Tracy Morse

Groundwater monitoring is essential to sustainable water resource management and climate resilience strategies – a source of key data to support decision-making. However, in many regions of the world including in Malawi, a country that is heavily reliant on groundwater, the scarcity of groundwater monitoring data is a persistent challenge. The scarcity of data is compounded by the in-operation of existing groundwater monitoring networks. While operational challenges have often been framed as a technical or financial issue, this study applies a co-creation methodology to explore the wider institutional, procedural, and social factors contributing to persistent data scarcity. Drawing from sourced grey literature and a series of participatory workshops held in Malawi with stakeholders from across the water sector, including community representatives, several systemic and interconnected challenges were identified. Themes of challenges include institutional and governance fragmentation, procedural ambiguity, limited and uncertain financing, and a lack of formalised community engagement. Participants emphasised that these challenges are not independent and addressing them in isolation is unlikely to lead to long-term improvement in data availability. Instead, data scarcity is a symptom of deeper systemic issues, and any attempt to improve the monitoring network must consider the broader context in which it operates. The findings suggest that future efforts, in Malawi and in other global contexts, should prioritise adaptive and inclusive strategies, including strengthened institutional coordination, updated procedural guidance, and an expanded role for community participation in monitoring activities.

Solid waste pollution is a multifaceted global challenge affecting the environment, economy, and human health, yet our understanding of environmental solid waste dynamics, such as waste type, weight(W), and volume(V), which inform waste management initiatives and policy frameworks remains limited in Sub-Saharan Africa. In this longitudinal study, we mapped informal waste disposal sites using transect-walks and drones in urban Malawi. Monthly characterisation of selected individual waste piles was undertaken for 12 months. Sampling (200L/waste pile) included both surface and compacted sections. (60 cm depth), which were characterised by weight(kg/m ² ), volume(m ³ ), and individual counts of plastic items(m ² ). Three-way ANOVA and a linear mixed-effect model were used to predict percentage recovery for the interactions between month, waste pile depth, and waste type as fixed factors. Fourteen out of 56 waste piles received detailed temporal characterisation. Waste piles were located along rivers(50%), streams(29%), and open-dumping spaces(21%). Soil (W:60%, V:19%), organic material (W:22%, 33%), and plastics (W:8%, V:24%) were the highest components by weight, and volume, making plastics the highest non-organic category of waste. Seven plastic polymer types were identified, with Low-Density Polyethylene being the most common (83% plastic items/m ² ). Seasonality, waste pile depth, and waste type (F(171, 4284) = 11.44, p < .001, η ² = .31) significantly affected percentage recovery of waste items, indicating their effect on waste pile dynamics. Sustainable waste management initiatives need to account for seasonal changes, material characteristics, and waste pile stratification to effectively improve waste management systems and the public health implications of waste piles.

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.

There are 48 countries where >5 million people lack a basic toilet. This makes sanitation resource allocation a live issue in infectious disease policy, but toilet user preferences often give greater weight to quality of life gains such as privacy and safety. These quality-of-life gains are never valued in benefit-cost analyses, risking resource misallocation. This study estimates the monetary value of a sanitation-adjusted person year, analogous to the quality-adjusted life year. We conducted a contingent valuation willingness to pay (WTP) study with 300 participants in rural Malawi. Participants first answered questions for the sanitation-related quality of life index (SanQoL-5), scored 01. They were then offered a hypothetical toilet upgrade and asked about WTP for resulting SanQoL-5 gains, first via double-bound dichotomous choice and then maximum WTP. The average WTP for a sanitation-adjusted person year was US$ 6.2 (95% CI: 3.0-9.3), based on regression adjusted for WTP for a benchmark good (maize). Experiencing a gain in SanQoL-5 from 0.45 to 0.75 on the 0-1 scale would therefore be worth about $2/year, a consequential benefit to the 700 million people living on less than $2.15 per day. Our findings enable the valuation of quality of life in sanitation benefit-cost analysis.

