Inactivation of pathogens in ecological sanitation latrines in Malawi: An observational follow up study

IntroductionIn Malawi, EcoSan sludge from ecological sanitation (EcoSan) latrines has been found to contain helminths, Salmonella and E. coli above WHO recommended levels making sludge unsuitable for direct handling and use on food crops. This research investigated survival of pathogens in EcoSan sludge with time after sealing the pit.MethodAn observational longitudinal follow-up study was conducted where EcoSan latrines were followed from August 2015 to July 2016 in Blantyre and Chikwawa in Southern Malawi. The study enrolled 51 latrines in total with 35 latrines [13 fossa alterna (FAs) and 22 urine diverting dry latrines (UDDLs)] remaining at the end of study. Samples were collected five times from each latrine and examined for helminths, Salmonella and E. coli in the laboratory. Poisson regression was employed to assess factors that significantly contribute to pathogen die off at p<0.05.ResultsAverage concentrations of all pathogens investigated reduced over 12-month follow-up period except for Salmonella which increased. A. lumbricoides, increased to 2.3 viable eggs during the second sampling and decreased to 0.4 viable eggs per gram after 12 months of follow-up. Time was the only consistent predictor for concentration of helminths. Type of latrine and location were not significant predictors of helminths concentration (p>0.05). However, Salmonella and E. coli colonies were significantly higher in UDDLs (Blantyre) than FAs (Chikwawa) (p<0.05).ConclusionPathogen concentration was highest after recommended six months of storage posing a public health risk to those handling and using it for agriculture purposes. It is therefore recommended that the current guidelines be reviewed to suit Malawi context. A storage period of one year or more is recommended.

Challenges to Hygiene Improvement in Developing Countries

Hygiene is defined as conditions or practices conducive to maintaining health and preventing disease. Hygiene has been shown to reduce diarrheal diseases and assist to improve social outcomes in the community. Improving hygiene faces several problems especially in countries with low income per capita of population. Currently, many developing countries already struggle to cope with consistent water shortages and rapid urbanization causing more pressure to limited resources which in turn result in poor hygienic practices in the communities. The common types of hygiene include personal hygiene, water hygiene, food hygiene, and hygiene during waste handling. Different nongovernmental and governmental organizations face different challenges in achieving high levels of hygiene in communities. Some of these challenges include poverty, lack of political commitment, lack of full community participation, inadequate gender inclusion, inadequate data, lack of coordination among actors, and behavioral issues. To reduce these challenges, several measures have been proposed including community empowerment, pushing for equitable access to hygiene needs, advocating for political commitment, promoting gender equity, and enhancing youth involvement

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

Review Report of the National Open Defecation Free (ODF) and Hand Washing with Soap (HWWS) Strategies

