Community Stages of Behaviour Change for Sustained Sanitation: A Transtheoretical Model Based Assessment Four Years Post -Open Defecation-Free Certification in Balaka District, Malawi

Malawi adopted Community-Led Total Sanitation (CLTS) in 2008 with the aim of achieving open defecation-free (ODF) status nationwide by 2015.Balaka District was certified ODF in 2017 but regressed to open defecation in 2019.This study assessed the community's stage of change (SoC) in behaviour, readiness to change (RtC), and committed action to change (CAtC) for four sanitation behaviours: latrine construction, hand washing facility (HWF) construction, latrine use, and hand washing with soap (HWWS) after defecation four years post-certification.A descriptive cross-sectional study was conducted using a structured questionnaire adapted from the University of Rhode Island Change Assessment (URICA).Data were collected from household heads.Principal Component Analysis and reliability testing (Cronbach's α = 0.82) were conducted.Means and standard deviations were calculated for Stages of Change (SoC: 1 = pre-contemplation to 4 = maintenance), RtC (range 1-12), and CAtC (range -1 to +1).Results showed that the community was at the action stage for latrine construction (Mean = 4.308 ± 0.003), latrine use (Mean = 4.335, SD = 0.076), and HWF construction (Mean = 4.349, SD = 0.076), but at pre-contemplation for HWWS (Mean = 3.171, SD = 0.065).Readiness to change was intermediate for latrine (Mean = 9.340) and HWF construction (Mean = 9.665), moderate for latrine use (Mean = 9.549), and low for HWWS (Mean = 6.660).Committed action to change scores were lowest for HWF construction (Mean = 0.017), latrine construction (Mean = 0.027), and latrine use (Mean = 0.113), and negative for HWWS (Mean = -0.055).In conclusion, the community maintains moderate engagement with latrine-related behaviours but shows low readiness and commitment to HWWS.Sustainable sanitation in Balaka requires renewed investment in behaviour change strategies, especially for hand washing with soap, focusing on motivation, habit formation, and social norm reinforcement.