Across low- and middle-income countries, there have been calls to expand wastewater and environmental surveillance to include non-sewered sanitation systems. Considering public opinion, understanding, and acceptance, as well as any related privacy and personal health information concerns, in this context is important. This study used an in-person survey to learn more about Malawian and Malawi refugee camp residents perceptions of wastewater and environmental surveillance as public health tools, and their perceptions of privacy and personal health information. A 15-question survey was conducted from May to July 2024 at three locations in northern, central, and southern Malawi, including a refugee camp (n = 536). Some respondents (n = 30) also completed a board game and a post-board game survey. The results indicated high public support for surveilling communicable diseases, deadly diseases, environmental toxicants, healthy eating, illegal drugs, mental illnesses, and prescription drugs. Respondents were less supportive of surveillance that may expose their lifestyle behaviors and alcohol use. Regarding sampling locations, the surveillance of an entire city or of camp and schools had the highest acceptance. Some opposition to surveillance in business and religious organizations was found. If their sanitation waste was to be monitored, the respondents wanted the results of the data analysis to be communicated. Our findings suggested that Malawian and Malawi camp residents supported, with little concern, ongoing wastewater and environmental surveillance for public health. Considering privacy thresholds and participant autonomy regarding public health surveillance tools among cultural relevancies is important for future policy development and investment.

The authors have declared no competing interest.

This work was supported by grants from the National Science Foundation (2236372 and 195006), Etscorn Summer Development Award, and the Ellis Foundation.

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This study was reviewed and approved by the Malawi University of Science and Technology Research Ethics Committee (P.01/2024/117) and the University of Louisville Institutional Review Board (24.0245). Written informed consent was obtained from all participants.  

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