OBJECTIVES

Share knowledge with local research partners at the College of Medicine, University of Malawi, through training in household and ambient air pollution and behavioural change techniques alongside participatory approaches to health promotion; and identify suitable research site.
Evaluate a range of behaviour change approaches used in the sanitation sector for applicability to a Community LedSmoke-free Village setting and review potential pollution reduction interventions in relation to effectiveness and suitability.
Using a mixed methods approach, carry out a baseline survey, participatory mapping and focus groups usingphotovoice, to 1) identify the main sources of HAAP and fire in the village 2) to assess community awareness ofHAAP and barriers and enablers to change.
Work with the community to identify those actions they wish to take forward to reduce HAAP and burns, that can beinstituted at a village level, and implement the resulting action plan.
Measure outcomes in relation to HAAP, behaviours, participation and barriers and enablers to scale up among thecommunity six months after institution of the action plan and make recommendations for future local and nationalpolicy actions based on the findings.
Integrate the project findings within a final report and share recommendations for future action with stakeholders ata local, regional and national level including through the development of a smokeless village toolkit.

METHODS

MILESTONE 1

This project will take a community-led mixed-methods participatory approach to the development of an action plan in a village setting in Malawi aimed at reducing HAAP. We propose to evaluate a range of behaviour change approaches used in the sanitation sector and co-identify those most suitable for application to a community-led HAAP project. We will also evaluate a range of pollution reducing interventions for presentation to, and discussion with, the community in order to inform the development of a community led action plan. Implementation of the plan will be evaluated using both quantitative and qualitative methods and findings will be used to develop a toolkit for the implementation of a whole village approach to reducing HAAP. Findings will be shared with regional and national policy makers in order to ensure their incorporation into ongoing national and regional policy development. Milestones have been identified at significant points to demonstrate the outcomes expected at the various stages of the project.

Share knowledge with local research partners at the College of Medicine, University of Malawi, through training in household and ambient air pollution and behavioural change techniques alongside participatory approaches to health promotion; and identify suitable research site.

We will offer two short courses, participatory in approach, at the College of Medicine, University of Malawi to relevant academic staff, community health workers and research staff employed directly on the project. The first course will provide a background to the problem of HAP, basic methods used to measure HAP and the key approaches currently being instituted to address the problem. The second course will cover behaviour change techniques including information and communication approaches and also participatory methods. Each course will be approximately two days in length. When the courses have been completed, we will spend a further day applying the methods learned to the context of this project, exploring how the knowledge and skills gained will be put into practice in the field. The courses will include discussion of the ethics of the research methodology being used and provide an opportunity to agree on the ethical approaches that the study will take. This part of the programme will be led by Professor Mbengo who is an expert in the field. It will inform the application for ethical approval which will be submitted following discussions with the project team.

In addition, whilst on site in Malawi, and using the knowledge and experience of our local partners, we will together identify potential project villages, with a population of approximately 100 households that have a high level of dependence on biomass, preferably where there is already a relationship between the project team at the University of Malawi and the village members. We will meet with the traditional authorities and village chiefs of potential project villages where feasible, to assess willingness to participate, village suitability, and best contacts.

2. Evaluate a range of behaviour change approaches used in the sanitation sector for applicability to a Community Led Smoke-free Village setting and review potential pollution reduction interventions in relation to effectiveness and suitability.

In tandem, we will carry out a systematic literature review of behaviour change approaches in the sanitation sector and assess their significance and applicability in the context of implementing a smokeless village approach in the chosen setting. This will include a) identification / adaptation of suitable indicators of progress and outcome, b) factors facilitating or constraining implementation, c) role of policy environment, d) implementation quality, e) administrative context, f) community environment, g) community capacity, h) community participation patterns and j) community behaviour. The review will provide a tool for analysing which behaviour change approaches are most suitable for the purposes of this project.

In addition, we will update and summarise the evidence for the effectiveness of interventions to reduce HAAP suitable for the Malawi setting. The summary will be based on the systematic review of scale up previously carried out by the Ireland-based PI (Stanistreet) and colleagues (Rehfuess et al., 2014; Stanistreet, Puzzolo, et al., 2014) which will be extended and updated. The review provides a comprehensive overview of the barriers and facilitators of the main cleaner cooking alternatives to a traditional stove. We will update and extend this work to review cleaner alternatives to other sources of HAAP such as lighting, and non-polluting crop management alternatives and review any relevant publications pertaining to cleaner cooking, which were published after 2011. Thus we will assess evidence for the barriers and facilitators to scale up of alternative approaches to lighting, crop management etc. alongside the cleaner cooking evidence that is currently available.

