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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.

This thesis aimed to determine the feasibility, acceptability and effectiveness of a behaviour change intervention delivered via mHealth in Chikwawa, Malawi. Three qualitative studies were executed to identify health needs in the area and to understand cultural practices which may influence intervention effectiveness. The Behaviour Change Wheel was then used to design an SMS intervention delivering contraceptive education to adolescents. This intervention was tested in two studies; a feasibility study and larger quasi-experimental study, to identify effectiveness in regards to contraceptive knowledge, attitudes to condoms and contraceptive behaviour. The SMS intervention was found to be feasible in terms of infrastructure, accessibility and participant acceptability. Intention-to-treat analysis found significant increases in attitudes at six months in the intervention group. However, 39% of the control group had access to the intervention, affecting results. Post-hoc analysis revealed significantly higher contraceptive knowledge and attitudes in those who received access to the intervention compared to those who did not, and this was sustained for six months. Additionally, contraceptive behaviour was more frequent in those who received access to the intervention at six months follow up. This thesis demonstrates the feasibility and acceptability of an SMS behaviour change intervention delivering contraceptive education to adolescents in Chikwawa and provides evidence of positive impact on contraceptive knowledge, attitudes and behaviour change. This thesis is the first to implement an mHealth intervention in a community setting in Malawi, and highlights the advantage it has in delivering health education in a relatively quick, simple and easy to access way, without negatively impacting health sector services. However study replication is required to build on the foundations of this research and conduct a large scale evaluation of intervention effectiveness, cost effectiveness and gender equality in mobile access to ensure it can be delivered across the country to those who need it most.