Background: Diarrhoea is a leading cause of morbidity and mortality among children under five in low-income regions. This study assessed the effectiveness of household solar disinfection (SODIS) in reducing diarrhoeal incidence among children in Chikwawa District, Malawi. Methods: We conducted a secondary analysis of a cluster quasi-experimental trial (March 2019–March 2020) involving 985 children from 793 households: control (369 children, 271 households), 20 L transparent polypropylene SODIS bucket (336 children, 258 households), and SODIS bucket with cloth filter (380 children, 264 households). Variables included water source, child age, sex, rotavirus vaccination, SODIS adherence. Analyses employed descriptive statistics, Chi-square, Kruskal–Wallis tests, and Poisson regression with robust standard errors in Stata 17. Results: Overall, diarrhoeal incidence was two cases per child-year. Households using SODIS buckets had an 88% reduction in incidence (adjusted incidence rate ratio (IRR): 0.12; 95% CI: 0.04–0.23), while those using SODIS with a cloth filter saw a 70% reduction (adjusted IRR: 0.30; 95% CI: 0.18–0.50). High SODIS adherence was linked to 90% reduction (adjusted IRR: 0.13; 95% CI: 0.02–0.81); medium adherence showed no significant effect. Conclusion: These findings support SODIS as an effective point-of-use water treatment, with adherence critical to health impact.

Introduction: While hygiene promotion is frequently included in sanitation programmes, few studies directly evaluate the effect of these interventions on hygiene outcomes. We assessed the effectiveness of a district-level Community-led Total Sanitation (CLTS) intervention with and without locally managed Care Groups (CG) on observed sanitation and hygiene behaviours in a rural area of Chiradzulu District, Malawi. Methods: This was a controlled before-and-after trial with two intervention arms and a control group implemented in three sub-districts (also known as Traditional Authorities [TAs]) in Chiradzulu District, Malawi. Two TAs received CLTS, which included an additional low-intensity government-led hygiene promotion campaign. One TA received the standard CLTS intervention (CLTS group), and one received the same intervention but with additional sanitation and hygiene promotion delivered through local Care Groups (CLTS+CG group). The third TA served as the control group. Hygiene and child faeces disposal outcomes were measured by fieldworker direct observation in a purposively sampled subset of 96 to 140 households per arm enrolled in the main trial at baseline (June 2023) and at endline (May 2024). We estimated intervention effects on observed handwashing behaviour and safe child faeces disposal with hierarchical logistic regression models. Results: In our per protocol analysis, neither intervention was associated with differences in observed handwashing with soap compared to the control arm nor with differences in observed child faeces disposal. Additional analyses found that both interventions were associated with large increases in hand rinsing with water only compared to control groups (CLTS+CG group adjusted relative risk ratio [aRRR] = 2.80, CI = 1.81, 4.33; CLTS group aRRR = 1.76, CI = 1.10, 2.83). The CLTS+CG intervention was associated with a slight increase in hand rinsing compared to the CLTS only group (aRRR = 1.65, CI = 1.01, 2.69). Conclusion: The CLTS+CG and CLTS interventions were associated with an increase in hand rinsing at critical junctures but not handwashing with soap, suggesting that current hygiene programmes require further focus on soap access and use. Future research should investigate barriers to the availability and competing uses of soap in households. Both interventions did not increase safe child faeces disposal, though the sample size was small. Future research should investigate further integration of child faeces management into CLTS and CG behaviour change interventions.

This study aimed to explore the factors influencing food hygiene behaviours among child caregivers in Chikwawa district, Malawi. This research focused on three specific hygiene behaviours: keeping utensils on an elevated surface, using soap to clean kitchen utensils, and washing hands with soap at critical times. These practises are known to contribute to the reduction in diarrhoeal disease. To understand these behaviours, this study utilised multilevel binary logistic models to examine variations at both the household and village levels. The findings reveal that educational background, age group, occupation, self-confidence, intervention, self-will, and perception were the most significant factors influencing food hygiene behaviours. Notably, there were significant variations at the village level (p < 0.00001), while no significant variations were observed at the household level (p > 0.1). Additionally, caregivers from areas where interventions were implemented showed a positive response to these interventions.

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

African communities have a high prevalence of antimicrobial-resistant bacterial carriage, alongside high levels of antibiotic usage and environmental pollution. Limited access to water, sanitation and hygiene infrastructure and wastewater treatment facilities enables the dissemination of resistant bacteria, antimicrobials and antibiotic resistance-driving chemicals (ARDCs) into local rivers. Few data exist quantifying the chemical drivers of antimicrobial resistance (AMR) in urban aquatic environments from African settings. In this longitudinal surveillance study, we investigated urban rivers in Blantyre, Malawi over an uninterrupted 12-month period, identifying a broad-range of chemical pollutants in urban river systems, including antibiotics, common pharmaceuticals, agricultural and industrial chemicals and heavy metals. Antimicrobial concentrations were found at levels selective for AMR and ARDCs exhibited seasonal variations, indicating that deficient sanitation infrastructure and anthropogenic factors result in high antibiotic and ARDC levels entering the river systems, which serve as an important ecological niche for the acquisition, maintenance and transmission of AMR.