Abstract Ref 001: A global scoping review of Water, Sanitation and Hygiene (WASH) interventions for adolescents

Rossanie.D. Malolo ^1,2,3., Monica Nzanga^1., Jasper Ceuppens³, Tara K Beattie ^3., Kondwani Chidziwisano ^1,2,3., Christabel Kambala^1,2., Tracy Morse^3.

¹ Centre for Water Sanitation Health & Appropriate Technology Development (WASHTED)

²  Malawi University of Business & Applied Science (MUBAS); P/Bag 303, Chichiri, Blantyre, Malawi

³ Department of Civil and Environmental Engineering, University of Strathclyde, Glasgow G1 1XJ,UK
*Corresponding author:

 Rossanie Daudi Malolo

Centre for Water Sanitation Health & Appropriate Technology Development (WASHTED) Malawi University of Business & Applied Science (MUBAS)

P/Bag 303

Chichiri, Blantyre, Malawi.

Correspondence: rossanie.malolo.2024@uni.strath.ac.uk  

Background

Adolescence presents an ideal opportunity to lay the foundations for healthy living, yet this age group receive limited targeted health interventions. This scoping review aimed to identify the focus of existing WASH interventions for adolescents, their characteristics, the extent of adolescent participation and their effectiveness.

Methodology

The Arksey and O’Malley framework was used to conduct this review. The extent of adolescent participation was measured using the Shier’s ‘Pathways to Participation’ model. A search was conducted in Scopus, PubMed, and Research for Life using keywords and Boolean operators, with additional reference list checks. Studies included were original research reporting on WASH interventions from anywhere in the world, targeting 10–19-year-olds and published in English between 2013 and 2023.

Results

Screening and eligibility assessment of 5432 sources resulted in 70 eligible studies. All were experimental studies, based in Asia (n=48), Africa (n=20), and South America (n=2). Only 2 of the 70 studies targeted adolescents only, the rest combined them with other age groups. Majority (58) of the interventions were implemented in schools and only two included both schools and households, the rest were in school. interventions with all components

(Water, sanitation & hygiene) were few (7), majority were on individual WASH components. The most targeted WASH topic was oral hygiene (n=23) (all implemented in Asia), followed by Menstrual Hygiene Management (MHM) (n=18) and hand hygiene (n=10). The reviewed WASH interventions were mostly educational, and Behaviour Change Communication only (n=43), with little focus of infrastructure. The implementation period ranged from 5 days to 2 years, but majority (55) were implemented in less than a year. Adolescent participation in interventions was low, with the majority (n=60) of the studies at Level 2 of the Shier’s Pathway to Participation, where adolescents were merely involved as informants and recipients of the interventions. Inclusion of adolescents with disabilities was also low (n=13). The primary outcomes evaluated included: oral hygiene status (n=24), MHM knowledge & practice (n=14), handwashing practices (n=10), health-related outcomes (n=5), and educational outcomes (n=4); only one study evaluated psycho-social outcomes. Forty-nine studies were reported as effective, 15 partially effective, and 6 ineffective in achieving their primary outcomes.

Conclusion

Few WASH interventions specifically target adolescents, missing an opportunity to develop life-long positive WASH skills and practices. WASH interventions need to prioritize delivery to vulnerable groups and regions, and balance education with infrastructure support. More active participation of adolescents in intervention development and implementation should be considered & out-of-school adolescents should also be targeted. Psycho-social outcomes must be prioritized along with the commonly evaluated WASH indicators.

Keywords: Adolescents; WASH Interventions; Menstrual Hygiene Management; Global Heal

Abstract Ref 002: Water, Sanitation and Hygiene in Early Childhood Development Centres: Compliance, Practices, and Barriers in Malawi

Kondwani Luwe*¹; Kondwani Chidziwisano¹; Tracy Morse² and Robert Dreibelbis³

¹Centre for Water, Sanitation, Health and Appropriate Technology Development, Malawi University of Business and Applied Sciences, Malawi

²Centre for Sustainable Development, University of Strathclyde, United Kingdom

³Department of Disease Control, London School of Hygiene & Tropical Medicine, United Kingdom

*Correspondence: kluwe@mubas.ac.mw

Abstract

Introduction

Traditional Water, Sanitation, and Hygiene (WASH) interventions often target households or primary schools, overlooking settings like Early Childhood Development Centres (ECDCs), where young children—who bear much of the diarrheal disease burden—spend considerable time. In Malawi, over 54% of children aged 3–5 attend ECDCs, presenting key opportunities for infection prevention and health promotion. This formative study assessed WASH infrastructure, compliance, hygiene behaviours, and their determinants in ECDCs in Blantyre, Malawi.

Methods

Using a mixed-methods, data were collected from 30 ECDCs (10 each in urban, semi-urban, and rural areas) between September and December 2024. WASH infrastructure was assessed using a checklist aligned with national standards and scored per centre across five domains: water access, sanitation, waste management, food, and hand hygiene. Compliance was categorised as low (0–49%), medium (50–74%), or high (75–100%). Quantitative data were analysed descriptively using STATA 17. Structured observations (n=30) captured hygiene behaviours, while in-depth interviews (n=60) with staff explored management practices and behaviour determinants using barrier and motive mapping framework.

Results

Rural ECDCs failed to meet the recommended caregiver-to-learner ratio of 1:15 (actual: 1:20), and support structures varied—urban centres relied on parental fees, while rural ones depended on NGOs. Only 37% of staff were ECD-trained, and awareness of WASH standards was low (20%). Two-thirds of ECDCs scored low in WASH compliance; only 5% achieved high compliance, mainly in water access. Urban centres consistently outperformed others. Despite toilet availability, open defecation (73%) and urination (98%) were common in all settings, with improper faeces handling. Handwashing with soap practice at critical times was rare (9%), and drinking water was accessed with unclean hands or cups. Meals were served on dirty surfaces (70%) and plates were often washed without soap (60%). Though staff cited motives like disease prevention and cleanliness, structural barriers (e.g., lack of tools, supplies) and competing priorities undermined hygiene behaviors.

Conclusions

Blantyre ECDCs face critical gaps in WASH training, infrastructure, and practices. Integrating theory-driven hygiene interventions with infrastructure support into routine operations is essential to promote child health and development.

Keywords: Early Childhood Development Centres; Water, Sanitation, and Hygiene (WASH); Hygiene behaviours; Standards Compliance; Formative research; Child health

Abstract Ref 003: Tracking the Sustainability of Hand-Washing with Soap after Defecation in Balaka District, Malawi: Challenges Four Years Post-Open Defecation Free Status Certification

Kamwana, L^1,*, Tembo M2, Chidya, R²

¹ Malawi Adventist University, Malamulo College of Health Sciences, P.O Box 55, Makwasa, Thyolo, Malawi.

