RESEARCH AND LEARNING

Formative Research Report // October 2017

NUTRITION AND WASH RESEARCH AND BEHAVIOUR CHANGE COMMUNICATION PILOT PROJECT FORMATIVE RESEARCH REPORT

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ACKNOWLEDGEMENTS

This report was written by Sanjib Saha, Sabina Pradhan and Mohd. Ayub. The authors thank

Mona Laczo, Emebet Wuhib-Mutungi, Rachel Aveyard, Sally Gowland, Lois Aspinall, and

Shobhana Pradhan for their input and feedback.

BBC Media Action, the international development organisation of the BBC, uses the power of

media and communication to supportw people to shape their own lives. Working with

broadcasters, governments, other organisations and donors, it provides information and

stimulates positive change in the areas of governance, health, resilience and humanitarian

response. This broad reach helps it to inform, connect and empower people around the world.

It is independent from the BBC, but shares the BBC’s fundamental values and has partnerships

with the BBC World Service and local and national broadcasters that reach millions of people.

The content of this report is the responsibility of BBC Media Action. Any views expressed

should not be taken to represent those of the BBC itself or of any donors supporting the work

of the charity. This report was prepared thanks to funding from the World Food Programme

(WFP) and United State Department of Agriculture (USDA), which supported BBC Media

Action in conducting research and communication aspects of the Nutrition and WASH project.

Commissioning editor: Mona Laczo Editor: Alexandra Chitty

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Table of Contents ACKNOWLEDGEMENTS ........................................................................................................................... 2

EXECUTIVE SUMMARY ............................................................................................................................ 4

1. INTRODUCTION ................................................................................................................................... 7

1.1 Project background ................................................................................................................. 8

1.1.1 Nutrition and WASH in Nepal ................................................................................................ 8

1.1.2 How can media and communication improve health? ........................................................ 11

1.2 Project objectives and activities ........................................................................................... 12

1.2.1 Formative research methodology ........................................................................................ 12

1.2.2 Strengths and limitations of the research..................................................................... 13

2. FINDINGS: WASH PRACTICES AND BARRIERS ................................................................................... 15

2.1 Water .......................................................................................................................................... 16

2.2 Sanitation .................................................................................................................................... 19

2.3 Hygiene ....................................................................................................................................... 22

3. FINDINGS: NUTRITION PRACTICES AND BARRIERS ........................................................................... 24

4. FINDINGS: THE NSMP IN ACTION AND PARENTS’ PERCEPTIONS OF IT ............................................ 26

4.1 Observation of the NSMP in action in schools ............................................................................ 27

4.2 Parents’ perceptions of the NSMP .............................................................................................. 29

5.1 Nepalis’ access to and consumption of media ............................................................................ 30

5.2 Sources of information about WASH and nutrition .................................................................... 30

6. RECOMMENDATIONS ........................................................................................................................ 32

6.1 Behaviours to prioritise and drivers of change to target ............................................................ 32

6.2 Building a media and communications strategy ......................................................................... 35

6.3 Ways forward: a few ideas .......................................................................................................... 38

ANNEX: RESEARCH METHODOLOGY ..................................................................................................... 41

1. Methods ................................................................................................................................ 41

2. Study location ....................................................................................................................... 41

3. Selection of participants ....................................................................................................... 41

Endnotes ............................................................................................................................................... 42

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EXECUTIVE SUMMARY

Despite making some progress since the dawn of the millennium, Nepal still suffers from high

levels of undernutrition. A large proportion of its children under the age of five are stunted.

Limited access to the foods required for adequate nutrient intake, coupled with poor water,

sanitation and hygiene (WASH) practices are largely to blame. To address this significant

public health issue, since 1996 the government of Nepal – with assistance from the World

Food Programme (WFP) – has been implementing the National School Meals Programme

(NSMP), that using schools as a platform to promote healthy WASH behaviours amongst

school children and providing free school meals to improve children’s nutrition intake.

To assist this endeavour, WFP funded BBC Media Action to undertake the ‘Nutrition and

WASH research and behaviour change communication pilot’. The project aimed to support

local actors to produce audience-informed nutrition and WASH behaviour change

communication materials that could be used in Achham and Sindhupalchowk districts. To this

end, BBC Media Action conducted qualitative research that sought to understand the barriers

to and enablers of improved nutrition and WASH behaviours and practices in the two districts.

This report summarises the findings of and proposes recommendations arising from the

research.

