Inclusion of persons living with disabilities in a district-wide sanitation programme: A cross-sectional study in rural Malawi.

Community-led total sanitation (CLTS) is embraced as a key strategy to achieve universal sanitation coverage (Sustainable Development Goal 6.2). Although inclusion is identified as a predictor of CLTS success, people living with disabilities are often excluded from community sanitation programmes and there is limited research exploring CLTS participation amongst people living with disabilities. This study aims to explore the extent to which people living with disabilities participated in a CLTS intervention delivered in rural Malawi using standard approaches. This cross-sectional study was conducted in the Chiradzulu district of Malawi. A household questionnaire was administered to collect information about CLTS participation. Multivariable logistic regression was performed to compare participation in different CLTS activities between households with (n = 80) and without a member with a disability (n = 167), and between household members with (n = 55) and without a disability (n = 226). No difference in CLTS participation was observed at the household-level, but there were marked differences in CLTS participation between household members with and without a disability. Household members without a disability felt they could give more input in triggering activities (OR = 3.72, 95%CI 1.18-11.73), and reported higher participation in the transect walk (OR = 4.03, 95%CI 1.45-11.18), community action planning (OR = 2.89, 95%CI 1.36-6.13), and follow-up visits (OR = 3.37, 95%CI 1.78-6.40) compared to household members with disabilities. There was no difference in the likelihood of being invited to triggering (OR = 0.98, 95%CI 0.41-2.36), attending triggering (OR = 2.09, 95%CI 0.98-4.46), or participating in community mapping (OR = 2.38, 95%CI 0.71-7.98) between household members with and without a disability. This study revealed intra-household inequalities in CLTS participation. To improve participation in CLTS interventions, facilitators should be trained on action steps to make CLTS more inclusive. Further research could include an in-depth analysis of predictors of CLTS participation amongst people living with disabilities, including disability types, severity and age.

Assessment of infrastructure, behaviours, and user satisfaction of guardian waiting shelters for secondary level hospitals in southern Malawi.

Guardian Waiting Shelters (GWSs) are an essential component of the Malawi's health care system as they serve as a temporary home for patient guardians while taking care of their relatives admitted to the hospital, and expectant mothers. Although GWSs play a crucial role in Malawi's healthcare system, past studies have primarily concentrated on maternity waiting homes, neglecting the role and importance of GWSs. The study examines GWS management structures and conditions, as well as guardian satisfaction and perception of health risks related to GWS use. In this explanatory sequential mixed methods design, we assessed 12 GWSs from southern region of Malawi. Qualitative data included interviews (n = 149) and focus group discussions with patient guardians (n = 72), interviews with GWS caretakers (n = 5), representatives from Hospital Management (n = 12) and Hospital Advisory Committees (n = 11). Lack of guidelines and standards for GWSs resulted in creating a customized facility checklist to quantitatively assess infrastructure present at GWSs (n = 12). Descriptive statistics and qualitative thematic analysis were utilized for data analysis, and a problem tree analysis was used to triangulate and summarize the findings. A total of 249 participants participated in the study. Each GWS had an average of 100 users daily, primarily adult females (71%). No one was accountable for GWS operation and maintenance due to the lack of a management hierarchy. GWS infrastructure conditions were poor, with inadequate functional sleeping rooms, insufficient access to water, sanitation and hygiene facilities. Notably, 50% of the GWSs lacked water access, and a quarter had non-functional toilets. Guardians felt unsafe and at risk of disease transmission when staying within GWS. Study findings highlight lack of clear, consistent GWS ownership as a root cause of challenges in GWSs. Clear policy and operational standards must be established for effective management and smooth functioning of GWSs.

Adherence to Hand Hygiene among Nurses and Clinicians at Chiradzulu District Hospital, Southern Malawi.

