Improving food hygiene behaviours among child caregivers in rural community households of Malawi

Globally, diarrheal disease accounts for over 90% of foodborne illness, with over 70% of this burden in Sub-Saharan Africa. However, traditional diarrheal prevention interventions focused on water, sanitation, and handwashing, with little integration of food hygiene. This thesis designed and implemented a theory-based complementary food hygiene intervention in rural Malawi and evaluated its impact on food hygiene behaviours. Formative research and intervention development was grounded in the RANAS (Risk, Attitude, Norms, Ability and Self-regulation) Model and targeted five behaviours: cleaning of cooking and feeding utensils, safe utensil storage, reheating of left-over food, child self feeding and handwashing with soap. The intervention was delivered for 9 months through village meetings in 800 household visits. Formative research indicated that risk, norms, ability and self-regulation factors were primary factors of the selected behaviours. Intervention was linked to Behaviour Change Techniques of the RANAS model. Villages were assigned to a control or intervention group and targeted caregivers of children aged five years and below. Intervention outcomes were measured using a before and after study with a control. Changes in food hygiene behaviours between baseline and follow-up data, and between the intervention and control groups were measured using ANOVA and t-test. Mediation models were used to uncover underlying mechanisms and effects of an intervention on changes in target behaviours. At end-line, three behaviours showed a significant difference among intervention recipients: cleaning utensils with soap (P=0.000); safe utensil storage (P=0.000) and handwashing with soap (P=0.000). For the three significant behaviours, psychosocial factors differed significantly between the intervention and control groups. Results showed that perceived risk, norm, ability and self-regulation factors (P=0.000) mediated the effect of the intervention on the significant behaviours among the intervention participants. The study suggests that theory driven behaviour change initiatives using contextual and psychosocial factors effectively improved food hygiene behaviours in rural Malawi.Globally, diarrheal disease accounts for over 90% of foodborne illness, with over 70% of this burden in Sub-Saharan Africa. However, traditional diarrheal prevention interventions focused on water, sanitation, and handwashing, with little integration of food hygiene. This thesis designed and implemented a theory-based complementary food hygiene intervention in rural Malawi and evaluated its impact on food hygiene behaviours. Formative research and intervention development was grounded in the RANAS (Risk, Attitude, Norms, Ability and Self-regulation) Model and targeted five behaviours: cleaning of cooking and feeding utensils, safe utensil storage, reheating of left-over food, child self feeding and handwashing with soap. The intervention was delivered for 9 months through village meetings in 800 household visits. Formative research indicated that risk, norms, ability and self-regulation factors were primary factors of the selected behaviours. Intervention was linked to Behaviour Change Techniques of the RANAS model. Villages were assigned to a control or intervention group and targeted caregivers of children aged five years and below. Intervention outcomes were measured using a before and after study with a control. Changes in food hygiene behaviours between baseline and follow-up data, and between the intervention and control groups were measured using ANOVA and t-test. Mediation models were used to uncover underlying mechanisms and effects of an intervention on changes in target behaviours. At end-line, three behaviours showed a significant difference among intervention recipients: cleaning utensils with soap (P=0.000); safe utensil storage (P=0.000) and handwashing with soap (P=0.000). For the three significant behaviours, psychosocial factors differed significantly between the intervention and control groups. Results showed that perceived risk, norm, ability and self-regulation factors (P=0.000) mediated the effect of the intervention on the significant behaviours among the intervention participants. The study suggests that theory driven behaviour change initiatives using contextual and psychosocial factors effectively improved food hygiene behaviours in rural Malawi

Self–reported versus observed measures : validation of child caregiver food hygiene practices in rural Malawi

Few studies have attempted to measure the differences between self-reported and observed food hygiene practices in a household setting. We conducted a study to measure the level of agreement between self-reported and observed food hygiene practices among child caregivers with children under the age of five years in rural Malawi. Fifty-eight child caregivers from an intervention and 29 from a control group were recruited into the study. At the end of a nine-month food hygiene intervention, household observations were conducted followed by self-reported surveys. Overall, practices were found to be more frequently reported than observed in both groups. However, the difference between self-reports and observed practices was minimal in the intervention compared to the control group. The odds ratio results confirm that more desirable practices were observed in the intervention group compared to the control group. Despite the effects of reactivity during observations, the study results imply that the intervention group did not just improve their knowledge, but also translated the messaging into better practice. Researchers and implementing agencies in water, sanitation and hygiene and food hygiene sector should ensure that interventions are context-appropriate, and that effective methods of observation are used to confirm any reported effects of an interventio

