Developing a Contextually Appropriate Integrated Hygiene Intervention to Achieve Sustained Reductions in Diarrheal Diseases

Abstract

Diarrheal disease in under-five children remains high in Sub-Saharan Africa; primarily attributed to environmental pathogen exposure through poorly managed water, sanitation, and hygiene (WASH) pathways, including foods. This formative study in rural Malawi used a theoretical base to determine the personal, social, environmental, and psychosocial factors that are to be considered in the development of an integrated intervention for WASH and food hygiene. Using a mixed methods approach, a stakeholder analysis was followed by data collection pertaining to 1079 children between the ages of four to 90 weeks: observations (n = 79); assessment of risks, attitudes, norms and self-regulation (RANAS) model (n = 323); structured questionnaires (n = 1000); focus group discussions (n = 9); and, in-depth interviews (n = 9) (PACTR201703002084166). We identified four thematic areas for the diarrheal disease intervention: hand washing with soap; food hygiene; feces management (human and animal); and, water management. The contextual issues included: the high level of knowledge on good hygiene practices not reflected in observed habits; inclusion of all family members incorporating primary caregivers (female) and financial controllers (male); and, endemic poverty as a significant barrier to hygiene infrastructure and consumable availability. The psychosocial factors identified for intervention development included social norms, abilities, and self-regulation. The resulting eight-month context specific intervention to be evaluated is described.

Health Outcomes of an Integrated Behaviour-Centred Water, Sanitation, Hygiene and Food Safety Intervention–A Randomised before and after Trial

“…As described previously [31], the study was a randomised before and after trial, with a control and two treatment arms, assessing the relative impact of the hygiene of complementary foods on the prevalence of diarrhoeal disease in children under five years old. For the programme, implemented from February-November 2018 in the rural District of Chikwawa in Southern Malawi, we recruited 1000 households in total.…”

“…For the programme, implemented from February-November 2018 in the rural District of Chikwawa in Southern Malawi, we recruited 1000 households in total. The two treatment arms were designed based on formative research: (1) a food hygiene intervention only (n = 400), and (2) an integrated WASH and food hygiene intervention (n = 400) [31], with a control group in which no intervention took place (n = 200). Although diarrhoeal disease was the primary outcome, respiratory infections were also monitored as indicators of improved WASH and food hygiene practices.…”

“…Treatment 2 included two TAs as there were insufficient eligible participants in the planned TA. Baseline data reported elsewhere showed homogeneity across all study groups in terms of household demographics, socio-economic status and hygiene related proxies [31]. All study sites were selected in collaboration with the District Coordinating Team (government intersectoral team) and had all been declared open defaecation free by the Government of Malawi.…”

“…Based on the findings of the formative and baseline data, and using a behaviour-centred approach, the 31-week intervention included four critical areas as outlined in Figure 1 and described elsewhere [31]. the caregiver.…”

“…The Hygienic Family (Banja la Ukhondo) intervention was based on formative research that found that children under the age of two were being exposed to multiple sources of faecal contamination within their domestic environments, particularly through complementary feeding at shared family meals, household drinking water, and exposure to environmental faeces [31][32][33]. However, as previous studies addressing food hygiene in low income settings measured success based on behavioural change, structural changes or the microbiological quality of food and water [5,9,10], our study was designed to measure the relative impact of the hygiene of complementary foods on diarrhoeal disease as a primary outcome, and the impact of a food hygiene intervention (food hygiene + handwashing) relative to a food hygiene and WASH intervention (food hygiene + handwashing + faeces management + water management) [31].…”