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People living in fishing communities have a high burden of preventable water, sanitation, and hygiene (WASH) related diseases but have often been neglected in research and policy. We explored practices and perspectives on WASH among fishing villages around Lake Malombe, Malawi. We employed a mixed methods design, and data were initially collected through participant observations (five weeks), followed by a second phase of qualitative interviews ( n = 16), focus group discussions ( n = 7), and quantitative surveys ( n = 242). We observed that safe water sources were scarce; latrines were basic; and handwashing facilities were limited. Seventy-one percent ( n = 174) of households collected water from unsafe sources (open wells and the lake). Eighty-six percent ( n = 207) of households had basic short-term latrines. Twenty-four percent ( n = 59) of households had handwashing facilities with soap. Qualitative data supported these observations and identified additional factors which compounded poor WASH practices including, a high transient population associated with the fishing trade, poor infrastructure design and construction which lacked consideration of the environmental factors, context and social and cultural norms. As such, fishing communities are underserved and marginalised with constrained access to WASH services, which must be addressed through behaviour-centered and context appropriate solutions.

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.

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.

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.

Diarrhoeal disease remains one of the leading causes of morbidity and mortality in the under-five population, particularly in low income settings such as sub-Saharan Africa. Despite significant progress in sanitation and water access, faecal-oral infections persist in these populations. Therefore, a better understanding of these transmission pathways, and how potential risk factors can be reduced within low income contexts is needed. This study, conducted in Southern Malawi from June to October 2017, used a mixed methods approach to collect data from household surveys ( n = 323), checklists ( n = 31), structured observations ( n = 80), and microbiological food samples ( n = 20). Results showed that food prepared for immediate consumption (primarily porridge for children) posed a low health risk. Poor hygiene practices increased the risk of contamination from shared family meals. Faecal and nosocomial bacteria were associated with poor hand hygiene and unhygienic eating conditions. Leftover food storage and inadequate pre-consumption heating increased the risk of contamination. Improvements in food hygiene and hand hygiene practices at critical points could reduce the risk of diarrhoeal disease for children under 2 years but must consider the contextual structural barriers to improved practice like access to handwashing facilities, soap, food and water storage., Competing Interests: The authors declare no conflict of interest.

A study was undertaken to determine the efficacy of hygiene practices in 2 primary schools in Malawi. The study determined: (1) presence of Escherichia coli on the hands of 126 primary school pupils, (2) knowledge, awareness and hygiene practices amongst pupils and teachers and (3) the school environment through observation. Pupil appreciation of hygiene issues was reasonable; however, the high percentage presence of E. coli on hands (71%) and the evidence of large-scale open defaecation in school grounds revealed that apparent knowledge was not put into practice. The standard of facilities for sanitation and hygiene did not significantly impact on the level of knowledge or percentage of school children's hands harbouring faecal bacteria. Evidence from pupils and teachers indicated a poor understanding of principles of disease transmission. Latrines and hand-washing facilities constructed were not child friendly. This study identifies a multidisciplinary approach to improve sanitation and hygiene practices within schools.

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. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance (AMR) is increasingly becoming a threat to global public health, not least in low- and middle-income countries (LMICs) where it is contributing to longer treatment for illnesses, use of higher generation drugs, more expenditure on antimicrobials, and increased deaths attributed to what should be treatable diseases. Some of the known causes of AMR include misuse and overuse of antimicrobials in both humans and animals, unnecessary use of antimicrobials in animals as growth promoters, and lack of awareness among the public on how to protect antimicrobials. As a result, resistant organisms are circulating in the wider environment, and there is a need to consider the One Health approach to minimise the continuing development of AMR. Environmental Health, specifically water, sanitation and hygiene (WASH), waste management, and food hygiene and safety, are key components of One Health needed to prevent the spread of antimicrobial-resistant microorganisms particularly in LMICs and reduce the AMR threat to global public health. The key Environmental Health practices in the prevention of AMR include: (1) adequate WASH through access and consumption of safe water; suitable containment, treatment and disposal of human excreta and other wastewater including from health facilities; good personal hygiene practices such as washing hands with soap at critical times to prevent the spread of resistant microorganisms, and contraction of illnesses which may require antimicrobial treatment; (2) proper disposal of solid waste, including the disposal of unused and expired antimicrobials to prevent their unnecessary exposure to microorganisms in the environment; and (3) ensuring proper food hygiene and safety practices, such as sale and consumption of animal products in which adequate antimicrobial withdrawal periods have been observed, and growing vegetables on unpolluted soil. Environmental Health is therefore crucial in the prevention of infectious diseases that would require antimicrobials, reducing the spread of resistant organisms, and exposure to antimicrobial residues in LMICs. Working with other professionals in One Health, Environmental Health Practitioners have a key role in reducing the spread of AMR including health education and promotion, surveillance, enforcement of legislation, and research. [ABSTRACT FROM AUTHOR]

