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

Abstract

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.

Perspectives and Practices on Water, Sanitation, and Hygiene from a Fishing Community along Lake Malombe, Southern Malawi

“…Similarly, our results support previous findings that water treatment and management promotion must be behaviour centered and context appropriate, taking into consideration the needs and wants of the community it is targeting [ 24 , 27 , 28 , 29 , 30 , 31 , 32 ]. Capacity in households and communities to monitor drinking water quality through practical and cost-effective methods, could re-enforce these messages in a more effective manner, as has been achieved with visual behaviour change techniques (e.g., Glo Germ ™ ) used elsewhere in Malawi [ 33 , 34 , 35 ].…”

Self-Reported Versus Observed Measures: Validation of Child Caregiver Food Hygiene Practices in Rural Malawi

“…Food alone has been suggested to be more important than water in the transmission of diarrhoeal pathogens in some low-income settings [4,[15][16][17]. Supplementing breast milk with food, commonly referred to as complementary feeding, at about six months of age [18] has been strongly linked to childhood diarrhoea, due to the foods' unhygienic preparation [11,[19][20][21].…”

“…Specifically, we measured the difference between reported and observed practices for both an intervention and control population to validate if the intervention group did not just improve their knowledge, but had also translated the messaging into better practice. This study was undertaken as part of the "Hygienic Family" research project that aimed at improving complementary food hygiene practices in rural households in Malawi [17,46,47].…”

Integrated Approach in Addressing Undernutrition in Developing Countries: A Scoping Review of Integrated Water Access, Sanitation, and Hygiene (WASH) + Nutrition Interventions

“…All 8 studies were conducted in rural areas in Asia and sub-Saharan Africa. In particular, the majority of the studies were carried out in sub-Saharan Africa and represented such countries as Malawi ( 23 ), Ethiopia ( 24 , 25 ), Zimbabwe ( 26 ), Burkina Faso ( 27 ), and Kenya ( 22 ). In Asia, the studies specifically took place in Nepal ( 28 ) and Bangladesh ( 21 ).…”

“…As shown in Table 2 , 2 interventions were primarily educational ( 23 , 25 ), while the remaining trials involved deliverables or the distribution of hardware in the treatment groups. Overall, community health workers familiar with the study area and the population were utilized to recruit, outreach, and collect data for evaluation.…”