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.

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.

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.

Background: Community-based behavior change interventions are a common approach to Water, Sanitation, and Hygiene (WASH). Yet, published evaluations of how these interventions work in district-wide approaches are rare. Objective: This study reports the baseline characteristics and study design for a trial assessing the effectiveness of a district-level Community-led Total Sanitation (CLTS) intervention compared to the additional integration of local care groups (CG) on sanitation coverage and use and hygiene behaviors in Chiradzulu District, Malawi. Methods: This study is a controlled before-and-after trial with 2 treatment arms and a control group. Clusters are rural villages in 3 traditional authorities (TAs). One arm will receive CLTS and the CG model (CLTS+CG group), one arm CLTS only (CLTS group), and one group will serve as the control. The trial is part of the wider WASH for Everyone (W4E) project, led by World Vision Malawi that aims to expand access to WASH services across the entire district by 2025. Study participants were selected from the 3 TAs. Systematic sampling procedures were used to select 20 households per cluster with a total of 1400 households at both baseline and end line. The primary outcome is sanitation coverage. Secondary outcome measures include sanitation use, safe disposal of child feces, observed handwashing facility, and Sanitation-related Quality of Life Index (SanQoL-5). Results: The baseline observations indicate a balanced distribution of potential demographic confounders in the trial arms with a slight variation on some WASH proxy measures. We noted the low coverage of handwashing facilities with soap and water in all 3 arms: 8% in the CLTS group, 4% in the CLTS+CG group, and 4% in the control group. There was a marginal variation in handwashing practices among the study arms with 3% of individuals handwashing with soap and water in the CLTS group, 5% in the CLTS+CG group, and 2% in the control group. Sanitation coverage also varied among the study arms at baseline as 83% of households had access to unimproved sanitation in the CLTS group, 70% in the CLTS+CG group, and 81% in the control group. Conclusions: Results from this trial will provide evidence on whether the CLTS+CG approach is effective at improving sanitation and hygiene practices in the W4E program area compared to CLTS alone and no intervention, as well as inform implementing partners on future interventions in Chiradzulu District, Malawi. The results are expected to be published in 2025. Trial Registration: ClinicalTrials.gov NCT05808218; https://clinicaltrials.gov/study/NCT05808218 International Registered Report Identifier (IRRID): RR1-10.2196/68280

This study is embedded within the Water, Sanitation, and Hygiene for Everyone programme in Chiradzulu District, Malawi, where one programme area achieved Open Defecation Free (ODF) status in December 2022 following a Community-Led Total Sanitation (CLTS) intervention. In March 2023, Tropical Cyclone Freddy made landfall in Chiradzulu District, causing widespread damage to essential infrastructure. This study compares household sanitation access, classified according to the WHO/UNICEF Joint Monitoring Programme (JMP) sanitation ladder, before and after the cyclone in a rural area of southern Malawi. Household surveys were administered in the same 311 households at programme baseline in April 2022, prior to CLTS implementation, and at 10-month follow-up in June 2023, three months after Cyclone Freddy. ODF status verification data were also used to estimate pre-cyclone sanitation access. These data were used to estimate the proportion of household sanitation facilities that collapsed and became unusable due to the cyclone. The types of JMP sanitation facilities most prone to collapse and those most likely to be reconstructed three months after the cyclone are also reported. Of the 311 households surveyed, 5% had access to basic sanitation, 3% to limited sanitation, and 92% relied on unimproved sanitation prior to Cyclone Freddy. Following the cyclone, 68% of households reported that their sanitation facility, primarily unimproved, had collapsed. Three months later, 36% of surveyed households had no sanitation facility at all, while 50% relied on unimproved sanitation. Among the 211 households whose facility collapsed, 43% rebuilt an unimproved facility. These findings underscore the vulnerability of sanitation infrastructure to tropical cyclones, which can cause affected communities to resort to unsafe sanitation practices or rebuild facilities that remain vulnerable to future cyclones. Improving the resilience of household sanitation infrastructure to extreme weather is critical to protecting public health, particularly in the context of climate change.

Community-Led Total Sanitation (CLTS) seeks to eliminate open defecation by empowering households to adopt improved sanitation and hygiene behaviours through latrine use. Widely integrated into national sanitation strategies in low- and middle-income countries, CLTS is implemented through pre-triggering, triggering, and post-triggering activities. However, limited evidence exists on how implementation process promotes behaviour change.This study retrospectively evaluates a community-based intervention in Chiradzulu District, Malawi, that employed CLTS alongside market-based sanitation and hygiene promotion campaigns. Using the UK Medical Research Council process evaluation framework, we analysed project documentation and collected data from household surveys (n=1,151), interviews (n=36), and focus group discussions (n=14).All planned activities were implemented, though adaptations affected fidelity and required additional household visits. Intervention reach was suboptimal: 46% of households attended triggering events, 64% received visits, 16% were exposed to market-based sanitation, and 47% received hygiene campaigns. Exposure to both triggering sessions and household visits increased the likelihood of latrine availability (OR = 1.63; CI = 1.55–1.72) and HWF presence (OR = 1.39; CI = 1.03–1.86). High costs, limited awareness of masons, and extreme weather events affected latrine adoption. Our findings emphasize the need for multi-level engagement, flexible delivery, and addressing barriers for sustainable sanitation adoption.