Background Typhoid fever remains a major cause of morbidity and mortality in low- and middle-income settings. In the last 10 years, several reports have described the reemergence of typhoid fever in southern and eastern Africa, associated with multidrug-resistant H58 Salmonella Typhi. Here, we identify risk factors for pediatric typhoid fever in a large epidemic in Blantyre, Malawi. Methods A case-control study was conducted between April 2015 and November 2016. Cases were recruited at a large teaching hospital, and controls were recruited from the community, matched by residential ward. Stepwise variable selection and likelihood ratio testing were used to select candidate risk factors for a final logistic regression model. Results Use of river water for cooking and cleaning was highly associated with risk of typhoid fever (odds ratio [OR], 4.6 [95% confidence interval {CI}, 1.7–12.5]). Additional risk factors included protective effects of soap in the household (OR, 0.6 [95% CI,.4–.98]) and >1 water source used in the previous 3 weeks (OR, 3.2 [95% CI, 1.6–6.2]). Attendance at school or other daycare was also identified as a risk factor (OR, 2.7 [95% CI, 1.4–5.3]) and was associated with the highest attributable risk (51.3%). Conclusions These results highlight diverse risk factors for typhoid fever in Malawi, with implications for control in addition to the provision of safe drinking water. There is an urgent need to improve our understanding of transmission pathways of typhoid fever, both to develop tools for detecting S. Typhi in the environment and to inform water, sanitation, and hygiene interventions. [ABSTRACT FROM AUTHOR]

Background: A key challenge for menstruating girls and women in low-resource countries is the inadequate and unreliable supply of menstrual products. Although development partners are implementing menstrual product interventions to address this challenge in Malawi, there is a paucity of information on the distribution of menstrual products and the acceptability of these interventions among users. Methods: We conducted in-depth interviews with girls (n = 20) and women (n = 26) and 4 focus group discussions (FGDs) with women (n = 35) and 7 FGDs with girls (n = 60) to explore the acceptability of menstrual products interventions in 8 districts. Teachers (n = 12), community leaders (n = 6), community health workers (n = 8) and service providers (n = 9) were also interviewed to explore implementation issues and their views regarding the effect of menstrual products interventions on girls and women. Data were analyzed using content analysis. Results: Common menstrual products being promoted include locally made reusable pads, commercially made disposable pads and menstrual cups. Overall, adult women preferred reusable pads and young girls preferred disposable pads. Reported benefits of using any type of material distributed included enhanced cleanliness and reduced school absenteeism for girls. While community leaders and teachers applauded the use of disposable menstrual products they expressed concern that they are not affordable for an average Malawian and bemoaned the indiscriminate disposal of used disposable pads. Women and girls highlighted their lack of facilities to effectively wash and dry reusable pads. Service providers bemoaned poor coordination and the lack of national standards to regulate the quality of menstrual products distributed at national level. Improved inclusion of males and health workers could enhance the sustainability of programmes. Conclusion: While the available menstrual products interventions are acceptable among participants, we note several challenges including affordability, poor disposal methods, lack of attention on sanitation facilities and the lack of standard protocols to regulate the quality of menstrual products. Recommendations to address these issues are reported. [ABSTRACT FROM AUTHOR]