“We Are Already Sick”: Infectious Waste Management and Inequality in the Time of Covid-19, a Reflection from Blantyre, Malawi

Absorbent hygiene products disposal behaviour in informal settlements: identifying determinants and underlying mechanisms in Durban, South Africa

BACKGROUND

Within South Africa, many low-income communities lack reliable waste management services. Within these contexts, absorbent hygiene product (AHP) waste, including nappies (diapers), are not recycled, and are often dumped, ending up in watercourses and polluting the local environment. The structural barriers to collection which have been well explored, however the behavioural determinants of safe disposal for AHPs remains poorly understood. The purpose of this study is to determine the psycho-social factors driving AHP disposal behaviour for caregivers, while identifying potential underlying mechanisms (such as mental health), which may be influencing disposal behaviour, with the intention of informing a future, contextually appropriate and sustainable, collection system.

METHODS

The cross-sectional study was conducted within three low-income communities located within eThekwini Municipality (Durban), South Africa. The study included a pre-study and a quantitative survey of 452 caregivers, utilising the RANAS approach of behaviour change. The quantitative questionnaire was based on the RANAS model to measure psycho-social factors underlying sanitary disposal of AHPs. Mental health was assessed using the Self-Reporting Questionnaire (SRQ-20). Statistical analysis involved regressing psycho-social factors onto disposal behaviour and exploring their interaction with mental health through a moderation model.

RESULTS

Our findings suggest that one third of caregivers do not dispose of nappies sanitarily, despite intent (86.9%). Regression analysis revealed ten psycho-social factors which significantly predict the desired behavioural outcome, the sanitary disposal of AHPs. Caregivers with poor mental health were less likely to dispose of AHP sanitarily, which reflects previous research linking poor mental health and the impairment of health-related daily activities, particularly within vulnerable groups. Specifically, several psycho-social factors underlying were moderated by poor mental health, the prevalence of sanitary disposal of AHPs depended on mental condition of caregiver.

CONCLUSIONS

Our findings confirmed the link between poor mental health and unsanitary AHPs disposal. This is especially relevant because poor mental health is common within South Africa. Addressing mental health problems within these communities is an essential step to providing sustainable waste management services. The findings informed an intervention strategy to implement a future collection system for these communities, and similar low-income or informal contexts within South Africa.

"It is unbearable to breathe here": air quality, open incineration, and misinformation in Blantyre, Malawi

Blantyre, Malawi's Queen Elizabeth Central Hospital (QECH), or Queen's, as it's known locally, is the country's largest public hospital. However, Queen's is not served by regular municipal waste collection. Rather, most hospital waste (infectious and non-infectious) is gathered by grounds staff and openly burned, in several constantly smouldering piles, sending up clouds of smoke. Speaking directly to an identified knowledge gap on air quality impacts linked to trash burning and the paucity of African urban dwellers' voices on air quality issues, this study employed a mixed-methods approach to both quantitatively measure the air quality around QECH, and to qualitatively investigate the perceived impacts amongst staff and caregivers. Low-cost sensors measuring particulate matter (PM) with particle sizes less than 10 μm (PM10) and less than 2.5 μm (PM2.5), expressed as the mass of PM per volume of air (μg PMx/m3 air) were recorded every 5 min at 8 locations across the QECH for 2 months. Qualitative data collection consisted of 56 interviews with patients, caregivers and hospital staff (including janitorial and maintenance staff, nurses, doctors, and administrators). Our results show that safe air quality thresholds are consistently exceeded across space and time and that the most problematic air quality surrounds the shelter for caregivers and those receiving treatment for HIV/AIDS. Moreover, staff and visitors are severely impacted by the poor air quality within the space, but feel powerless to make changes or address complaints. Waste management interventions are desperately needed lest the patients who arrive at Queen's leave with more health issues than the ones with which they arrived.

COVID-19, the environment and animal life in Malawi compared to other countries: A brief scooping review for a research agenda in the developing countries

The impact of COVID-19 on the human population in Malawi has been documented. However, its impact on the animal population and the environment has not been thoroughly researched. Because of the well-known inter-relationship between human and animal populations and the environment, a study based on a brief scooping review of previous related studies, media and survey reports, was conducted. The findings reveal that except for a few selected studies, the research gap on COVID-19's impact on the environment and animals in Malawi is wide compared to other countries. Nonetheless, from the few identified related studies, this study has revealed that as the restriction of movement and closure of borders disrupted the supply chain of forest resources in the country, the COVID-19 pandemic has led to increased pressure on forests as a coping strategy due to significant loss of jobs in the informal sector. Although the quality of water and air improved in most parts of the globe due to reduced human activity, there is no substantial literature on the same in Malawi partly due to ineffective monitoring systems. However, COVID-19 has exposed the deficiencies in water security in Malawi, thereby creating opportunities to address them. Conversely, increased demand for water at household levels due to restricted movements contributed to environmental pollution at suburb levels. In particular, the less developed and overpopulated countries suffered from land pollution due to poor disposal of plastic generated from hospitals and personal protection equipment. Elsewhere, studies show that minimal human interference with animals outside homes resulted in an increase of fish and bird biomasses. But, unemployment rates caused by the pandemic have seriously contributed to illegal poaching in developing countries. Therefore, a rapid assessment of the impact of the pandemic on environment in Malawi, to generate the evidence needed for policy makers to use in support of the affected and also plan for the recovery and sustainability of wildlife, is recommended.

