Afikepo Takes Bold Action in the Battle against Cholera

Over the past year, Malawi has experienced its worst cholera outbreak in two decades. Currently, 59,000 people have contracted the disease, and 1,761 died.

As infection and fatality cases continue to decline, there are still challenges regarding community behaviour change.

Health surveillance assistant, Dynes Josiah, says behaviour change in Sani village Thyolo started to become a reality when five cholera cases were detected in the area in January and February this year.

"Initially, when we did door-to-door household visits on good hygiene practices to prevent cholera, people never took us seriously. It took time for the message to sink in, and when the area registered cases, people started to listen," she explains.

Since then, the last reported cholera case in Sani village was on February 17. Josiah attributes this to the collaborative work she has undertaken with the village's leadership, promoters, cluster leaders, and care groups to help arrest the spread of the disease by enforcing hygiene standards.

One of the people Josiah has been working closely with is Olive Mpomba, the promoter for the Afikepo Nutrition Programme for Sani village.

Mpomba explains that the Community Behaviour Tracking Tool (CBTT) has played a significant role in tracking the village's best hygienic practices.

The CBTT is a monitoring and evaluation tool deployed under the Afikepo Nutrition Programme, which contains indicators to track the progress communities are making in terms of behavioural change towards nutritional uptake among pregnant women, lactating mothers, adolescent girls, and nutritional assessment of children under the age of five using middle upper circumference tapes as well as handwashing practices.

The Afikepo nutrition programme is funded by the European Union (EU) in partnership with UNICEF Malawi and the Food and Agriculture Organisation (FAO) to address the problem of undernutrition, particularly in children under five.

The WASH component in the CBTT provides guidelines for washing hands on five occasions: before preparing food, after changing a nappy, after visiting the toilet, before eating, and before breastfeeding a baby.

"The handwashing component helps in cholera prevention. Under-five children are dependent on their parents, so we encourage parents to wash their hands. Children usually copy the behaviour of their parents. If parents don't wash their hands, their children will follow suit. If people wash their hands, we can prevent cholera," says Iness Chitedze, one of the contributors to the CBTT. Mpomba also explains that the CBTT has become all the more critical with the outbreak of the cholera epidemic.

"We go around the village advising women and caregivers about the importance of hygiene, especially the need to have toilets and tippy-taps outside these facilities," Mpomba says.

As one way of fostering community dialogue and continuous feedback, the village holds regular dialogue sessions. While sparks don't fly when they have these engagement meetings, resolutions agreed upon during such gatherings are binding, and anyone who falls foul of them receives the wrath of the village chief, Witness Chimombo.

Chimombo appreciates the work that health workers, promoters, and care groups are doing, and he set by-laws to complement their work.

"We made a by-law that any household that doesn't have a toilet would be fined a chicken. If they ignore the fine, their case will be escalated to the T/A. But most toilets collapsed due to Cyclone Freddy, so we cannot enforce that law now. We have given people a grace period for reconstruction," he says.

Mercy Chikaonda is ahead of the curve and has taken extraordinary precautions to ensure her household remains untouched by cholera. She has a well-tended toilet and tippy-taps outside, forbidding her household members from washing plates in the river.

"We receive chlorine every two weeks, which I apply to water. If I don't have chlorine, I draw drinking water in a bucket with a lid. When I bring it home, I boil it," Chikaonda.

Josiah is encouraged by the village's progress, but she vows never to relent until cholera is decisively dealt with.