² Mzuzu University. Department of Water and Sanitation. P Bag 21, Luwinga, Mzuzu

*Corresponding Author: Email: lastonkamwana@gmail.com.

Abstract

Introduction

Hand-washing with soap after defecation is a key public health behavior that interrupts the transmission of fecal–oral diseases. In rural Malawi, hand-washing facilities typically locally made and placed near latrines support this practice. Community-Led Total Sanitation is widely implemented to eliminate open defecation and promote hygiene behaviors such as latrine usage and hand-washing with soap (HWWS) after defecation. However, sustaining these practices post Open Defecation Free (ODF) status certification remains a major concern. This study assessed the sustainability of HWWS after defecation in Balaka, a certified ODF model district in Malawi four years after certififcation.

Methodology

 A community-based cross-sectional study was conducted in six purposively selected villages. Quantitative data were collected through structured interviews with 438 household heads, nine focus group discussions (FGDs) and obsevation. Quantitative data were analyzed using Chi-square tests, ANOVA, and multivariate logistic regression at a 95% confidence interval. Thematic analysis was used for qualitative data from FGDs.

Results

There was low hand washing facility coverage (36%) and HWWS after defecation (24%). Key challenges included the unavailability of water and soap, destruction of facilities by animals, and lack of maintenance. Significant predictors of sustained HWWS included knowledge, attitudes, marital status, cultural and religious beliefs, technical, social, and ecological conditions (p < 0.001). FGDs confirmed that initial enthusiasm for hwws though without continuous support, follow-up, and community accountability structures.

Conclusion and Recommendations

Despite initial success in eliminating open defecation, Balaka District shows declining sustainability of hand hygiene practices, posing risks to long-term public health outcomes. The study recommends intensified post-ODF follow-up, hygiene promotion, regular monitoring and supervision, re-verification of ODF status, and the use of community structures and social norms to reinforce and sustain HWWS behavior.

Key Words: Community Led Total Sanitation, Hand-washing facility, Hand-washing with soap, Open defecation, Sustainability

Abstract Ref 004: National telephone survey on water needs of primary level healthcare facilities in Malawi

Ngozo E.^1*,Kogoya E¹, Pittalis C.², Mussa D.¹, Chisesele A.¹, Torok Z.², Osuna A.², McGuigan K.G.³, Gajewski J.², Kambala C¹

¹Public and Environmental Health Dept, Malawi University of Business and Applied Sciences, Private Bag 303, Chichiri, Blantyre 3, Malawi.

²Institute of Global Surgery, School of Population Health, and ³Physiology and Medical Physics Dept., RCSI University of Medicine and Health Sciences, Ireland.

Correspondence: ngozoemmanuel03@gmail.com

Background: Access to safe water is crucial for maintaining health and providing essential healthcare services, but many healthcare facilities, particularly in rural areas of sub-Saharan Africa, lack reliable water sources. This poses significant hygiene challenges and compromises the quality of care for both healthcare workers and patients, particularly mothers and newborns. To our knowledge, the extent of this issue is currently unknown in Malawi. Therefore, this study aimed to assess access to water and water-related needs of primary-level healthcare facilities in Malawi, with a specific focus on health centres.

Materials and Methods: A nationwide quantitative cross-sectional telephone survey was conducted to collect data from primary-level healthcare facilities across Malawi. Data were collected using a questionnaire from all public health centres delivering primary care in Malawi (n=310), the majority of which provide delivery and newborn care services. The data were collected over 5 days. The descriptive statistics were used to determine the specific outcomes of the variables. The survey was conducted alongside an ongoing project piloting harvested rainwater solar disinfection technology in Malawi.

Results: Out of 310 primary healthcare facilities, 293 (94.52%) were health centres and 17 (5.48%) were rural community hospitals. Most (93.87%) of the health facilities had a functional water source within the health facility. 108 (34.74%) health facilities had no running water from the labour room sinks. In 64.52% of the health facilities, water was always available when needed in the labour room, and about 58.06% had water of sufficient quantity for the labour room needs. Reported major challenges include interruptions in the main water supply, non-functional water pipes, damaged or broken water storage tanks, and non-functional boreholes with either a hand pump or an electrical /solar pump. More than half (56.45%) of the health facilities used untreated water.

Conclusion and Recommendations: While most primary healthcare facilities in Malawi have a functional water source on-site, challenges remain regarding consistent water availability, running water in critical areas like labour rooms, and the water quality. These findings highlight a need for sustainable water infrastructure and treatment systems to enhance hygiene and the quality of care.

Keywords: Malawi, primary healthcare facilities, water access, hygiene

Abstract Ref 005: Conceptual Business Model Innovation for Faecal Sludge Management in Blantyre City-Malawi

H.M. Chirwa*^a, E. Mtonga ^b and W. Chipeta^c

^bc Mzuzu University, Private Bag 201, Luwinga Mzuzu.

^a Ministry of Water and Sanitation, Private Bag 390, Capital City, Lilongwe 3

*Correspondence: harold.chirwa@gmail.com

Abstract

Blantyre City in Malawi faces major challenges in faecal sludge management due to rapid urbanization, poor sanitation infrastructure, and weak regulations. These issues pose public health risks, harm the environment, and hinder resource recovery. This study assessed an innovative business model to address gaps in the sanitation service chain using a mixed-methods approach. Data were collected through 452 household surveys, 12 key informant interviews, and 8 focus group discussions. Quantitative data were analyzed using SPSS version 26, while qualitative data underwent thematic analysis.

The assessment shows that scheduled desludging, mobile transfer stations, and call center models have high potential to improve faecal sludge management in Malawi’s informal settlements by optimizing emptying services, lowering costs, and improving service coordination. No single model fits all contexts, so an integrated, phased approach is recommended in the short term, with options like licensing, incentivized disposal, and franchising to be considered in the medium to long term.

Findings revealed a high potential daily demand for sludge recovery (mean = 2229.19; SD = 1275.199), but current services are inadequate to meet growing demand (r = 0.09, p = 0.042). Key challenges include limited infrastructure, poor disposal practices, financial constraints, and weak stakeholder collaboration. Despite this, the study identified strong business opportunities in composting and biogas production, which support environmental sustainability and the circular economy.

The proposed business model promotes integrated solutions through innovative technologies, public private partnerships, and community engagement to improve public health and support socio-economic growth in Blantyre and similar cities.

Key words: Blantyre city, business models, disposal, faecal sludge, treatment

Antimicrobial Resistance (AMR), Non-Communicable Diseases & Health Promotion

Abstract Ref 006: Community-Centered AMR Awareness: The “Maama Naka and Maama Namu” Project

Ahumuza Bridget¹

¹Makerere University Environmental Health Students Association (MUEHSA) Uganda.