First evidence of microplastics isolated in European citizens' lower airway

Microplastics (MPs) have been detected in all environmental locations, including the atmosphere. However, few studies have investigated the presence of airborne MPs in the human respiratory system. Our research purpose was to investigate these pollutants in the lower human airways of 44 adult European citizens, using bronchoalveolar lavage fluid (BALF) collection as a minimally invasive method, that enables the detection of these pollutants in living patients. We studied the relationship between the patients' life habits and physiological parameters, based on background information and medical and occupational history, and the concentration of MPs isolated from their respiratory systems. Our results indicate that most MPs were in the form of microfibers (MFs) (97.06%), with an average concentration of 9.18 ± 2.45 items/100 mL BALF, and only 5.88% (0.57 ± 0.27 items/100 mL BALF) were particulate MPs, without a significant relationship with environmental, physiological, or clinical factors. The average size was 1.73 ± 0.15 mm, with the longest dimension (9.96 mm) corresponding to a polyacrylic fiber. Taken together, the results demonstrated the occurrence of MPs in the lower human airway, although more studies are necessary to elucidate the negative effects these pollutants could induce in the human respiratory system and its associated diseases.

Examining challenges and multi-strategic approaches in waste management during the COVID-19 pandemic: A systematic review

The COVID-19 pandemic has a negative impact on the environment. Waste generation and improper management during the COVID-19 pandemic posed a major threat to human health and the environment. Irregular and improper waste collection, handling, suspension of waste recycling and unsanitary disposal were all important issues in the processing and management of generated waste. This study emphasised a systematic review and content analysis to categorise all types of waste management (WM) during the COVID-19 pandemic to accomplish a well understanding of the relation between the COVID-19 pandemic and its impacts on WM within the literature. In this systematic review, a number of published papers on different aspects of WM during March 2020 to February 2021 were considered in order to identify major challenges in handling WM during the pandemic time and highlight multi-strategic approaches suggested. A content analysis of the 58 relevant papers was carried out by incorporating different types of WM at local as well as global scales. The present review results revealed that the COVID-19 has impacted the quantity and composition of waste, and the crisis caused by the pandemic has also altered the nature of global WM system. A comprehensive analysis on how the systems of WM were affected through the advancement of COVID-19 and what would be the healthier solutions was also highlighted in this systematic review. The results of this systematic review would be beneficial for better policymakers to holistically address potential future pandemics, if any.

Preparedness for and impact of COVID-19 on primary health care delivery in urban and rural Malawi: a mixed methods study

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.

Plastic and its consequences during the COVID-19 pandemic

During the pandemic outbreak of COVID-19, the important role of plastic becomes evident since vital equipment such as respirators have plastic parts, as well as personal protective equipment (PPE), which avoids the transmission of the SARS-CoV-2 virus, is made of plastic. So, plastic during a pandemic is considered a life savior in the struggle against the virus. However, the same material that is a protector becomes a polluter when inadequately disposed of in the environment, generating or worsening socio-environmental problems, such as pollution of water bodies by plastic. This work proposes a reflection about the role and the importance of plastic in our society, bringing an overview of its main applications and consequences during the COVID-19 pandemic, correlating its use with aspects related to environmental problems and public health. Some questions revolving around the concerns caused by plastic pollution are posed, and some possible solutions to the problems are outlined.

Development and application of tools to cost the delivery of environmental health services in healthcare facilities: a financial analysis in urban Malawi

BACKGROUND

Environmental health services (EHS) in healthcare facilities (HCFs) are critical for providing a safe, functional healthcare environment, but little is known about their costs. Poor understanding of costs impedes progress towards universal access of EHS in HCFs. We developed frameworks of essential expenses required to provide EHS and conducted an ex-post financial analysis of EHS in a network of medical research and training facilities in Lilongwe, Malawi, serving an estimated 42,000 patients annually through seven outpatient buildings.

METHODS

We estimated the cost of providing the following EHS: water, sanitation, hygiene, personal protective equipment use at the point of care, waste management, cleaning, laundry, and vector control. We developed frameworks of essential outputs and inputs for each EHS through review of international guidelines and standards, which we used to identify expenses required for EHS delivery and evaluate the completeness of costs data in our case study. For costing, we use a mixed-methods approach, applying qualitative interviews to understand facility context and review of electronic records to determine costs. We calculated initial costs to establish EHS and annual operations and maintenance.

RESULTS

Available records contained little information on the upfront, capital costs associated with establishing EHS. Annual operations and maintenance totaled USD 220,427 for all EHS across all facilities (USD 5.21 per patient encounter), although costs of many essential inputs were missing from records. Annual operations and maintenance costs were highest for cleaning (USD 69,372) and waste management (USD 46,752).

DISCUSSION

Missing expenses suggests that documented costs are substantial underestimates. Costs to establish services were missing predominantly because purchases pre-dated electronic records. Annual operations and maintenance costs were incomplete primarily because administrative records did not record sufficient detail to disaggregate and attribute expenses.

CONCLUSIONS

Electronic health information systems have potential to support efficient data collection. However, we found that existing records systems were decentralized and poorly suited to identify EHS costs. Our research suggests a need to better code and disaggregate EHS expenses to properly leverage records for costing. Frameworks developed in this study are a potential tool to develop more accurate estimates of the cost of providing EHS in HCFs.