In relation to the identified HAP interventions, we will then categorise interventions, using an adaptation of the Quinn et al. model (2018) under the five domains to allow the identification of actions required at different levels. For the purposes of the village action plan, we will take forward those actions relating to consumer demand and user and community needs and perceptions. Actions falling under the other categories will be taken forward to the final report to share with regional and national stakeholders as part of a longer term strategy (see objective 6). However, if it is feasible to address any of the actions in the environment, industry or energy domains within the scope of the project, these will also be taken forward as part of the village action plan. For example, if the villagers wished to purchase solar stoves and a local distributor was able to make these available locally, this would be included as part of the village action plan.

In summary, these two reviews will provide a comprehensive overview of a) the most appropriate behaviour change approaches that could be instituted as part of the project along with a framework to guide implementation in the field b) the potential interventions available to the community that could be instituted to reduce HAAP. In relation to the latter, it will also provide a guide to the advantages and disadvantages of each intervention to present to the community for consideration.

MILESTONE 2 - COMPLETION OF TWO REVIEWS AS DESCRIBED, AND COMPLETION OF ETHICS APPLICATION

3. Using a mixed methods approach, carry out a baseline survey, participatory mapping and focus groups using photovoice, to identify 1) the main sources of HAAP and fire in the village 2) to assess community awareness of HAAP and barriers and enablers to change.

We will carry out a baseline survey to assess the types of stoves used, sources of smoke, sources of lighting in village households, prevalence and seriousness of burns injuries and the extent of other practices associated with HAP, such as stove stacking, rubbish burning, crop burning etc. Other baseline indicators will be incorporated based on the review of sanitation indicators undertaken (as part of Objective 2) as appropriate. In a sample of consenting homes with children under 5, and following strict ethical guidelines, we will carry out baseline measurements of 48 hour personal exposure (PM2.5 and CO) for the woman of the household. We will also measure outdoor air quality (PM2.5and CO) at a central location in the village for a period of two weeks at the commencement of the study.

We will identify the main issues in relation to HAAP and burns from the community perspective through participatory approaches with village members and relevant stakeholders, including village elders. We will use a range of approaches including, transect walks, photovoice and community mapping exercises as a means of identifying key sources of smoke and dust. From an epistemological perspective, we will take an interpretive phenomenological approach to the qualitative aspects of the study. This will enable a focus on community lived experience and will support the integration of narratives of multiple individuals (Creswell, 2014). Methods including Photovoice and transect walks will be used as these methods draw on personal experience of community members and reflect the participatory approach being taken.

Community mapping

Our approach to community mapping will utilise a community based participatory research approach following the guiding principles laid down by Israel et al. (Israel, Schulz, Parker, & Becker, 2008). CBPR is a partnership approach which equitably involves community members, practitioners and researchers in all aspects of the process. Working with households, using transect walks as a tool, (Keller, 2019) we will identify current air pollution sources in and around the home as well as potential factors that participants associate with poor respiratory health, enabling all local sources of HAAP to be mapped diagrammatically. We will integrate this knowledge with the data collected from the quantitative survey describing the main sources of air pollution and burns risk in the village to produce a community map of HAAP and burns risk.

Photovoice

Photovoice is a practice that promotes dialogue among a community using a specific photographic technique. As a practice, it enables people to record and reflect their community's strengths and concerns, promote critical dialogue and knowledge about important issues through large and small group discussion of photographs, and also provides a tool to reach policymakers (Wang & Burris, 1997). We will use the methodology outlined by Wang and Burris and carry out focus groups with community members as a means of identifying sources of household air pollution and associated behaviours from a community perspective. Photovoice will be utilised as a tool to promote dialogue among community members through photographic discussion. The PI has used this methodology in the context of HAP previously, with considerable success (Ronzi et al., 2019).

The number of focus groups will depend to some extent on the variation in cooking heating and lighting practices within the village, but it is anticipated that there will be at least four focus groups with household members. Thematic analysis will be used to analyses focus group data based on Braun and Clarke’s six stage framework (Braun & Clarke, 2006) The framework is arguably one of the most influential in social sciences as it is not tied to any specific epistemology but offers a clear and useable approach to analysing data thematically. The steps include 1) Becoming familiar with the data 2) Generating initial codes 3) Searching for themes 4) Reviewing themes, 5 ) Defining themes 6) Writing up.