Correspondence: bridgetahumuza825@gmail.com

Introduction

In Uganda, approximately 8 in 10 people practice self-medication contributing significantly to antimicrobial resistance (AMR). With more than 14,000 registered pharmacies and 1000 drug shops compared to over 6000 hospitals, access to antimicrobials without prescription remains widespread. Innovative community centred awareness strategies are needed to address this public health challenge.

Methods

The “Maama Naka and Maama Namu” awareness campaign led by MUEHSA students employed story telling through skits to increase public awareness about AMR. Relatable characters were developed to model positive and negative behaviours regarding antibiotic use. Skits were performed in Luganda and disseminated to commonly used social media platforms like Tik tok and X formerly Twitter. Data on reach and engagement were collected from social media analytics and community feedback.

Results

The campaign reached over 10,000 views across the social media platforms with active engagement through comments, shares and tagging of peers. Viewers reported improved understanding of the dangers of self-medication and the usefulness of seeking medical advice when one presents with signs and symptoms of a disease. Social media proved particularly effective in engaging young audiences with access to digital platforms.

Conclusion

Community based story telling combined with digital platforms can effectively raise awareness on AMR and influence health seeking behaviour. Integrating culturally relevant and easy to understand approaches into health promotion strategies can enhance public understanding and contribute to reducing self-medication practices in the population.

Keywords: Antimicrobial Resistance; Community Awareness; Storytelling; social media

Abstract Ref 007: Promoting Health Through Exercise and Diet: A Pre–Post Study on Reducing NCD Risk Factors Among Women in Rural Malawi

^*Gausi T.¹, John C.² and Mandaaliza A.³

¹^,2,3 Malawi University of Science and Technology, Department of Clinical Sciences, Sports Science program, P.O. Box 5196, Blantyre.

^*Correspondence: thokozanigausi5@gmail.com

ABSTRACT

Background
Non-Communicable diseases (NCDs) are responsible for approximately one-third of adult deaths in Malawi. Despite this burden, women in rural areas often receive limited communication and education on preventive lifestyles. Obesity and hypertension are among the most prevalent modifiable risk factors contributing to this trend.

Objective
This study aimed to assess whether a community-based program integrating structured physical activity and nutrition education could significantly reduce Blood Pressure (BP) and Body Mass Index (BMI) among women in Phereni Community, rural Lilongwe.

Method
A six-week quasi-experimental pre-post study was conducted among 100 women aged 18–70 in Phereni Community, Lilongwe. Participants were purposively assigned to an intervention group (n = 50) and a control group (n = 50). Baseline measurements of BMI and blood pressure (BP) were recorded for all participants, with follow-up assessments conducted at week 3 and week 6. The intervention group engaged in thrice-weekly structured exercise sessions and received weekly nutrition education through community meetings, visual aids, and WhatsApp messages. The control group maintained their usual routines. Paired t-tests were used to assess within-group changes, and one-way ANOVA was applied to compare between-group differences. Statistical significance was determined at p < 0.05.

Results
Out of 100 participants, 92 (92%) completed the program. In the intervention group, mean BMI decreased from 29.4 ± 3.1 kg/m² to 27.1 ± 2.8 kg/m² (∆ = 2.3 kg/m², p < 0.01), and mean systolic BP reduced from 142 ± 11 mmHg to 128 ± 9 mmHg (∆ = 14 mmHg, p < 0.01). No statistically significant changes were observed in the control group. No adverse events were reported.

Conclusions and Recommendations
Community-driven interventions that combine structured physical activity with culturally appropriate nutrition education can significantly and safely reduce key NCD risk factors among rural women. Scaling this model through existing village structures, health workers, and mobile platforms could help reduce Malawi’s NCD burden. Future research should explore long-term adherence and broader health outcomes, including glucose control.

Keywords: health communication; physical activity; women’s health; non-communicable diseases; BMI; blood pressure

Abstract Ref 008: Risk Perception and Safety Behaviors Among Motor Riders in Lilongwe, Malawi: A Cross-Sectional Study

Chiona M.¹, Mvula J. M.¹, Luhanga M.¹

¹Environmental Health Department, Malawi College of Health Sciences, P.O. Box 30368, Lilongwe 3.

*Correspondence: jmwaulemu@mchs.mw jmwaulemu@yahoo.com

Introduction

Motorcycle injuries contribute to approximately 30% of global road traffic accident (RTA) deaths, with 90% occurring in low-income countries. In Lilongwe, Malawi, over 60% of RTAs in 2024 involved motorcycles, mainly affecting individuals aged 21–40 years. This study by the Malawi College of Health Sciences Environmental Health Department aimed to identify risk predictors, safety behaviors, and policy gaps related to motorcycle RTAs to inform targeted interventions aligned with Sustainable Development Goal (SDG) 3.6.

Research Design and Methodology

A cross-sectional survey was conducted from January to March 2025 using a Malawi-adapted Motorcycle Rider Behavioral Questionnaire (MRBQ), assessing risk perception, traffic errors, speeding, stunt riding, and protective equipment use among riders. Stratified random sampling selected participants from 20 motorcycle ranks in Lilongwe. Data were analyzed using descriptive and regression models.

Findings

Results showed 18% of riders perceived themselves at high risk of RTAs, with helmet use significantly higher among this group (AOR = 2.41; 95% CI: 1.4–4.3; p = 0.0001). Most riders (97.9%) reported speeding over 60 km/h, and 68% admitted alcohol use. Overall helmet use was 15%, and other protective gear use was 8%. Poor road conditions and signage (58%) also contributed to crash risk. Additionally, 78% reported traffic or control errors, 65% engaged in stunts, and only 2% had formal training on traffic regulations.

Conclusions

Low risk perception increases vulnerability to injury. Enhanced regulation, rider training, and awareness campaigns are essential. The Directorate of Road Traffic and Safety Services should consider establishing rider committees and improving road infrastructure to reduce RTAs in Malawi.

Keywords: Road traffic accidents, Motorcycles, Risk-perception, Regulations

Environmental Health & Exposure Risks

Abstract Ref 009: Assessment of Groundwater Storage Depletion Using GRACE and Land Surface Models in Mzimba District, North Malawi

John Sichone^a*

1. Department of Civil Engineering, Malawi University of Business and Applied Sciences, Private Bag 303, Chichiri, Blantyre 3, Malawi.

*Correspondence: j.jsichone@gmail.com

Introduction

Groundwater plays a crucial role in providing drinking water and supporting public health systems in Malawi. However, due to climate change and overexploitation, groundwater reserves have depleted globally to the extent that well yield have decreased, pumping cost have risen, and land have irreversibly subsided. In Malawi, groundwater quantity is a national crisis, specifically in Mzimba district due to severe droughts. This study assessed trends in groundwater storage in Mzimba District using satellite data and land surface models, aiming to inform environmental health strategies and improve water security in vulnerable communities.