Introduction Diarrhoeal diseases pose significant health risks for the rural population and account for 18% of deaths each year in children under the age of 5. Increasing access to basic sanitation and hand washing with soap at critical times are key interventions to the prevention of future diarrhea and cholera cases. The Government of Malawi with its development partners developed the Open Defecation Free (ODF) Malawi (2011 – 2015) and the National Hand Washing Campaign 2011-2012 Strategies, in line with the MDGs to support attainment of its goal to create a clean, safe and healthy environment. As the initial strategies came to an end (2011-2015), the global community entered the new phase of Sustainable Development Goals (SDGs 2016-2030). As such, Malawi also felt the need to up-date the ODF and the National Hand Washing Campaign strategies to be in line with the national sanitation and hygiene targets and SDG Goal 6.2: by 2030. It is against this background that the National Open Defecation Free Task Force (NOTF) commissioned this consultancy whose TORs were to provide a framework for facilitating the review and development of the new National ODF and Hand Washing with Soap (HWWS) strategies. This report is as a result of field data collection, literature review and stakeholder consultation which are informing the revision of the ODF and HWWS strategies to support Malawi in meeting the SDG targets. Objectives NOTF outlined specific objectives for this review which have been arranged in two stages as follows: Stage 1: • Review of current country strategies with emphasis on original assumptions. • Review the effectiveness of the scope, mechanisms and actions applied in the implementation of the ODF/HWWS Strategies. • Review the extent to which different programmes, approaches and other cross cutting issues (by Government, NGOs and development partners) have contributed to the implementation of the ODF/HWWS strategies. Stage 2 • Examine the extent that the changing assumptions and indicators impact achievement of ODF Malawi and Hand Washing behaviours. • Examine how the strategies link in with other WASH related strategies and approaches • Identify gaps in the ODF Malawi Strategy (2015) and National Hand Washing Campaign and incorporate lessons and practical experiences from field application. Methods The assignment used a number of data collection methods including stakeholder analysis, desk review, field research and stakeholder consultation detailed as follows: Stakeholder analysis: Stakeholder analysis was used to identify project's key people with stake, interest or influence in reducing open defecation and promoting hand washing with soap. Stakeholder analysis was a useful tool for identifying people and organizations and institutions that assisted in providing information regarding ODF and HWWS. The information from identified stakeholders was gathered using Key Informant Interviews (KII) and Focus Group Discussions (FGD) during field research and stakeholder meetings. Desk review: The desk review constituted an important step in the process of reviewing the national ODF and HWWS strategies. It provided the evidence base for the review. Reviewing all documentation (grey, published and peer reviewed information) relating to the issues covered in the existing strategies to develop as complete a picture as possible of the current state of ODF and HWWS both in and outside Malawi. This involved using the following techniques: Internal Desk Research, External Desk Research, Online Desk Research, Government published data and Customer desk research. Field Research: This involved creation and collection of primary data from the field setting. The process involved determining what precise data was necessary and from where this information needed to be obtained. Field research was performed by the consultancy team in person in 6 Districts and with key stakeholders, through KIIs (n=24) and FGDs (n=38). Purposive sampling was used to recruit participants for both the KIIs and FGDs. Stakeholder Workshop was undertaken to get provide feedback and validation of the desk review and field results, as well as receive input from further Districts and stakeholders. The workshop used presentations, world café consultation and direct feedback. Results Key Findings Findings demonstrate that there have been positive results and progress towards meeting strategic targets from 2011-2015. Nevertheless there are still significant barriers and challenges to the achievement of key goals of ODF and HWWS across Malawi. The main gaps identified include: Scope • The ODF strategy focuses only on the rural population, which has limited the focus and success of ODF achievement. • The ODF strategy referred only to households with no requirement for ODF status in public spaces and institutions. • There is no reference or integration of ODF strategy with menstrual hygiene management. • Neither strategy has specific reference or support for vulnerable and marginalized groups. Mechanism • Both the ODF and HWWS strategies do not provide specific definitions of latrines, hand washing facilities, etc. which leads to variation in implementation. • The ODF strategy does not consider the whole sanitation chain (capture to disposal). • ODF strategy implementation was to be overseen by the NOTF which represents the Ministry of Health and the Ministry of Agriculture, Irrigation and Water Development with key development partners and civil society which doesn’t include other ministries. • The current ODF strategy is limited to the use of Community Led Total Sanitation (CLTS) and sanitation marketing and does not take into consideration the use of other participatory