Background:
In Malawi, Guardian Waiting Shelters (GWS) serve as temporary residential homes at healthcare facilities for essential caregivers (guardians) whose relatives have been admitted to hospital. Patient guardians can be short or long-term residents at GWS and use these facilities for sleeping, preparing meals for family members, and play an essential role in health service provision in low-resource contexts. Crowded and unsanitary conditions at the GWS may present significant risks for communicable disease transmission between guardians, patients, and the community. Our study explored environmental conditions and their consequences for guardians in healthcare facilities in Southern Malawi.
Methods:
A rapid assessment was conducted in 12 GWS at ten public and two private hospitals. The assessment examined GWS management structures, available infrastructure and services, and the behaviours and
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perceptions of stakeholders and guardians. A checklist (n=12) captured the general infrastructure of the GWS (e.g., latrines, water and handwashing facilities, cooking and sleeping areas). Key Informant Interviews were conducted with caretakers, hospital staff and Hospital Advisory Committee members (n=28). In-depth Interviews (n=72) and Focus Group Discussions (n=23) with guardians, explored issues of management, access and use of infrastructure and associated behaviours, plus general life at the GWS. Qualitative and quantitative methods were used to analyse the data.
Results:
GWS supported on average 100 patient guardians per day, the majority of whom were predominantly female. Of the 12 GWS assessed, four also served as maternity waiting shelters and four charged user fees for guardians to buy cleaning and lighting materials. Stakeholders described perspectives on who owns and manages GWS. Guardians assumed that GWS belonged to the health care facilities they served, while hospital management typically viewed the GWS as a district or community service that should be managed by those stakeholders. In the absence of clear management and ownership, environmental conditions at GWS were poor. Guardians complained of congested sleeping rooms, lack of electricity, and no facilities to store belongings. Guardians reported intermittent and sporadic access to water (n=5), which limited guardians ability to cook and care for their own hygiene. Nine of the GWS had unusable and or unhygienic toilets which were either full or contained exposed faeces, disregarded used nappies and menstrual hygiene materials. Guardians alternatively used hospital ward latrines, bathing shelters as toilets or openly defecated. Handwashing facilities were only observed in privately owned GWS (n=2) and soap was unavailable. Consequently, GWS users feel their safety and well-being were compromised and were at risk of disease transmission when staying within GWS, such as cholera and COVID.
Conclusion:
GWS are an essential yet much-neglected component of the health service system in Malawi and a much-needed resource for those who attend to their relatives in the hospital. However, their place in the local government systems for management and maintenance is currently unclear, and this has led to long-term neglect. Thus, a coherent and accountable structure is important, which will provide the necessary infrastructure to ensure access and use of GWS is a safe, healthy and dignified environment for guardians and their families.