Food Hygiene Matters, Handwashing and Water Management

A series of information and learning resources designed to empower caregivers to wash utensils with soap and protect their children from diarrhoeal diseases. Resource also explore how caregivers can hygienically store household water. Resources developed under the auspices of The Centre for Water, Sanitation, Health and Technology Development (WASHTED), Malawi

Development of a protocol for assessing the role of WASH in AMR distribution in the environment

Resistance in Malawi and Uganda (DRUM) consortium to measure the role of WASH in the transmission and control of AMR Abstract In Low and Middle Income countries (LMICs), there is a high incidence of severe bacterial infection, a critically inadequate health system infrastructure to diagnose and treat bacterial infections and widespread and uncontrolled availability of antimicrobials. This situation causes both a huge burden of morbidity and mortality, and is increasing selective pressure for the emergence of antimicrobial resistance (AMR) in pathogens. As LMICs will be the last to benefit from new classes of antimicrobials it is therefore urgent to undertake research addressing AMR in LMICs that aims to identify drivers and interrupt transmission of AMR determinants responsible. Exposures associated with WASH are integral to enteric bacteria and AMR transmission. AMR elements have been found in water, faeces and wastewater in LMICs, and this is compounded by a lack of faecal management (e.g. open defaecation, lack of access to faecal sludge management) and multiple uses of water (e.g. washing, irrigation, animal management and drinking). These factors contribute to community borne AMR transmission, and must be considered across multiple exposure pathways within the community. Focused in urban, peri-urban and rural settings in Malawi and Uganda, the Drivers of Antimicrobial Resistance in Uganda and Malawi (DRUM) consortium is an interdisciplinary programme funded by the Medical Research Council (2018 – 2021). The study aims to address three key questions (1) What are the drivers of ESBL E. coli and ESBL Klebsiella pneumoniae transmission in Uganda and Malawi?; (2) What are the critical points at which efforts to interrupt human AMR acquisition are likely to have the greatest impact?; and (3) Which strategies are likely to be most affordable and feasible to societies and how far is this specific to context? The research will develop agent-based models to enable us to predict how these transmission pathways can be interrupted. Data will be collated on a range of issues including: antibiotic use; antibiotic availability; illness; household demographics; and environmental contamination using both qualitative and quantitative methods. Key to this model will be the under researched area of AMR and WASH. This will develop a clear understanding of water, sanitation and hygiene (WASH) infrastructure and practices both domestically and institutionally [transect walks n=8; observations and checklists at household n=255; institutions n=50], identify the underlying influences on current practices [in depth interviews n=75; key informant interviews n=50; behavioral determinant questionnaires n=500; focus group discussions n=25] and identify drivers which may be amenable to change. These methods will be described in detail. Data will be collected with extensive environmental sampling to identify the transmission routes, support the design of the model and inform interventions. Existing national and international policies in the WASH sector do not currently consider AMR, and the production of evidence in this area is key to supporting and driving policy integration and uptake

Environmental health practitioners : a key cadre in the control of COVID-19 in sub-Saharan Africa

The multidisciplinary nature of environmental health practitioners (EHP) allows them to understand where different sectors can intersect to maximise severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related interventions. EHPs have the necessary skills to support the transdisciplinary approach required to halt the further spread of SARS-CoV-2. Governments should support the work of EHPs across the region and include them among key decision-making stakeholders

Challenges in implementation of a combined WASH and food hygiene intervention to reduce diarrhoeal diseases in children under age of five years

Recently published results of rigorously designed and evaluated WASH studies have shown minimal impacts on primary health outcomes, e.g. diarrheal disease. Reasons and speculation for these findings have been reported including the possible impacts of collective efficacy, social capital and the limitations of reporting systems. Within this context, this poster outlines the methods used in an ongoing integrated WASH and food hygiene intervention study being conducted in Southern Malawi. This cluster randomized before and after trial with a control is being supported by the Sanitation and Hygiene Applied Research for Equity (SHARE) Consortium, and aims to determine the relative impact of a combined WASH and food hygiene study with a food hygiene study alone on diarrheal disease in the rural district of Chikwawa

