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Background Antimicrobial resistance (AMR) represents an important threat to achieving the sustainable development goals in Sub-Saharan Africa (sSA). sSA is reported to have the highest estimated death rate attributable to AMR, with Extended-Spectrum Beta-Lactamase-producing Enterobacterales, such as Klebsiella pneumoniae and Escherichia coli, representing the greatest challenge. However, the dynamics of human colonisation with such bacteria in the sSA community setting are not well known. Inadequate water, sanitation and hygiene (WASH) infrastructure and associated behaviours are thought to play an important role in transmission of AMR-bacteria, and an improved understanding of the temporal dynamics of within-household transmission could help inform the design of public health policies that interrupt transmission of AMR-bacteria. Methods and Findings In this 18-month study, individuals from households in diverse areas of Southern Malawi were recruited and human stool samples were longitudinally collected. Using microbiological data and household surveys, we built a multivariable hierarchical harmonic logistic regression model to identify risk factors for colonisation with ESBL-producing E. coli and K. pneumoniae, reflecting household structure and temporal correlation of colonisation status between timepoints. Important risk factors were identified, with men having a lower risk of becoming colonised with ESBL-producing E. coli (OR 0.786 CrI[0.678-0.910]) and the use of a tube well or a borehole as a water drinking source highly increasing the risk of becoming colonised (OR 1.550 CrI[1.003-2.394]). Coming into contact with standing water also appeared to be negatively associated with colonisation status (OR 0.749 CrI[0.574-0.978]). For ESBL-producing K. pneumoniae, having recently taken a course of antibiotics increased the risk of being colonised (OR 1.281 CrI[1.049-1.565]). We also found a negative association between eating from shared plates and colonisation with ESBL-producing K. pneumoniae (OR 0.672 CrI[0.460- 0.980]). Finally, we detected a temporal correlation range of eight to eleven weeks, providing evidence that within-household transmission occurs within this time frame. Conclusions We suggest that interventions aimed at preventing transmission might have the best impact when targeted at the household-level and focused on a combination of improving WASH infrastructure and modifying associated behaviours. Additionally, we showed that antibiotic use is important when looking at colonisation with ESBL-producing K. pneumoniae and therefore infection prevention and control measures and antibiotic use and stewardship training could help in reducing transmission.

Supplemental material, sj-docx-1-ehi-10.1177_11786302221139964 for Perceptions of Inclusivity and Sustainability in Urban Sanitation in Global South Cities by Kondwani Luwe, Rebecca C Sindall, Flor Y Garcia-Becerra, Annatoria Chinyama, Huda Lohiya, Caitlin Hope, Fryderyk Paczkowski, Hans C. Komakech and Tracy Morse in Environmental Health Insights

Background: Neonatal sepsis is responsible for a considerable burden of morbidity and mortality in sub-Saharan African countries. Outcomes from neonatal sepsis are worsening due to increasing rates of antimicrobial resistance. Sub-optimal Infection Prevention and Control (IPC) practices of health care workers and caregivers are important drivers of infection transmission. The Chatinkha Neonatal Unit at Queen Elizabeth Central Hospital, Blantyre, Malawi has experienced multiple outbreaks of neonatal sepsis, associated with drug resistant Klebsiella pneumoniae. We aimed to understand the barriers to implementation of optimal IPC focusing on hand hygiene practice. Methods: We used a qualitative research methodology to meet the study aim. Combining participant observation (PO) over a seven-month period with semi structured interviews (SSI) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward. Results: While most staff and some caregivers, had a good understanding of ideal IPC and understood the importance of good handwashing practices, they faced substantial structural limitations, and scarce resources (both material and human) which made implementation challenging. For staff, the overwhelming numbers of patients meant the workload was often unmanageable and practicing optimal IPC was challenging. Caregivers lacked access to basic amenities, including linen and chairs, meaning that it was almost impossible for them to maintain good hand hygiene. Limited access to soap and the erratic water supply for both caregivers and healthcare workers further worsened the situation. Communication challenges between different cadres of staff and with patient caregivers meant that those handling neonates and cleaning the wards were often unaware of outbreaks of drug resistant infection. Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.