MILESTONE 3 – COMPLETION OF BASELINE ASSESSMENT OF VILLAGE AIR POLLUTION SOURCES THROUGH A BASELINE SURVEY, PHOTOVOICE AND COMMUNITY MAPPING.

4. Work with the community to identify those actions they wish to take forward to reduce HAP and burns, that can be instituted at a village level, and implement the action plan.

Through the medium of village meetings, and continuing our community based participatory approach, we will present the findings of the two reviews that have been undertaken in an accessible format, providing them with potential actions they could undertake as part of an action plan. Each action will include an estimated cost, and where feasible a guide to the effectiveness of the intervention itself (high, medium low, using ISO standards where applicable) along with advantages and disadvantages of implementation. We will then support the community to identify those actions they would like to take forward as part of the smokeless village project, which can be instituted at a community level. Working with the community, we will then institute the actions as appropriate. The method of implementation will vary depending on the actions. Examples of possible actions include an information campaign that encourages mothers to take children away from the fire during cooking, a traffic light system to indicate ambient air quality, improving home ventilation, developing a savings scheme for community members to buy improved cookstoves, and introducing mulching and composting for crop residues for example. Approaches will be informed by the findings of the two reviews carried out under Objective 2). A budget of up to 3,500 euros will be made available for this work. The team at the University of Malawi will support the implementation of the action plan, visiting the village weekly to offer advice as required and to deal with any issues raised by implementation of the plan.

MILESTONE 4 – PRODUCTION AND IMPLEMENTATION OF ACTION PLAN

5) Measure outcomes in relation to HAAP, burns, behaviours, participation and barriers and enablers to scale up among the community six months after institution of the action plan and make recommendations for future local and national policy actions based on the findings.

We will undertake a repeat household survey to measure whether there has been any change in relation to cooking heating and lighting practices. Outcomes will be measured in relation to the main sources of HAAP and fire; stove use, lighting, crop and rubbish burning and behaviour change, in addition to any indicators identified from the sanitation sector literature that were measured at baseline. We will also carry out repeat measurements of 48 hour personal PM in a sample of homes and ambient PM over a two week period. The specific outcome measures will depend on the actions that the community take. We will carry out a repeat exercise with Photovoice, and up to four focus groups to identify from a community perspective where changes in practice have occurred and where barriers still remain to reducing air pollution.

MILESTONE 5 – COMPLETION OF EVALUATION OF ACTION PLAN

6 ) Integrate the project findings within a final report and share recommendations for future action with stakeholders at a local, regional and national level including through the development of a smokeless village toolkit.

The final report will include integration of the qualitative and quantitative findings in respect of the main outcome measures using a convergent parallel design (Stanistreet, Hyseni, Bashin, Sadumah, & Daniel, 2014). Qualitative and quantitative findings will be triangulated. This consists of combining results into meta-themes and using a convergence coding matrix to report whether results from both components are in agreement, silence or dissonance (Fetters, Curry, & Creswell, 2013).

It will include a toolkit which will provide a guide to the methodology used and outline the challenges and benefits of the smokeless village approach as well as setting out local, regional and national recommendations in the context of current national policy. Those recommendations that require action at regional and national level will be fed back to relevant stakeholders through a national workshop organised alongside colleagues at Renew’N’Able Malawi and the University of Malawi. The workshop will run over one full day and will be held in Blantyre during the final stages of the project. Participants will include relevant government officials, academics and policymakers and key stakeholders as appropriate. Irish Aid will also be invited to participate in the planning and organisation of the workshop. A written report will also be made available at the workshop and online. Our findings will be shared with the Department of Public Health, Environmental and Social Determinants of Health of the World Health Organisation who are currently developing a toolkit for Clean Household Energy Solutions (CHEST), with a view to integrating the whole village participatory approach into their ongoing work. This will potentially provide a global reach for the findings of the work and the potential for similar projects in other contexts and settings.

MILESTONE 6 - COMPLETION OF FINAL REPORT, DEVELOPMENT OF TOOLKIT AND HOLDING OF NATIONAL WORKSHOP IN BLANTYRE

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