Methods

The study was conducted on a temporal scale between 2002 and 2024 in Mzimba District. NASA’s Gravity Recovery and Climate Experiment (GRACE) satellite data were used to evaluate Total Water Storage (TWS) anomalies, while the Global Land Data Assimilation System (GLDAS) and Global Surface Water Explorer (GSWE) provided supporting hydrological components including soil moisture, and surface water, respectively. Groundwater storage changes were estimated by subtracting these components from TWS. Temporal trend analysis and GIS visualization were employed to assess spatial variation in depletion.

Results

The results demonstrate that groundwater storage is depleting at an average rate of -1.0 ± 0.06 cm yr^-1 (0.1043 km³yr^-1), with the highest depletion rate of up to -1.2 cm yr^-1 (0.12516 km³yr^-1) observed in the western region, and the lowest rate of –0.4 cm yr^-1 (0.04172 km³ yr^-1) occurring in the eastern region of the study area. Furthermore, we also observed that groundwater storage in the study area exhibited pronounced seasonal and spatial variability, increasing from −13 cm in November to a peak of 15 cm between April and May. Importantly, drought conditions were identified as the primary driver of the observed depletion trends, with significant negative correlations between actual evapotranspiration and groundwater depletion (r = −0.577) and between downward surface shortwave radiation and groundwater depletion (r = −0.678).

Conclusion

This study demonstrates the potential of satellite-based monitoring for evaluating groundwater depletion in Malawi. The results call for urgent integration of groundwater sustainability into public health planning, including WASH (Water, Sanitation, and Hygiene) strategies and drought preparedness programs. Improved data-driven decision-making can reduce the risk of water insecurity and its associated public health burdens.

Keywords

Groundwater depletion, GRACE satellite, Public health, Mzimba District, Water security

Abstract Ref 010: Assessing the Impact of Naturally Occurring Radioactive Elements on Rural Households: A Case of Chaphuka Village in Machinga District

*Leckson F. Msombaa^a

^aDepartment of Geography and Environmental Studies, The Catholic University of Malawi.

*Correspondence: leckson.msomba@cunima.ac.mw         

Introduction

Naturally occurring radioactive elements are found in a variety of geologic formations and are present in varying concentrations throughout the world. The dose released by naturally occurring radioactive nuclides including contains cosmic, gamma, beta and alpha rays. Due to lack of evaluation of radiation in rural homes, the exposure and related health hazards to people are not well understood. Therefore, this study assessed the health impact of naturally occurring radioactive elements in rural households in Chaphuka village, Machinga district.

Methods

Radio-Spectrometer machine (RS-125, version:5.19) were used to collect radiation dose for   Uranium (238U), Thorium (232Th), and Potassium (40K) present in Chaphuka village. The Radiation Dose was determined and compared with the international recommended dose limits standards (1mSv/y). Furthermore, radiological hazard parameters were computed to assess health risks to the people of Chaphuka village.  

Results

The corresponding mean radioactivity concentration doses were 2.40% (40K), 46.99ppm (238U), and 498.85ppm(232Th). The detected readings are not within the recommended values according to the International Commission on Radiological Protection ICRP (40K = 1.316%, 238U = 2.834 ppm, and 232Th = 11.084 ppm). The yearly average dose came out to be 17.29 mSv/y which is above the recommended limit 1mSv/y. The mean computed values for radiological hazard parameters were 24.62, 9.54, 1522.73 nGy/h, 10494.93 µSv/y, 5891.58 µSv/y, and 20.62 for the gamma index (Iᵧ), external hazard index (Hex), absorbed dose rate (ADR), annual gonadal dose rate (AGDE), annul effective dose rate (AEDE), and excess lifetime cancer risk (ELCR), respectively. The obtained results are higher compared to those compiled by United Nations Scientific Committee on the Effects of Atomic Radiation UNSCEAR (Iᵧ = ≤ 1, Hex = ≤1, ADR = 60 nGy/h, AEDE = 70 µSy/y   the AGDE = 300 nGy/y, and ELCR = 2.9 X 10^-3).

Conclusion

The study’s findings indicate that rural households in Chaphuka village, Machinga District, are exposed to elevated levels of naturally Occuring radioactive elements exceeding dose limits. This poses potential health risks to the residents, emphasizing the need for public health interventions. Therefore, it’s important for healthy organizations to develop strategies to address and ensure a safer environment for residents of Chaphuka village.

Keywords; Radioactive Elements, Chaphuka village & Radiological Health Parameters

Abstract Ref 011: Quantification of Extended-Spectrum Beta-Lactamase E. Coli and K. Pnuemoniae in wastewater treatment plant and perceived health risks in Blantyre, Malawi

Andrew Mnkhwamba^1*, Madalitso Mphasa², Dyson Kazembe¹, Atupele Mulaga³,Taonga M. Kumwenda¹, Kondwani Chidziwisano^1,4

1. Centre for Water, Sanitation, Health and Appropriate Technology Development (WASHTED), Malawi University of Business and Applied Sciences, Private Bag 303, Chichiri, Blantyre 3, Malawi.
2. Malawi Liverpool Wellcome Program P.O. Box 30096, Chichiri, Blantyre 3
3. Department of Mathematics, Malawi University of Business and Applied Sciences, Private Bag 303, Chichiri, Blantyre 3, Malawi
4. Department of Environmental Health, Malawi University of Business and Applied Sciences, Private Bag 303, Chichiri, Blantyre 3, Malawi

Correspondence^*: amnkhwamba@mubas.ac.mw

Abstract

Background

The emergence of Extended-Spectrum b-lactamase (ESBL) producing bacteria has contributed to antimicrobial resistance (AMR), which is currently a public health challenge. ESBL producing bacteria presence in the environment has been linked to ineffective wastewater treatment. In Malawi, effluent drains into rivers, however, less has been assessed about its health impact to the communities. We quantified ESBL E. coli and Klebsiella. pnuemoniae at Zingwangwa municipal wastewater treatment plant and identified perceived health risksto generate evidence-based information for interventions.

Methods

A cross-sectional mixed method approach was used to obtain water (n=112), and vegetable (n=28) samples, and in-depth interviews (n=13) with community. The samples were cultured on ESBL selective media CHROMagar^TM and confirmed through qPCR. Descriptive analysis was used to show temporal differences in bacteria counts. Significant differences in bacterial counts amongst sampled points were identified using One way ANOVA, with thematic analysis to understand community health risk perception.

Results

Our study revealed no significant differences (p=0.999) in bacteria counts between influent and effluent suggesting inefficient removal of bacteria during treatment process. However, there was significant difference (p=0.026) between influent and downstream implying natural dilution effect. Furthermore, ESBL klebsiella species and E. coli were isolated from 72% and 75% of vegetable samples respectively signifying bacteria colonization through food chain.  Lastly, 76% of participants perceived health risks associated with effluent for instance diarrhoea diseases.

