Infection prevention and control and WASH: developing a unique training package for health workers in Malawi
In Malawi, poor access to water, sanitation and hygiene (WASH) in healthcare facilities contributes to some of the highest maternal and neonatal mortality rates in the world. In this blog, we describe the development of an innovative training package designed to bridge the gap between WASH and infection prevention and control (IPC), and support safe healthcare for all.
Our journey to develop a novel IPC-WASH learning package for frontline healthcare workers began in 2020 when the government of Malawi published new IPC and WASH guidelines (PDF) in recognition of how crucial WASH is to quality healthcare. The launch of these guidelines coincided with an ongoing WaterAid Malawi project, funded by the Wimbledon Foundation, to improve the WASH status of four healthcare facilities in Ntchisi district. This project is part of the country programme’s flagship “150 Healthcare Facility Challenge” to improve WASH services and behaviours in 150 healthcare facilities.
A key element of the project involves bringing together Malawian government ministries, IPC and WASH experts, and healthcare staff to develop an innovative, engaging and scalable IPC-WASH training package. The package is designed to enhance frontline health workers’ awareness of the critical importance of WASH for effective IPC, the links between IPC and WASH, and the role of a multi-disciplinary team in achieving IPC-WASH goals for quality patient care.
Developing the materials
Before developing the training package, we first commissioned independent IPC experts at KS Healthcare to conduct a structured review of existing IPC and WASH resource gaps (PDF) to inform the new training materials. This was followed by formative research in the four healthcare facilities in Ntchisi district to better understand the drivers for, and barriers to, healthcare workers achieving IPC-WASH standards. This research was carried out by Professor Wendy Graham and her team at the London School of Hygiene and Tropical Medicine, alongside Dr Save Kumwenda and his team from the Malawi University of Business and Applied Sciences. After overcoming some delays and challenges caused by the COVID-19 pandemic, the formative research was completed and analysed in March 2022.
To design the IPC-WASH training, we established a multi-disciplinary project team responsible for the day-to-day design and development of the learning materials. The team included staff from WaterAid Malawi and WaterAid UK, Malawian healthcare professionals from the Infection Prevention and Control Association of Malawi and the Infection Control Africa Network, global IPC and WASH consultants, an adult learning specialist consultant, and Chembe Collaborative, a creative agency with a strong track record in Malawi.
Together, the project team identified that the new IPC-WASH training materials needed to meet several requirements, such as:
- Avoid duplication: As Malawi is already a leader in recognising the interconnectedness of IPC and WASH, it was essential that any materials we designed would complement and enhance Malawi’s national IPC-WASH guidelines, introduced in 2020, without duplicating them. Using our structured review of resource gaps and the findings of the formative research, we developed an initial outline of the proposed learning package and then used a series of workshops to hone our understanding of the target audience, scope, priority training needs and desired learning outcomes.
- Context specific: The scenarios and images presented in the learning package needed to be specific enough to speak directly to Malawians and draw in learners who are not used to seeing their own context reflected in materials produced with NGO and donor support. Based on their extensive experience of designing engaging multimedia training for stakeholders in Malawi and the southern Africa region, Chembe Collaborative developed a brand look and feel for the learning materials which incorporated vibrant colours and bold shapes, recognisable characters and dress, and faded photographs of real local settings.
- Widely applicable: The training content also needed to apply to different types of healthcare settings found in Malawi to support national uptake and, ideally, be adaptable to other contexts across the region. The process of developing narratives for the training materials was highly consultative, not only bringing in the project team’s range of expertise, but regularly engaging a core group of other key stakeholders through hybrid and in-person workshops.
- Accessible: The learning materials needed to align with technical best practice – locally and globally – and be pitched at a level appropriate for all healthcare workers. The formative research highlighted the critical importance of reaching non-clinical staff, such as cleaners and grounds labourers, as well as patient guardians who play an important role in community healthcare facilities. This meant that materials needed to be highly visual and available in both English and Chichewa, with certain materials targeted at specific groups within the health workforce.
