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.
Highlights
Diarrheal disease continues to be the second leading cause of death in children under five, with approximately 700,000 deaths worldwide annually [1]
The WASH Benefits study in Bangladesh did demonstrate a small reduction in diarrhea, albeit with evidence that there was no benefit from a combined WASH intervention over individual sanitation or hygiene programs [13]
The results showed that health workers had a good level of understanding of water and sanitation issues (80% know to use water and soap for effective hand washing; 93% believe poor hand washing with soap (HWWS) due to lack of soap/poverty; 69% understood animal feces could transmit disease), there was limited knowledge in relation to food hygiene practices (10% could describe critical behaviors Saursotauinnabdilitfyo2o01d9,h11y,gx iFeOnReP)E
Summary
Diarrheal disease continues to be the second leading cause of death in children under five, with approximately 700,000 deaths worldwide annually [1]. The WASH Benefits study in Bangladesh did demonstrate a small reduction in diarrhea, albeit with evidence that there was no benefit from a combined WASH intervention over individual sanitation or hygiene programs [13]. This may be attributed to a number of factors, including the large number of pathways in which children may become exposed to diarrheal disease pathogens. The contribution of food in the transmission of diarrhea has been supported by the 2015 WHO report, which attributed 70% of the burden of foodborne disease to sub Saharan African and South East Asia, with 40% of this affecting children under the age of five [26]. Attempts to model the complex mechanisms that potentially link poor sanitation and hygiene to diarrheal disease, enteric enteropathy, under nutrition, and child development, highlight the challenges of understanding the myriad of environmental transmission routes and sources of contamination, which may contribute to diarrheal and other related diseases [1,5,27,28,29]
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