Discussion

Like many other similar studies, this study highlights how bacteria community colonization could be promoted through infective wastewater treatment. With lack of community awareness, this has the potential to increase cases of antimicrobial resistance when people get exposed to resistant bacteria contaminated effluent. Wastewater treatment plant being a sink for different pathogens must adopt treatment technologies that are not only easy to maintain but also safeguards public health.

Conclusion

ESBL producing bacteria presence in effluent highlights the potential risk of AMR to the environment and human health, which calls for infrastructural investments for effective treatment of wastewater, and public awareness on AMR risk to limit exposure.

Key words:  Antimicrobial resistance; Extended-Spectrum b-lactamase; Effluent; Influent; risk

Abstract Ref 012: Assessment of the level of adherence to healthcare waste management guidelines among Medical and Non-Medical Health Care workers in Ntchisi’s district healthcare facilities

Laston Zungu^a, Kondwani Chidziwisano^bc   and Save Kumwenda^bc

^aWaterAid Malawi, Private Bag 364, Lilongwe, Malawi

^b Department of Public and Environmental Health Sciences, Malawi University of Business and Applied Sciences, Private Bag 303, Blantyre, Malawi.

^c Centre for Water, Sanitation, Health and Appropriate Technology Development (WASHTED), Malawi University of Business and Applied Sciences, Private Bag 303, Blantyre, Malawi

Correspondence: lastonzungu@gmail.com

Abstract

Introduction
Healthcare waste management (HCWM) is critical to safeguarding public health and the environment. In Malawi’s Ntchisi District, adherence to national HCWM guidelines is hindered by limited infrastructure, irregular training, and weak institutional oversight. This study assessed levels of guideline adherence among medical and non-medical healthcare workers and identified key influencing factors.

Methodology
A cross-sectional mixed-methods study using an explanatory sequential design was conducted between July and August 2024. Quantitative data were collected from 126 randomly sampled healthcare workers across 12 public health facilities. Binary logistic regression identified predictors of adherence. Three key informant interviews were analysed thematically to contextualise the quantitative findings.

Results
Overall adherence to HCWM guidelines was 60%. Segregation (85.9%) and transportation (71.8%) protocols were commonly available, while emergency response guidelines were least accessible (30.8%). Medical staff were significantly more likely to adhere to guidelines than non-medical staff (OR = 6.14; p < 0.001). Workers with over 10 years of experience also showed higher adherence (OR = 9.06; p = 0.003). Facilities with healthcare waste management committees had better compliance (OR = 0.19; p = 0.019).

Conclusion
Adherence to HCWM guidelines is moderate, with disparities across roles and facility structures. Institutional oversight and experience strongly influence compliance.

Recommendations
Facilities should establish waste management committees, expand targeted training, and implement regular audits to improve adherence.

Keywords: Healthcare Waste Management; Guideline Adherence; Institutional Oversight; Ntchisi District; Malawi

Abstract Ref 013: Water Tank Storing Technologies and Universally Access to Safe Drinking Water in Urban Malawi: Opportunities and Challenges

Sane Pashane Zuka¹

¹ Malawi University of Business and Applied Sciences, School of Built Environment

Correspondence: szuka@mubas.ac.mw

Abstract

This article examines the extent to which current technologies adopted for the delivery of safe domestic water in urban Malawi can contribute to achieving universal access to safe potable water. Focusing on domestic water storing technologies (tanks), the paper responds to the following questions: What is driving the adoption of water tank technologies? Which group of people are adopting the water tank technologies? And finally, what is the impact of the water tank storing technologies on the achievement of universal access to safe and potable water? Drawing from the experiences of households in Mpemba in Blantyre City, the article demonstrates that, despite the tank water storing technologies ensuring availability of water at all times, the technologies disproportionately favor the economically able households at the expense of the vulnerable households. The study found that while 8% of

households enjoy constant access to safe domestic water, 92% experience disruptions. Unlike those without water tank storing technologies, households with water tanks technologies are able to store water when supply is disrupted. This article argues that if water tanks storing technologies are to contribute to the achievement of universal access to safe domestic water, low-income groups of people have to be included in the implementation of these technologies.

Keywords: Domestic Water Storage; Water Tanks; Urban Malawi; Access to Safe Water

Maternal, Child, and Reproductive Health

Abstract Ref 013: Shifting Landscapes of Childbirth in Malawi: Trends in Birth Location and Attendant Choice, 2019–2023

Vincent Samuel Phiri¹, Bertha Kayuni², Francis Kalonga², Kenasi Kasinje³, Elizabeth Hazel⁴, Adamson Sinjani Muula¹

¹Kamuzu University of Health Sciences, School of Global and Public Health

²Ministry of Health

³Global Financing Facility

⁴Johns Hopkins University

Correspondence: vsamuel@kuhes.ac.mw

Background

 Despite progress in expanding maternal health services, Malawi continues to record a maternal mortality ratio estimated at 349 deaths per 100,000 live births. Increasing access to skilled birth attendance and institutional deliveries remains a priority to sustain reductions in preventable maternal and neonatal deaths. However, updated evidence on how birth location, birth attendant cadre, and surgical interventions have evolved in recent years is limited.

Methods

We analyzed secondary data from Malawi’s District Health Information System 2 (DHIS2) reports, recent Demographic and Health Survey (DHS) data, and published national health sector performance reports spanning 2019 to 2023. Descriptive statistics and time-series graphs were used to examine changes in institutional delivery rates, use of skilled birth attendants, and cesarean section (C-section) uptake. Trends were disaggregated by district, urban/rural location, and health workforce density to identify subnational patterns.

Results

The national institutional delivery rate increased from 35.2% in 2019 to 95.4% by mid-2023, driven by expanded facility coverage, stronger referral linkages, and community engagement. Home births fell from an estimated 62% to less than 5% in the same period. The proportion of births attended by a skilled provider rose from 42% to 98%, with nurse-midwives accounting for over 70% of all skilled deliveries. The national C-section rate increased from 5.5% in 2019 to 9.4% in 2023, with urban districts such as Lilongwe and Blantyre recording rates as high as 12%, compared to rural district averages of 6–8%. Subnational disparities were observed in the districts such as Likoma report 100% skilled birth attendance, whereas Mzimba South and Mangochi still face shortages of midwives and functional maternity beds.

Conclusion

Malawi has made significant progress in shifting childbirth practices towards safer, facility-based deliveries attended by skilled health workers. However, uneven progress in C-section availability, workforce distribution, and quality of care highlights the need for midwifery training, and equitable obstetric care. These improvements are critical to closing the gaps and achieving national and global maternal health targets.