approaches such as Participatory Hygiene and Sanitation Transformation (PHAST) and mechanisms to achieve ODF. • Although there is the inclusion of 2 levels of ODF status in the strategy (i.e. 1- appraising a community towards the attainment of the ODF status; 2- sustenance of ODF status after attaining the ODF status), there is little reference to the effective use of the sanitation ladder to achieve continued improvement and sustainability. • HWWS strategy uses health facilities and schools as key locations for good practice and development of agents of change, but in many cases these were identified as having the poorest standards. • The use of Health Surveillance Assistants (HSAs) in the drive for ODF was reported as inconsistent across partners. • CLTS was seen as a ‘project’ by HSAs, and once partners were gone the implementation also stopped. • HSAs were used to receiving allowances to undertake this work and therefore stopped their CLTS/ODF activities when they became routine activities. • Data was inconsistently reported and in some cases validity is called into question. • In the implementation of both strategies there has been a focus on infrastructure with little concentration on behavior change communication for sustained change. Key recommendations Scope • The scope of the strategies should include proper definitions of a latrine (including menstrual hygiene management) and hand washing facilities, and should consider the whole sanitation chain. • Areas must ensure ODF and HWWS in all households and public areas and institutions before they can be declared ODF. • New strategies must tackle both urban and rural populations. • Support for vulnerable and marginalized populations must be more effectively integrated. • Integration of menstrual hygiene management • Criteria and mechanisms for being declared ODF should be reviewed. Mechanism • NOTF should be more multidisciplinary in its membership with the inclusion of representatives from nutrition, disabilities and other appropriate government departments to ensure integration of services. • Effective sanitation marketing and financing models need to be more fully integrated into CLTS triggering programmes. • Movement towards a requirement for standard systems to be constructed should be considered which would improve quality of latrines and create business for masons and entrepreneurs. • Training of masons should be linked to technical training colleges and schools. • ODF must be incorporated into the routine activities of HSAs without the requirement of allowances. • Funding must be ring-fenced for ODF activities from the District budget. • Stakeholders reported the need for integration in community structures for effective implementation, and the valuable role of Natural Leaders. They suggested a continued use of traditional and natural leaders to support the implementation, achievement and sustainability of ODF status. It was also suggested that natural leaders and their roles in community sanitation and hygiene achievement should be recognized. • Vulnerable and marginalized groups should be engaged from the offset of the CLTS programme and be involved in the training, implementation and verification processes to ensure appropriate systems are in place to support them. • By laws should continue to be encouraged but must be enforced consistently for all community members and be facilitative rather than punitive, taking into consideration human rights. • Large ODF celebrations attended by the Minister and dignitaries should only take place when the District has achieved ODF status. • School WASH standards need to be completed and circulated to ensure improvement at facilities. These standards must include a range of low cost HWF suitable for school settings. • The concept of using schools and children as agents is still a welcome one but needs better integration and structure • Health facilities must be supported to ensure that they are modeling improved sanitation and HWWS to promote good behaviour. • HWWS promotion needs to be integrated into all relevant clinics, e.g. antenatal, growth monitoring, immunisations, OPD, etc. • Behaviour change messaging needs to be developed based on sound principles and with an understanding of the audience and behavioural factors which are being targeted. • The need for, and promotion of HWWS requires effective public private partnerships and these require to be engaged on a more regular and formal basis. • Strengthen CLTS and HWWS monitoring systems: There is need for more detailed monitoring and evaluation of progress and effectiveness. • Improved integration of behavior change communication to support sustained improvements in ODF and HWWS throughout Malawi. Cross cutting recommendation for future strategy development It is clear from the feedback from all stakeholders and desk review, that future strategies must address concerns regarding integration of sanitation and hygiene programmes to ensure sustained change across Malawi and achievement of the SDGs by 2030. With this in mind, it is the overall recommendation of this review that the current ODF and HWWS strategies should be integrated into a more general ‘hygiene and sanitation’ strategy. This would support not only the integration of HWWS and ODF programmes, but also the inclusion of key issues raised in stakeholder meetings such as menstrual hygiene management and solid waste management (including faecal sludge management). This would be an all encompassing strategy which targets rural and urban populations, domestic houses, commercial premises and institutions across the country. Only then can Malawi truly meet the target of Universal Sanitation and Hygiene for All