- Free to access in different formats: We knew from the formative research that learners wanted to have access to resources post-training for continued learning and sharing with peers unable to attend in-person training, as well as supportive supervision and refresher training. It was essential that the full learning package was freely accessible online to enable sharing within and beyond Malawi. However, poor internet connectivity and expensive data costs mean social messaging platforms like WhatsApp play a major role in information sharing among professional networks. This led to a novel package structure, with individual materials specifically designed for sharing via WhatsApp.
The complete training programme
The finalised IPC-WASH learning package consists of three thematic sessions, bookended by a participatory introductory session to orient learners to the collaborative focus of the training, and a final action planning session with follow-up activities.
Each of the three thematic sessions is structured around a topical learning video, which is complemented and supported by a range of other materials, such as posters, learning cards, job aids and short video clips of Malawian health workers talking about how they champion best practice in IPC-WASH in their healthcare facilities.
Delivering the new training package
We have used several strategies to ensure that the new training materials are used beyond the life of the project and the initial target area of Ntchisi district.
From the start, the Government of Malawi, through its Ministry of Health (MOH), assumed leadership of the project and recommended the coordination structures and stakeholders the project would work with. Collaborating with the MOH has ensured that the new training materials have been formally adopted into the national IPC-WASH training curriculum which means that, going forward, they will be used during every IPC-WASH training session in the country.
What’s more, officers from the two MOH directorates of Preventive Health and Quality Management were part of the project team and participated in the creative development and review of the training materials. The project team also included national IPC-WASH trainers who gave their support to align the new materials with existing training resources and pilot them as part of the national training structure, which will help to orientate a wider group of national trainers to deliver the training package.
The training materials are hosted on the MOH website, in both print and WhatsApp format. This makes them accessible to all and easy to distribute across social media technical working groups, which are common in Malawi.
We also hope to use a virtual knowledge sharing platform for healthcare workers – the Extension for Community Healthcare Outcomes model, commonly known as “Project ECHO” – to disseminate the materials via their learning sessions for IPC-WASH professionals within Malawi and other countries.
What did we learn?
The journey to develop these training materials has revealed a number of valuable lessons that could be applied by others interested in mirroring the approach.
- Identifying the opportunity to improve IPC-WASH practice was key. This included an initial trigger for action, developing a clear, collective vision and ensuring the availability of necessary resources.
- Project management was critical to develop and execute such an ambitious undertaking. This relied on strong leadership and organisation from the project team and core group of stakeholders.
- Feedback from those involved has also highlighted the importance of inclusivity and a commitment from day one to shape the project using insights on the local situation to deliver a fit-for-purpose package. The presence of consistent and tenacious local people was a critical driver of progress.
Our learning has informed a flow diagram that sets out the key steps in the development of a tailored IPC and WASH training.
Download the process evaluation report for developing the IPC-WASH training package
Linking to global best practice
The most recent global progress report on water, sanitation, hygiene, waste and electricity services in healthcare facilities calls for the development and empowerment of the health workforce at national and local level. The report authors, WHO and UNICEF, call in particular for all healthcare facility staff to be supported on good WASH and IPC practices – including through clear job descriptions, pre-service and in-service training, mentoring and career development opportunities.
This innovative training package, developed to enhance the knowledge of all health workers on IPC in combination with WASH, could not have been more timely. It is our hope that by focusing on relationships, responsibilities and interlinkages, these training materials will empower health workers to take action on achieving IPC-WASH standards and become champions in their own health facilities – throughout Malawi and beyond.
Claire Kilpatrick and Julie Storr are subject matter experts in IPC, working at global level on guidance and implementation.
Natasha Mwenda is Programme Manager for WASH for Health.
Arielle Nylander is WaterAid’s Senior Policy Analyst – Health.
Kyla Smith is WaterAid’s Senior WASH Manager – Health.
Top image: Nurse midwife Zelifa Mzoma, 39, washes her hands in a washbasin at Mkhuzi Health Centre, Ntchisi. December 2022.