Keywords: Maternal health, institutional delivery, skilled birth attendance, cesarean section, Malawi, trends, health workforce

Abstract Ref 014: Assessment of Usage of Insecticide-Treated Nets Distributed Routinely in Health Facilities to Pregnant Women

Mfuyeni S¹ and Yafeti YDM²

¹Ministry of Health, Health Promotion Division, Malawi

²Department of Public Health, Lake Malawi Anglican University, Malawi

Correspondence: smfuyeni@gmail.com

Abstract:

Background
Malaria during pregnancy remains a significant contributor to poor pregnancy outcomes in Malawi. To mitigate this, Insecticide-Treated Nets (ITNs) are routinely distributed to pregnant women through health facilities. Despite high distribution rates, the actual usage of ITNs among pregnant women in Ntchisi has not been well documented. This study aimed to determine the rate of ITN usage and identify factors influencing their utilisation among pregnant women in Ntchisi.

Methodology
A cross-sectional study design was employed. Trained community-based health workers administered structured questionnaires to participants. Respondents were selected from all thirteen health facilities in Ntchisi District. One health post from each facility was randomly sampled, and all pregnant women who had initiated antenatal care at the selected posts were included in the study.

Results
Out of 258 respondents, 67.4% self-reported using an ITN, while 64.0% were confirmed users based on physical verification of ITNs hung over sleeping areas. The main reasons for ITN usage included: prevention of mosquito bites (79.3%), prevention of malaria (75.9%), and avoidance of malaria-related foetal complications (16%). Reasons for non-use included: lack of an ITN (50%), inability to hang the net (21.4%), and damaged or torn nets (7.1%).

Conclusion
ITN usage among pregnant women in Ntchisi remains below the national target of 90%. To address this gap, the study recommends: (i) incorporating messages about the role of ITNs in improving pregnancy outcomes into health promotion activities, (ii) conducting regular ITN hang-up campaigns, and (iii) mobilising community health workers and volunteers to assist pregnant women with hanging ITNs properly.

Keywords: Insecticide-Treated Nets, Malaria, Pregnant Women, Routine Distribution, Utilisation

Abstract Ref 015: Investigating Household Behavioural Factors Influencing Under-Five Child Under-Nutrition: The Case of Bowe Extension Planning Area in Dowa, Malawi

Steven Chekecheke¹, Andrew Chimpololo^{1, *} and Grace Kadzakumanja¹

¹Institute of Continuing Education, Malawi University of Business and Applied Sciences, Blantyre, Malawi

*Correspondence: achimpololo@mubas.ac.mw

Abstract:

Introduction

This paper investigates household behavioural factors influencing child undernutrition in the Bowe Extension Planning Area (EPA) of Dowa District in Malawi. Globally, in 2020, about 22% of children under five were stunted. While stunting was rated 37% in Malawi, in Bowe (Dowa) the prevalence was at 41%, significantly high against the global target of 20% by 2025.

Methods

This is a case study employing the explanatory sequential design under the pragmatism paradigm. Simple random sampling was used to select 365 mothers for the one-on-one structured interview, and 30 distinct mothers for three focus group discussions. Purposive sampling was applied to select four nutrition technical officers (key informants). Data were collected using a structured interview guide on the socio-demographic and TPB constructs, the focus group discussion and the key informants’ interview guides were administered as a follow-up on the outcome values with confirmed validity and reliability. Thematic analysis was used to analyse the qualitative data based on the Theory of Planned Behaviour (TPB). A multivariable linear regression model was further used to assess predictors of behavioural intention towards dietary diversity and against undernutrition, at p-value ≤ 0.05 using IBM® SPSS® statistics version 22.

Results

The potential predictor of mothers’ intention to functionally provide their children with dietary diversity were the subjective norms (b = 0.67, t=18.29, p < .001), followed by attitudes (b = 0.17, t =4.51, p < .001) with the TPB model indicating 66% of the variance. Furthermore, the mothers’ descriptive norms and intention towards children’s dietary diversity were outweighed by factors such as the grandmothers’ influence, cultural norms and food taboos, interrupted exclusive breastfeeding with early complementary feeding, and parental competing priorities over children’s nutritious diet. 

Conclusion

Behavioural change nutritional promotion targeting the grandmothers, opinion leaders and Bowe governance structures has the potential to unlock social-cultural barriers to healthy eating habits. Such initiatives could enhance mothers’ descriptive subjective norms and lead to household production of ignored value-chains (fruits, legumes, livestock) and adoption of total sanitation in the child play environment.

Keywords: Undernutrition, under-five children, household behavioural factors, Theory of Planned behaviour

Abstract Ref 016: GIS Mapping of hard-to-reach communities to improve access to vaccination and health services delivery in Malawi

Atupele Kapito-Tembo^1,2, Tapiwa Ntwere¹, Harrison Msuku², Glory Mzama², Vinjeru Shonga², Gracian Msosa², Laurent Nyamabalo³, Absalom Mwamlima³, Jane Dzoole³, Doreen Ali⁴, Mike Chisema³, Precious Phiri⁴

Affiliations:

1. Kamuzu University of Health Sciences, Community and Environmental Health department, School of Global and Public Health
2. Kamuzu University of Health Sciences, MAC-Communicable Diseases Action Centre
3. Malawi Ministry of Health EPI unit
4. Malawi Ministry of Health Community Health Section

Email: akapito@kuhes.ac.mw

Background

Malawi continues to experience barriers to access primary health services including vaccination due to distance and other geographical barriers. Communities living more than 5 km from a health facility or separated by geographical barriers such as impassable rivers, mountains, poor roads are classified as hard-to-reach areas (HTRAs). However, there are no data on communities living in HTRAs to inform effective planning and delivery of health services to these communities. To address this gap, there is a need for a nationwide mapping to identify HTRAs so as to improve the planning and delivery of health services in Malawi.

Objective

To identify and map out all the HTRAs and communities in all the 29 health districts to inform planning and delivery of vaccination and health care services in Malawi.

Methods

A national cross-sectional mapping survey was conducted in all the 29 health districts in Malawi from 2022 to 2024. All HTRAs in Malawi were mapped using GIS approaches. Distance from district health office to the HTRA was obtained using GIS pathway tracker applications on tablets. Desk review and checking of list of HTRAs was conducted. A questionnaire interview was conducted with health surveillance assistants serving the HTRAs to obtain information on HTRA population, availability of social amenities such as mobile phone network, water, and schools among others. Data were analyzed and maps generated using Stata and QGIS software.    

Results

A total of 4,944 HTRAs were identified and mapped in all the 29 health districts with a total population of 9,178,077, which is 42% of 2025 national statistical office projected population.  Seventy-five percent (75%)of the HTRAs are located more than 5 km from the nearest health facility and 25% are due to other reasons such as mountains and impassable rivers. The average distance from a health facility to a HTRA in Malawi is 8.5 km ranging from 0.2km to 99 km. District level static and iterative maps of HTRAs on Google have been developed.