Using participatory methods to design an mHealth intervention for a low income country, a case study in Chikwawa, Malawi

This research was conducted by the Scotland Chikwawa Health Initiative. We would like to thank Sothin Ziba and Rossanie Daudi for their contribution to the facilitation of the focus group discussions. This study was funded by the Scottish Government grant MW22.Peer reviewedPublisher PD

Is manure from ecological sanitation latrines safe for use to fertilize crops? A review of evidence from literature

Studies have shown that manure harvested in ecological sanitation (ecosan) latrines has more thermo tolerant bacteria and helminthic eggs than the World Health Organisation (WHO) recommendation. The review was aimed at assessing adequacy of available guidelines on use of ecosan to produce safe manure. Relevant literature was searched and critically reviewed. Literature on effect on pathogen die off was not consistent from one study to the next and in some situations conflicting results have been found. Guidelines on waiting period after pit is sealed differed from one country to the next and there is an agreement that six months waiting period is not enough to produce safe manure. There is need for further research in real latrine situation to investigate all potential factors that affect pathogen die off. These may assist to explain inconsistencies in literature on pathogen die off and assist to develop specific guidelines for different locations

Assessment of implementation of the health management information system at the district level in southern Malawi

Background Despite Malawi’s introduction of a health management information system (HMIS) in 1999, the country’s health sector still lacks accurate, reliable, complete, consistent and timely health data to inform effective planning and resource management.Methods A cross-sectional survey was conducted wherein qualitative and quantitative data were collected through in-depth interviews, document review, and focus group discussions. Study participants comprised 10 HMIS officers and 10 district health managers from 10 districts in the Southern Region of Malawi. The study was conducted from March to April 2012. Quantitative data were analysed using Microsoft Excel and qualitative data were summarised and analysed using thematic analysis.Results The study established that, based on the Ministry of Health’s minimum requirements, 1 out of 10 HMIS officers was qualified for the post. The HMIS officers stated that HMIS data collectors from the district hospital, health facilities, and the community included medical assistants, nurse–midwives, statistical clerks, and health surveillance assistants. Challenges with the system included inadequate resources, knowledge gaps, inadequacy of staff, and lack of training and refresher courses, which collectively contribute to unreliable information and therefore poorly informed decision-making, according to the respondents. The HMIS officers further commented that missing values arose from incomplete registers and data gaps. Furthermore, improper comprehension of some terms by health surveillance assistants (HSAs) and statistical clerks led to incorrectly recorded data.Conclusions The inadequate qualifications among the diverse group of data collectors, along with the varying availability and utilisation different data collection tools, contributed to data inaccuracies. Nevertheless, HMIS was useful for the development of District Implementation Plans (DIPs) and planning for other projects. To reduce data inconsistencies, HMIS indicators should be revised and data collection tools should be harmonised

Social outcomes of a community-based water, sanitation and hygiene intervention

Social benefits of water, sanitation and hygiene (WASH) interventions are less documented compared to health benefits such as the reduction of diarrheal diseases. Although most decisions in WASH investments are based on potential health outcomes, interventions may also lead to social benefits, such as income generation, increased school enrollment, improved levels of dignity, self-esteem and civic pride, which can have a significant value both personally and to the wider community. This qualitative case study was used to assess the perceived social outcomes of purposively selected stakeholders from a WASH intervention study in Malawi. In-depth Interviews (n = 10), focus group discussions (n = 4) and key informants interviews (n = 10) were conducted with caregivers (male and female), community leaders, traditional leaders and community coordinators. Thematic analysis identified eight social outcomes: formation and strengthening of relationships (n = 32), becoming role models to community members (n = 23), women empowerment (n = 20), time-saving (n = 17), change of status (n = 12), receiving awards (n = 12), reduced medical costs (n = 11) and obtaining new skills (n = 7). Social capital among caregivers was also found to be high. No negative outcomes from the intervention were reported. WASH interventions have multiple, important, but difficult to quantify social benefits which should be measured, reported and considered in WASH investment decision-making

Towards complementary food hygiene practices among child caregivers in rural Malawi

Despite being preventable, foodborne diseases remain a global health challenge. Poor food hygiene practices such as improper handling of kitchen utensils are among the major causes of diarrhea transmission. A formative study was conducted in Malawi to inform an intervention design to promote complementary food hygiene practices. An assessment of contextual and psychosocial factors for behavior change was conducted using Risk, Attitude, Norms, Ability, and Self-regulation model. We conducted 323 household surveys with caregivers of children aged 6 to 24 months. Analysis of variance was used to estimate difference between doers and non-doers of three targeted behaviors: washing utensils with soap, keeping utensils on a raised place, and handwashing with soap. Analysis of variance analyses revealed that literacy level, ownership of animals, and presence of handwashing facility and dish racks were contextual factors predicting storage of utensils on an elevated place and handwashing frequencies. Psychosocial factors, such as time spent to wash utensils with soap, distance to the handwashing facility, and cost for soap, had an influence on washing utensils and handwashing practices. Perceived vulnerability determined effective handwashing and storage of utensils. Perceived social norms and ability estimates were favorable for the three targeted behaviors. Promotion of already existing targeted beneficial behaviors should be encouraged among caregivers. Risk perceptions on storage of utensils and handwashing practices should be increased with motivational exercises such as paint games. Caregivers' technical know-how of local dish rack and tippy tap construction is essential