Healthcare associated infections (HAIs) are a burden in many countries especially low-income countries due to poor hand hygiene practices in the healthcare settings. Proper hand hygiene in the healthcare setting is an effective way of preventing and reducing HAIs, and is an integral component of infection prevention and control. The objective of this study was to determine adherence to hand hygiene guidelines and associated factors among nurses and clinicians. A quantitative cross-sectional study was conducted at Chiradzulu District Hospital (Malawi) where stratified random sampling was used to obtain the sample of 75 nurses and clinicians. Data were collected using self-administered questionnaires (n = 75), observation checklists (n = 7) and structured observations (n = 566). The study findings confirmed low adherence to hand hygiene practice among healthcare workers (HCWs) in Malawi. Overall, higher hand hygiene practices were reported than observed among nurses and clinicians in all the World Health Organization's (WHO) five critical moments of hand hygiene. This calls on the need for a combination of infrastructure, consumables (e.g., soap) and theory driven behavior change interventions to influence adoption of the recommended hand hygiene behaviors. However, such interventions should not include demographic factors (i.e., age, profession and ward) as they have been proven not to influence hand hygiene performance.

Process Evaluation of "The Hygienic Family" Intervention: A Community-Based Water, Sanitation, and Hygiene Project in Rural Malawi.

Process evaluations of environmental health interventions are often under-reported and under-utilized in the development of future programs. The "Hygienic Family" intervention targeted improvements in hygiene behaviors of caregivers with under five-year-old children in rural Malawi. Delivered through a combination of open days, cluster meetings, household visits, and prompts, data were collected from two intervention areas for ten months. A process evaluation framework provided indicators that were measured through intervention implementation and expenditure reports, focus groups discussions, interviews, and household surveys. The collected data assessed the intervention fidelity, dose, reach, acceptability, impact, and cost. Results indicated that all planned hygiene promotion messages were delivered, and study participants were better reached primarily through household visits (78% attended over 75% of the intervention) than cluster meetings (57% attended over 75% of the intervention). However, regression found that the number of household visits or cluster meetings had no discernible effect on the presence of some household hygiene proxy indicators. Intervention implementation cost per household was USD 31.00. The intervention delivery model provided good fidelity, dose, and reach and could be used to strengthen the scope of child health and wellbeing content. The intensive face-to-face method has proven to be effective but would need to be adequately resourced through financial support for community coordinator remuneration.

Preparedness for and impact of COVID-19 on primary health care delivery in urban and rural Malawi: a mixed methods study.

OBJECTIVE: Across Africa, the impact of COVID-19 continues to be acutely felt. This includes Malawi, where a key component of health service delivery to mitigate against COVID-19 are the primary healthcare facilities, strategically placed throughout districts to offer primary and maternal healthcare. These facilities have limited infrastructure and capacity but are the most accessible and play a crucial role in responding to the COVID-19 pandemic. This study assessed health facility preparedness for COVID-19 and the impact of the pandemic on health service delivery and frontline workers. SETTING: Primary and maternal healthcare in Blantyre District, Malawi. PARTICIPANTS: We conducted regular visits to 31 healthcare facilities and a series of telephone-based qualitative interviews with frontline workers (n=81 with 38 participants) between August 2020 and May 2021. RESULTS: Despite significant financial and infrastructural constraints, health centres continued to remain open. The majority of frontline health workers received training and access to preventative COVID-19 materials. Nevertheless, we found disruptions to key services and a reduction in clients attending facilities. Key barriers to implementing COVID-19 prevention measures included periodic shortages of resources (soap, hand sanitiser, water, masks and staff). Frontline workers reported challenges in managing physical distancing and in handling suspected COVID-19 cases. We found discrepancies between reported behaviour and practice, particularly with consistent use of masks, despite being provided. Frontline workers felt COVID-19 had negatively impacted their lives. They experienced fatigue and stress due to heavy workloads, stigma in the community and worries about becoming infected with and transmitting COVID-19. CONCLUSION: Resource (human and material) inadequacy shaped the health facility capacity for support and response to COVID-19, and frontline workers may require psychosocial support to manage the impacts of the COVID-19 pandemic.