Conclusion

Innovative GIS mapping exercise for HTRAs was successfully conducted and provided key data for all districts in Malawi. The available HTRAs information and created maps will facilitate and improve targeted planning, delivery and promote equity access to vaccination and health services to the underserved populations in Malawi.

Key words: GIS, Hard to reach areas, vaccination, health services delivery, community

Infectious Diseases, Vaccination & Surveillance

Abstract Ref 017: Integrating COVID-19 Vaccination into HIV Care in Malawi: Feasibility, Acceptability, and Health System Implications

Nyanyiwe Masingi Mbeye¹, Gerald Manthalu², Maganizo Chagomerana³, Sangwani Salimu⁴, Roselyn Chipojola¹, Olipa Shaba⁵, Aaron Mdolo⁵, Charles Nwosisi⁵, Sandra Christelle Mounier⁶

¹Kamuzu University of Health Sciences, ²Ministry of Health, Malawi, ³UNC Project Malawi, ³Malawi Liverpool Welcome Trust, Kamuzu University of Health Sciences, ⁴UNICEF Malawi, ⁵UNICEF, HQ, USA

Correspondence: nyanyiwembeye@gmail.com, nmbeye@kuhes.ac.mw

Background

The COVID-19 pandemic has disproportionately impacted people living with HIV (PLHIV), heightening their risk of severe illness and mortality. In Malawi, initial vaccine rollout efforts relied on mass campaigns, which often failed to reach high-risk populations effectively. In response to evolving global guidance, this study explored the feasibility, acceptability, and operational realities of integrating COVID-19 vaccination into routine HIV care services.

Methods

A mixed-methods implementation research design was employed. This included a scoping review of integrated vaccine delivery models for PLHIV in low- and middle-income countries, a cross-sectional quantitative survey, costing analysis, and extensive qualitative interviews guided by a conceptual framework for health systems integration. Data were collected from health workers, PLHIV, and facility managers across selected sites.

Results

COVID-19 vaccines were primarily delivered through mass campaigns, with limited integration into HIV platforms. Facilities that piloted integrated approaches reported improved uptake and patient satisfaction. PLHIV expressed strong preference for receiving vaccines within familiar care environments, citing reduced stigma and increased trust. Key facilitators included committed health workers, community support structures, and streamlined service delivery. Barriers included lack of operational guidelines, inadequate staffing, and inconsistent vaccine supply. Costing analysis revealed incremental costs per dose ranging from $0.33 to $0.67, with total integration costs estimated between $276,987 and $558,775—primarily driven by training, supplies, and planning. Minimal additional costs were incurred for supervision and cold chain maintenance.

Conclusions

Integrating COVID-19 vaccination into HIV care in Malawi is both feasible and cost-efficient. The approach enhances patient-centered care and service efficiency. Findings underscore the need for targeted investments in training, infrastructure, and policy alignment to support sustainable vaccine delivery for high-risk populations. This evidence offers actionable insights for future public health emergency preparedness and resilient health systems.

Keywords

COVID-19 vaccination, HIV care integration, Feasibility, Acceptability, Implementation research, Health Systems Strengthening

Abstract Ref 018: Advancing Polio Surveillance in Malawi through Wastewater Surveillance
Francis Mwanoka¹, Gareth Nyirenda¹, Randy Mungwira¹, Akosua Ayisi¹, Chris Kaliisa¹   Joyce Beyamu², McWilliam Kalua² Edward Soko², Mike Chisema²

¹World Health Organization, Malawi Country Office

² MoH EPI, Malawi

Correspondence: kubwaloh@who.int

Background:

Environmental surveillance (ES) compliments Acute Flaccid Paralysis (AFP) surveillance for detection of circulating polio virus as part of a robust integrated disease surveillance and response system. By testing sewage runoff, ES enables early detection of polio virus shedding in asymptomatic individuals in communities through stool. After the re-emergence of Wild Poliovirus (WPV1) in 2022, ES has become an important tool for Malawi’s polio eradication strategy. World Health Organization (WHO) has supported implementation of ES through 11 active sites across all geographical regions of Malawi.

Objective:
To evaluate the implementation and performance of Malawi’s polio ES program and identify opportunities for optimization and integration with broader public health surveillance systems.

Methods:
The evaluation of Malawi’s Environmental Surveillance program was conducted through a mixed methods approach up to July 2025. This included desk reviews of program documents, stakeholder interviews, and field assessments across 11 surveillance sites. Supplementary data was gathered from national mentorship reports, supportive supervision visits, quarterly review meetings, and findings from in-country consultants. Monitoring of ES activities was facilitated through a program performance tracking system, which enabled real-time sample tracking and identification of operational bottlenecks. This comprehensive approach ensured a robust assessment of program implementation, performance, and areas requiring strategic improvement.

Results:
As of July 2025, Malawi’s Environmental Surveillance program demonstrated strong performance across key indicators. Enterovirus detection averaged 59%, surpassing the WHO target of ≥50%, with Kamuzu Barracks and Zomba Treatment Plant achieving the highest rates of 88.9%. Sample collection completeness and timeliness both reached 100%, while sample condition stood at 83.3%, all exceeding program benchmarks. Despite these successes, challenges persisted in underperforming sites such as Bunda College and Blantyre Treatment Plant, and delays in sample shipment to the laboratory remained above the recommended seven day threshold. Continued supervision, stakeholder engagement, and targeted interventions were recommended to sustain and enhance program effectiveness.

Conclusion:
To sustain and enhance effectiveness of Malawi’s ES program, strategic actions are recommended. These include strengthening supply chain management to ensure timely and quality sample transport, increasing number of trained personnel to address staff turnover and capacity gaps, and establishing a dedicated polio laboratory to improve diagnostic efficiency. Expanding ES coverage to high-risk regions will bolster early detection efforts. Furthermore, integrating ES with multi-pathogen wastewater surveillance represents a transformative advancement in public health surveillance and preparedness, enabling a more comprehensive response to emerging infectious threats

Keywords: Polio, Environmental Surveillance, Wastewater, Early Detection, Program Performance

Abstract Ref 019: Community dialogue sessions between Malawi and Mozambique communities reduced cholera cases to zero at Chipwaila and Therere Health Centers in Chikwawa

Hudson Wenji Kubwalo¹, Adams Chimutu¹, Settie Piriminta²

¹World Health Organization, City Centre, P.O. Box 30390, Lilongwe 3, Malawi

²Chikwawa District Hospital, P.O. Box 32, Chikwawa, Malawi.

Correspondence: kubwaloh@who.int

Introduction

In response to the ongoing cholera outbreak in Chikwawa District, Malawi, the Ministry of Health (MoH), in collaboration with the World Health Organization (WHO), conducted two targeted community dialogue sessions in September 2023 at Therere Health Centre. These sessions aimed to address the cross-border health-seeking behavior of Mozambican cholera patients who were bypassing Therere Health Centre—located near the border—in favor of Chipwaila Health Centre, situated 10 kilometers away. This behavior contributed to the spread of cholera along transit routes and delayed timely access to care.

