Background and Methodology
In Malawi, diarrheal illness is a leading cause of morbidity and mortality in children. Safe storage and treatment of water at the household level, access to and effective use of a sanitation facility, and hand washing with soap reduce the risk of diarrhea. The US Agency for International Development (USAID) sponsored a pilot program in collaboration with UNICEF, the Government of Malawi Ministry of Health (MOH), and PSI, to test the feasibility of promoting hygiene improvement interventions (specifically disinfection and safe storage of water at the point-of-use, and hand washing with soap) through Malawi’s antenatal health care system. The purpose of this initiative was to improve maternal health and decrease diarrheal diseases in two districts in Malawi. The pilot program involved the distribution of hygiene kits, including a water storage container with a tap, a bottle of WaterGuard, a 500 gram bar of soap, and 2 sachets of ORS, as incentives for pregnant women to come to a hospital or clinic for antenatal care and delivery. The pilot was evaluated in 2008 by comparing knowledge prevention and use of WaterGuard and hand washing with soap across the two pilot districts, including both the target group and their relatives. In total the sample size was 775 households. The objectives of the evaluation were to: 1. determine the program’s impact on knowledge and practices, rates of WaterGuard and ORS usage, and improved hand washing practices among pregnant women enrolled in the program (program participants) and their female relatives and friends with children less than 5 years old in these two districts. 2. Describe factors that motivated and inhibited changes in knowledge and practices among program participants. 3. Determine the program’s impact on frequency of antenatal clinic attendance, delivery at a health care facility, and postnatal checks among program participants.
The evaluation demonstrates that Malawi’s antenatal care system is a very effective platform for promoting key hygiene behaviors among mothers. The program evaluation showed significant increases in knowledge about WaterGuard, reported WaterGuard use, observed WaterGuard use, and WaterGuard purchase among program participants in both districts after the program period. There were also significant increases in hand washing knowledge and ability to demonstrate correct hand washing procedures among these program participants.
In addition to improvements in water treatment and hygiene practices, the evaluation also noted additional program benefits. Program participants had high use of antenatal, delivery, postnatal, and newborn health services, which could also improve maternal and child health. Finally, the evaluation also showed significant improvements in water treatment and hand washing practices among the friends and relatives of program participants, demonstrating diffusion of the intervention into the community, particularly among other women with children under 5 years who are at highest risk of diarrhea.
Program recommendations include: 1. Program continuation in Blantyre and Salima Districts, and expansion of program to other districts in Malawi with interim evaluation. 2. Future program expansion should include education components by nurses in the health facilities and HSAs during home visits, encouraging HSAs to conduct program monitoring during home visits. 3. Initiate a pilot program for promotion of key hygiene behaviors through the expanded program in immunizations (EPI).
While the cost-effectiveness of the approach remains to be demonstrated at national scale experiences from the pilots should be used in the dialogue with Government of Malawi and Development Partners.
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Water and Environmental Sanitation
Government of Malawi, USAID