This review essay lays out the conceptual and historical groundwork for the primary research that the WATERSPOUTT social science team will carry out through the project period over four research sites in Ethiopia, Malawi, South Africa and Uganda. We have described it as a report synthesising secondary data on conflict, gender, and class relations in the four case study areas. However, it is emphatically not intended as an exhaustive description of the specificities of the four research sites – the sections that follow will traverse quite unevenly across these regions. The essay will instead offer an overarching reading of how these research sites are situated within wider structures and relationships of power. It will engage the recurrent themes and key debates that have dominated the relevant literatures in the fields of social theory and historical and social studies in order to build a broad foundation of understanding for the empirical research that is to come.

Introduction: Malawi implemented a Health Management Information System (HMIS) in 1999 whose aim was to improve health data management. However, there still exists a deficiency of accurate, reliable and timely health data to inform effective planning and resource management. Methods: A cross sectional survey was conducted where qualitative and quantitative data was collected through in-depth interviews, documentation review and focus group discussions. Study participants comprised of 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 and the data collected was transcribed to identify theme and key points. Results: The study established that 1 out of 10 HMIS Officers was qualified for the post using Ministry of Health HMIS minimum requirements. The HMIS Officers stated that data collectors for HMIS from the district hospital, health facilities and the community included Medical Assistants, Nurses/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 lead to information provided not being reliable. 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. The study suggests that collection of data by a wide range of health workers and use of different tools leads to inaccuracy of the data being reported. Nevertheless, data users reported that they find the system useful for development of District Implementation Plans (DIPs). Conclusion: There is need for the review of HMIS indicators and harmonization of data collection tools feeding into the HMIS to reduce data inconsistencies. We suggest that Ministry of Health should consider employing HMIS Officers with suitable qualification as stated under the job requirement, and quarterly refresher courses should be organized to increase the competence of staff involved in data management at all levels.

Fossa Alternas and Double Vault Urine Diverting Dry (DVUDD) latrines have been extensively promoted as ecological sanitation (EcoSan) latrine options in Malawi but little is known about whether they are used properly. A qualitative study of EcoSan users was conducted in the Blantyre and Chikwawa districts, Malawi. Data was collected using in-depth interviews (IDI) and observations. Twenty-eight (28) IDIs were conducted with household heads who had Fossa Alternas and 17 who had DVUDD latrines. Recorded data was transcribed verbatim and analysed thematically. Of the total 45 EcoSan users, only one had no knowledge about how EcoSan latrines operate, 4 had low while 40 had moderate to high knowledge on how the latrines are used. The negative attitudes about EcoSan use were related to problems of reported blockages of urine diversion systems and the intensive management and maintenance needed for the latrines. Practices included the use of soil, ash, urine diverting, using hot water and chemicals to kill maggots, urinating in the drop-hole of the DVUDD latrine and poor maintenance of roof. It is therefore recommended that government, through water monitoring assistants and health surveillance assistants to periodically monitor the practices on EcoSan latrines use and provide necessary support to users.