Methodology

The two sessions engaged traditional leaders from both Malawi and Mozambique, religious leaders, Health Centre Management Committees, and health volunteers. The initial session was a behaviour investigation session with the village head Therere village with a few of his subordinates and the in-charge of Therere Health Centre. At the second sessions a total of 168 participants attended the sessions at Therere, comprising 92 males and 76 females, demonstrating strong community involvement. Key barriers identified included perceptions of inadequate medical supplies at Therere, negative attitudes from health workers, and nighttime access to services due to structural design of the facility. Action plans were developed to address these issues, hygiene practices and water chlorination including sensitization on facility operations, and exploration of a cholera treatment unit near the border.

Furthermore, the initiative supports the principles of the International Health Regulations (IHR 2005), which call for strengthened surveillance, timely response to public health risks, and international cooperation to prevent disease spread across borders. By fostering dialogue and trust among border communities, the MoH and WHO have demonstrated an evidence-based, community-centered approach to cholera control that can serve as a model for other endemic regions.

Results

The Chikwawa District Hospital reported that the cholera cases at Chipwaila Health Centre significantly reduced and in a period of two weeks both facilities reported zero cases of cholera.

Conclusion

Community dialogue interventions to disease outbreaks aligns with the WHO’s Global Task Force on Cholera Control (GTFCC) Roadmap to 2030, particularly Axis 1: Early detection and rapid response and Axis 2: Multi-sectoral interventions in cholera hotspots, which emphasize community engagement and cross-border collaboration. The roadmap advocates for improved WASH infrastructure and oral cholera vaccination (OCV) as critical strategies to reduce cholera mortality by 90% by 2030.

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Keywords: International Health Regulations (IHR 2005); Oral Cholera Vaccine (OCV); Community Dialogue

Abstract Ref 020: Closing the Gaps: Monitoring Equity in Immunization Coverage in Malawi

Vincent Samuel Phiri¹, Mike Chisema², Elizabeth Hazel³, Adamson Sinjani Muula¹

1. Kamuzu University of Health Sciences, School of Global and Public Health
2. Ministry of Health
3. Johns Hopkins University

Correspondence: vsamuel@kuhes.ac.mw

Abstract

Background

Malawi’s immunization coverage has steadily improved over the past two decades, helping reduce child morbidity and mortality. However, national averages can mask persistent inequalities in access to vaccination services across different socioeconomic groups. Disparities by household wealth, maternal education level, and place of residence can undermine progress towards universal coverage and the equitable reduction of vaccine-preventable diseases. This equity analysis examines trends in Pentavalent 3 and Measles1 coverage from 2000 to 2024, focusing on gaps by wealth quintile, maternal education attainment, and urban–rural residence to identify groups at risk of being left behind.

Methods

We generated equiplots to visualize trends in immunization coverage stratified by household wealth quintile, maternal education level, and rural–urban residence. The analysis used Demographic and Health Survey (DHS) microdata for national estimates and routine DHIS2 service delivery data for district-level trends from 2010 to 2023. Equity gaps were calculated by comparing coverage between the highest and lowest wealth quintiles, as well as between mothers with no formal education and those with secondary education or higher. Confidence intervals were plotted to show uncertainty around point estimates.

Results

Early 2000s data show large gaps in coverage: wealthier households and mothers with higher education consistently had higher Penta3 and Measles1 coverage. By 2010, gaps narrowed, suggesting successful outreach and community engagement. However, recent trends show worrying reversals. By 2019, the wealthiest households again achieved higher vaccination rates, with gaps of 8–12 percentage points for Penta3 and 6–10 points for Measles1 compared to the poorest households. Education-based gaps also widened, with mothers with secondary or higher education maintaining higher child vaccination coverage. Notably, rural communities achieved higher Penta3 coverage than urban areas during 2015–2019, highlighting the impact of targeted rural campaigns and sensitization.

Conclusion

While Malawi’s routine immunization system demonstrates high overall coverage, persistent and reemerging inequities underline the need for targeted approaches. Equitable access must remain a priority through microplanning, intensified outreach, and continuous data-driven monitoring to identify and close hidden gaps, especially among the poorest and least educated households.

Keywords: Immunization, equity, Penta3, Measles1, wealth quintile, maternal education, Malawi

Abstract Ref 021: Improving Routine Health Facility Data Quality for Immunization in Malawi: Trends and Lessons Learned

Vincent Samuel Phiri¹, Mike Chisema², Elizabeth Hazel³, Adamson Sinjani Muula¹

1. Kamuzu University of Health Sciences, School of Global and Public Health
2. Ministry of Health
3. Johns Hopkins University

Abstract

Background

Reliable routine health facility data are vital for effective immunization programme planning and monitoring in Malawi. However, variations in data quality metrics which include completeness, outlier frequency and internal consistency can affect evidence-based decision-making. This analysis reviews national trends in immunization data quality metrics from 2019 to 2024 in Malawi.

Methods

Using DHIS2 reports and data from 2019 to 2024, we assessed data completeness, presence of extreme outliers and internal consistency ratios for key indicators (ANC1/Penta1 and Penta1/Penta3) reflecting initiation and dropout patterns. These were assessed based on WHO/UNICEF threshold and benchmarks. Trends were explored nationally and by district with attention to disruptions caused by COVID-19 and natural disasters.

Results

Overall completeness of facility reporting improved from 83% in 2020 to 98% in 2024, surpassing the national benchmark. The percentage of districts with full reporting rose from 47% in 2020 to 98% in 2024. Extreme outliers dropped, with 100% of vaccine data free from extreme values nationally by 2023. Internal consistency remained variable while the Penta1/Penta3 ratio stayed close to 1, suggesting strong follow-up for children starting vaccination, the ANC1/Penta1 ratio remained low (<0.3), pointing to under-reporting or data system gaps for maternal visits. The annual data quality score improved from 62% in 2020 to 82% in 2023, but dipped slightly to 74% in 2024 due to localized disruptions, including cyclone displacements and disease outbreaks such as cholera.

Conclusion

Malawi’s routine immunization data have shown remarkable improvements in data completeness and outlier control, demonstrating resilience despite shocks such as COVID-19 and cyclones. However, persistent inconsistencies between service points (e.g., ANC and immunization data streams) highlight the need for harmonized reporting tools, stronger cross-programme coordination and routine data audits. Continued investments in digital platforms, supportive supervision and capacity building will be essential to sustain high-quality routine data for effective immunization programming and broader primary healthcare performance tracking.

Keywords: Data quality, DHIS2, immunization, routine health data, Malawi, completeness, consistency