Handwashing Practices among New Mothers and their Guardians: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Malawi

BackgroundPatient guardians perform hygiene-related roles during postnatal care but are often overlooked in hygiene Interventions. This study examined perceived facilitators and barriers to handwashing behaviour among Malawian new mothers and their guardians in healthcare facilities and households. MethodsThis cross-sectional study was conducted in Postnatal Care (PNC) wards (n=2) and households (n=20) in two districts in Malawi. In the PNC wards, 15 mother/guardian pairs were observed and interviewed. In the households 20 new mothers were observed and interviewed while 15 of their guardians were interviewed and/or observed. Water, sanitation and hygiene facilities, handwashing opportunities and actions were documented and analysed using Stata. Behaviour determinants were assessed using the Capabilities, Opportunities and Motivation model in NVivo 14. ResultsPNC wards had Handwashing Facilities (HWFs) without soap. Hand rinsing with water only was observed in 20% of all hand hygiene opportunities in the wards (n = 41), with guardians practising it more than mothers. 90% of households lacked HWF. Baby care activities were integrated with chores. Hands were rinsed with water only in 38% of all hand hygiene opportunities (n = 128); before eating (91%), preparing food (36%) and breastfeeding (13%). Participants knew the importance of handwashing but mothers in wards reported being too tired to get out of bed to wash their hands. The HWFs presented opportunities for handwashing but practice was limited by intermittent water supply, restricted access and soap absence. Participants expressed motivation to buy soap but didnt prioritise it for handwashing. Mothers often prioritised pacifying their crying newborns and forgot to wash their hands. Guardians were frequently excluded from health promotion activities at the facility. DiscussionContext-specific behaviour change interventions among new mothers and their guardians are needed. Utilising guardians support; placing HWFs and reminders strategically; and having innovative approaches to promote soap use should be promoted.