Malawi Policy and Research Lanscaping and Stakeholder Analysis for Wash Sector

Malawi has an estimated population of about 15 million, 85% of whom reside in rural areas. High population growth rates, coupled with high rates of migration to urban areas, have placed pressure on the demand for safe water and improved sanitation services

Improving complementary food hygiene behaviors using the Risk, Attitude, Norms, Ability, and Self-Regulation approach in rural Malawi

The study evaluated the effectiveness of an intervention to improve complementary food hygiene behaviors among child caregivers in rural Malawi. Formative research and intervention development was grounded in the risk, attitude, norms, ability, and self-regulation (RANAS) model and targeted washing hands and kitchen utensils with soap, safe utensil storage, reheating of leftover food, and feeding of children by caregivers. Longitudinal research was applied at baseline and follow-up surveys among 320 caregivers. Determinants of selected behaviors were found, and interventions were developed based on the behavior change techniques aligned with these determinants in the RANAS model. The intervention was delivered over 9 months through group (cluster) meetings and household visits and included demonstrations, games, rewards, and songs. We randomly assigned villages to the control or intervention group. Follow-up results indicated a significant increase in three targeted behaviors (washing kitchen utensils with soap, safe utensil storage, and handwashing with soap) among intervention recipients. Several psychosocial factors differed significantly between the intervention and control groups. Mediation results showed that the intervention had a significant effect on these three targeted behaviors. For handwashing, feelings, others’ behavior in the household, and remembering; for washing kitchen utensils, others’ behavior in the household and difficulty to get enough soap; for safe utensils storage, others’ behavior in the village and remembering mediated the effect of the intervention on the targeted behaviors. The study demonstrated that targeting food hygiene behaviors with a theory-driven behavior change approach using psychosocial factors can improve the behavior of child caregivers in rural Malawi

Hygiene in early childhood development centres in low-income areas of Blantyre, Malawi

Diarrhoeal disease remains a leading cause of death in children in sub-Saharan Africa, attributed to environmental health factors such as inadequate water, sanitation and hygiene (WASH) and food hygiene. This formative study in low-income areas of Blantyre focussed on the practices in Early Childhood Development Centre (ECDCs) environments where children spend a significant amount of time. A mixed-methods approach was applied to identify key hygiene behaviours in ECDCs through; checklist and structured observations (n = 849 children; n = 33 caregivers), focus group discussions (n = 25) and microbiological sampling (n = 261) of drinking water, food handler’s hands, and eating utensils. ECDCs had inadequate WASH infrastructure; coupled with poor hygiene practices and unhygienic environments increased the risk of faecal-oral disease transmission. Presence of E. coli in drinking water confirmed observed poor water handling habits by staff and children. Addressing undesired hygiene practices in ECDCs has the potential to improve the health outcomes of children in low-income settings

Health outcomes of an integrated behaviour centred water, sanitation, hygiene and food safety intervention - a randomised before and after trial

Diarrhoeal disease in children under five in low income settings has been associated with multiple environmental exposure pathways, including complementary foods. Conducted from February to December 2018 in rural Malawi, this before and after trial with a control used diarrhoeal disease as a primary outcome, to measure the impact of a food hygiene intervention (food hygiene + handwashing) relative to a food hygiene and water, sanitation and hygiene (WASH) intervention (food hygiene + handwashing + faeces management + water management). The 31-week intervention was delivered by community-based coordinators through community events (n = 2), cluster group meetings (n = 17) and household visits (n = 14). Diarrhoeal disease was self-reported and measured through an end line survey, and daily diaries completed by caregivers. Difference-in-differences results show a 13-percentage point reduction in self-reported diarrhoea compared to the control group. There were also significant increases in the presence of proxy measures in each of the treatment groups (e.g., the presence of soap). We conclude that food hygiene interventions (including hand washing with soap) can significantly reduce diarrhoeal disease prevalence in children under five years in a low-income setting. Therefore, the promotion of food hygiene practices using a behaviour-centred approach should be embedded in nutrition and WASH policies and programming