Background mHealth, the use of mobile communication in the health sector, has become increasingly popular, particularly in Sub-Saharan Africa. Primarily due to the wider accessibility of mobile technology which has increased in recent years. In Malawi, approximately 30% of the population own a mobile phone, including both contract and pre-paid devices (ITU, 2013). This number has risen dramatically with a 70% increase in subscribers in the last six years, and it is still on the rise (ITU, 2013). Mobile phone ownership has increased in line with advancements in cellular coverage; with rates currently standing at 94% of the population having access to adequate mobile coverage, reaching 79% of the geographical area of Malawi (GSMA, 2014). In addition, Malawians spend on average 56% of their monthly income paying for and maintaining a mobile phone (ITU, 2014). This figure is staggering and depicts the high priority which is placed on this technology. Therefore in light of the technological advancements and the wide accessibility of mobile devices in Malawi, the potential for mobile communication to aid the health sector in terms of health education delivery is promising. The Scotland Chikwawa Health Initiative (SCHI), a consortium led by the University of Strathclyde, working in the Chikwawa District of Malawi conducted extensive baseline analysis before the implementation of the WHO ‘Health Settings’ approach in the area. From these 144 focus group discussions at village level it has been highlighted that local residents require health education on areas such as family planning, HIV/AIDS, malaria, cholera and nutrition. Youth were particularly vocal about their need for health education and the lack of youth friendly services for family planning and HIV. These are issues which have the potential to be overcome with the introduction of mhealth resources. As designing and developing mobile based health education programmes through SMS messaging can increase health education reach (Cole-Lewis & Kershaw, 2010) and also increase youth engagement through specifically targeted programmes (Wohl et al.,2011; Yukari et al., 2014; Rana et al., 2015) Aim The aim of this research is to examine the feasibility of using mHealth tools to implement health education programme in Chikwawa, Malawi. Qualitative analysis will be conducted within 2 of the project villages to inform the design, content and structure of the SMS Messaging Service and ensure tailoring of the service to the residents of Chikwawa. Method Seventy-five residents from two SCHI supported villages, Chimoto and Sikenala, took part in 8 focus groups discussing health education needs and the potential for mhealth service introduction. Four focus groups occurred in Chimoto; Male Youth (8 participants), Female Youth (11 participants), Male Adults (7 participants) and Female Adults (9 participants). Four focus groups occurred in Sikenala; Male Youth (10 participants), Female Adults (14 participants), Male Adults (7 participants) and Female Adults (14 participant). The focus groups were conducted in Chichewa, the local language, using a semi-structured question guide and lasted between 45 and 60 minutes. Discussions were recorded, transcribed verbatim and then translated into English by the facilitators. Thematic analysis was then used to analyse the data, using the Braun & Clark (2006) step by step guide to thematic analysis. Results Five themes were identified encapsulating the opinions and beliefs of the residents in Chimoto and Sikenala; Current Health Education Practices, Message Content, Mobile Phone Access, Trust in the SCHI and Sustainability. Current Health Education Practices refers to the current availability of health education, the access to such information and self-reported need for further information in more accessible means. Message Content depicts participants’ need for practical application of the messages they receive and adequate information for the participant to make an informed choice about their own health. In terms of the SMS Messaging Service, participants had no preference as to frequency or volume of messages but stated they would prefer to receive messages out with school hours. Mobile Phone Access represents the participants’ fears around accessibility of the service to those without mobile devices. The sharing of messages and mobile phones with friends and family was discussed as a potential method to overcome this barrier. Trust in the SCHI depicts the residents’ positive views of the project and that they would believe the content of the messages because they trust the SCHI as the source, especially if they recognised a designated project mobile number. This was affirmed by their declaration to share messages with those without phone access. Weariness of the service was identified only in terms of cost because of negative experiences with other subscription services. Finally Sustainability encapsulates the participants’ views on the long term aims of the messaging service and their request for the project to follow up with visits and services in addition to the messages. They particularly emphasising a need for face-to-face communication. Conclusions From this analysis it appears that the sampled participants are on board with the messaging service, and have provided in depth detailed examples of the type of information they require, specifically regarding reproductive health. All focus groups reported a willingness to use the service, to encourage others to use the service and to share the information they receive. Efforts now need to be focused on identifying ways to ensure the service can be provided equally to all, both in terms of mobile phone access and confidence in user ability. In addition, as well as creating health messages based on best practice, complimentary services such as facilitated peer discussions and other mhealth based educational resources need to be identified and incorporated into the intervention. It is the intention of SCHI to implement an interactive SMS Messaging Service, working closely with the local health centre, to make the requested health information more widely accessible and personally tailored to the residents of the Chikwawa District.