability and quality of care; intensification of health education messages on the use and management of ORS, and prompt and timely treatment of diarrhoeal illness

Epidemiology of diarrhoeal disease in rural Malawi - a case study of cryptosporidiosis

A rural community based case control study was conducted in Malawi, over a 23 month period, to identify determinants influencing human cryptosporidiosis in under fives. 96 home interviews were conducted in 24 communities (cases n=24; unmatched controls n=72). 61 risk factors were investigated by questionnaire, combined with quantitative data from drinking water and domesticated animal stool samples. Cryptosporidium oocysts were not detected in either sample type. Multivariate logistic regression of questionnaire data revealed an increased risk of cryptosporidiosis associated with ownership of pigs (OR7.2, 95%CI 1.9–27.5, p=0.004), presence of diarrhoea in the household (OR8.8, 95%CI 1.8–53.4, p=0.008), bathing in the river (OR76.7, 95%CI 1.1–23.8, p=0.037) and no education within the household (OR3.6, 95%CI 1.1–11.8, p=0.038). Bacteriological results indicating faecal contamination of both drinking water stored within the home, and the surface of guardians’ hands were indicative of poor hygienic practices and potential sources of infection

The pattern of variation between diarrhoea and malaria coexistence with corresponding risk factors in, Chikhwawa, Malawi : a bivariate multilevel analysis

Developing countries face a huge burden of infectious diseases, a number of which co-exist. This paper estimates the pattern and variation of malaria and diarrhea coexistence in Chikhwawa, a district in Southern Malawi using bivariate multilevel modelling with Bayesian estimation. A probit link was employed to examine hierarchically built data from a survey of individuals (n = 6,727) nested within households (n = 1,380) nested within communities (n = 33). Results show significant malaria [σ2ul = 0.901 (95% CI : 0.746,1.056) ] and diarrhea [σ2ul = 1.009  (95% CI : 0.860,1.158) ] variations with a strong correlation between them [ru(1,2) = 0.565 ] at household level. There are significant malaria [σ2v1 = 0.053 (95% CI : 0.018,0.088) ] and diarrhea [σ2v2 = 0.099 (95% CI : 0.030,0.168 ] variations at community level but with a small correlation [rv(1,2) = 0.124 ] between them. There is also significant correlation between malaria and diarrhea at individual level [re(1,2) 0.241]. These results suggest a close association between reported malaria-like illness and diarrheal illness especially at household and individual levels in Southern Malawi

Pattern of Maternal Knowledge and Its Implications for Diarrhoea Control in Southern Malawi: Multilevel Thresholds of Change Analysis

A survey was conducted in Southern Malawi to examine the pattern of mothers’ knowledge on diarrhoea. Diarrhoea morbidity in the district is estimated at 24.4%, statistically higher than the national average at 17%. Using hierarchically built data from a survey, a multilevel threshold of change analysis was used to determine predictors of knowledge about diarrhoeal aetiology, clinical features, and prevention. The results show a strong hierarchical structured pattern in overall maternal knowledge revealing differences between communities. Responsible mothers with primary or secondary school education were more likely to give more correct answers on diarrhoea knowledge than those without any formal education. Responsible mothers from communities without a health surveillance assistant were less likely to give more correct answers. The results show that differences in diarrhoeal knowledge do exist between communities and demonstrate that basic formal education is important in responsible mother’s understanding of diseases. The results also reveal the positive impact health surveillance assistants have in rural communities

Care-seeking behaviour and implications for malaria control in Southern Malawi

Although malaria is a controllable and preventable disease, it remains among the leading causes of mortality and morbidity in southern Malawi. The importance of early diagnosis and prompt treatment with hospital prescribed drugs and effective home management to control malaria is well established; however, these in part depend on how households make their decisions when family members have suffered from malaria. This study examines the behaviour of households with regard to decisions they make in managing malaria illness. Using hierarchically built data from a survey of 1,400 mothers nested within 33 communities, a series of two-level logistic regression models with Bayesian estimation was used to determine predictors of care-seeking behaviour towards malaria when a family member or a child was perceived to have malaria. The results show that most families normally visit or use medication prescribed at health facilities for both adult (80%) and child (86%) members when they are perceived to have malaria. The main obstacle to accessing the nearest health facility was distance and transport costs (73%) and the main problems encountered at health facilities were long waiting time or absence of health workers (73%) and shortage of drugs (35%). Among the main predictor variables for choices of treatment for childhood malaria was the absence of a health surveillance assistant for those that visited hospitals [β=0.56; 95% CI:-0.86,-0.26]; bought medication from open markets [β=0.51; 95% CI:0.20,0.82]; and those that used other traditional methods or did nothing [β=0.70; 95% CI:-0.04,1.44; p=0.06].. The results have an important role to play in the control and prevention of malaria in Malawi. The results reveal the need for increased awareness about the dangers of purchasing drugs from non-medical and/or uncertified private institutions and sources such as those found in open markets. They also show the important role of community health workers in the delivery of health systems. The study recommends empowerment of community health workers through rigorous and relevant health promotion programmes to update both their knowledge and their skills in communication and counselling