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Key findings

Although the research participants reported overall awareness about the WASH practices

studied (e.g. using safe water, using toilets, washing one’s hands with soap and water at

critical moments and managing solid waste safely), the study identified a number of barriers

preventing the uptake of such behaviours. These centred on insufficient knowledge of, and

harmful attitudes and norms towards, improved WASH practices. For example, residents of

Achham and Sindhupalchowk do not treat the water they drink because they do not know

how to do so properly and lack knowledge of the dangers of invisible (and harmful) bacteria

and germs. They are also unaware of the various sources of contamination present when

collecting and storing drinking water. The misperception that natural water equals clean

water is widespread and has led to low levels of risk perception. Therefore, even those with

some knowledge of the diseases that can be caused by drinking unsafe water generally

believe water treatment is unnecessary.

Likewise, although using toilets has become the norm for adults of the two districts, the study

found that the same was not true for children; they regularly defecate in the open, and this

practice is widely accepted. Such a situation may be the norm due to the erroneous and

widely-held perception that children's faeces are less harmful than adults’ and/or due to a

lack of awareness of the importance of, and ways to, safely dispose of the waste. Indeed,

unsafe disposal of younger children’s/infants’ faeces is widespread in the two districts. The

research also revealed that parents and other childcare providers are reluctant to ensure

children use a toilet and to monitor this practice, and that a lack of water in schools prevents

children from practising such improved sanitation behaviours.

Researchers additionally observed that handwashing with soap is not practised at all critical

times and found that research participants feel this is only necessary when one’s hands are

visibly dirty and/or odorous. At other times, it is the norm to rinse hands with water alone, if

at all. This norm and the lack of knowledge about when and why washing one’s hands with

soap is required represent major barriers to the uptake of improved hygiene practices in the

two districts. So too does the dearth of soap in designated handwashing areas (particularly

near toilets) and the absence of the required and consistent reminding and close monitoring

of children at home and in schools. Formative research also observed poor hygiene practices

in storing, preparing and serving school meals.

The study also highlighted similar knowledge-related barriers to healthier nutrition

behaviours. For example, despite being aware of the concept of nutrition and having a

positive attitude towards ensuring their families eat well, research participants were found to

lack understanding of the nutritional value of different food groups and of the importance of

having a varied diet for their children’s physical and cognitive growth. This had led to them

incorrectly perceiving that their current diet – locally produced - provides adequate nutrients

and believing that their children are healthy. Indeed, researchers observed a major gap in

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nutritional intake that parents confirmed in FDGs: family meals mainly consist of

carbohydrates and vegetables for many families because dairy, meats and poultry are usually

neither available nor affordable for all and very few suggested of eating seasonal fruits. Access

is, therefore, also a substantial barrier to improved nutrition in these two districts.

Recommendations

The study identified that a lack of knowledge and understanding around improved practices,

entrenched social and cultural norms, and poor motivation among parents, teachers and

other childcare providers all act as significant barriers to improving WASH and nutrition

behaviours in the two research sites. Thus, this report recommends that future

communication strategies concurrently: target the motivational and emotional drivers of

these behaviours, inform people about improved practices, and target parents, school

officials and other family members.

This report therefore recommends that the following behavioural objectives are prioritised in

future communication interventions:

1. Encourage families and schools to treat drinking water

2. Encourage families to use safe water for all household activities

3. Enable families and school officials to ensure that children do not defecate in the open

and to safely dispose of younger children’s faeces

4. Encourage communities to safely dispose of solid waste

5. Encourage parents, teachers and children to wash their hands with soap at all critical

times

6. Encourage parents and teachers to ensure soap is always available at designated

handwashing areas

7. Encourage teachers and parents to ensure school meals are prepared and served in a

hygienic way and using utensils

8. Enable families to eat a more varied diet

Reflecting participants’ communication preferences, this report recommends implementing

multimedia programming that is supported by interpersonal communication (IPC) through

strong outreach activities in both the study’s districts. Bringing health professionals and

community leaders into media programming to provide accurate and trusted information to

audiences, and strengthening the capacity of local institutions – such as health workers and

local media outlets – to produce and deliver high-quality social and behaviour change (SBCC)

communication materials should ensure the sustainability of such interventions.

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1. INTRODUCTION

This report presents the findings of formative research conducted in the Achham and

Sindhupalchowk districts of Nepal as part of the WFP-assisted ‘Nutrition and WASH research

and behaviour change communication pilot’ project. It outlines the barriers families and

school going children face to practising improved nutritional and WASH behaviours, and

highlights drivers that could influence people to change their existing behaviours. The report

also documents findings from observations of the NSMP in action in schools. NSMP is a joint

initiative by WFP, USDA and the government of Nepal, and seeks to improve nutritional and

WASH practices in the research sites. Finally, the report highlights the drivers of change that

media and communication can influence to contribute to families and school going children

adopting healthier nutritional and WASH behaviours and practices, and recommends

activities that could be undertaken.

This report has been written for WFP, supporter of this formative research and the project. It

will be disseminated to local actors who are supporting Nepal’s government and WFP to

improve nutrition in schools and communities through the NSMP, and will be used to develop

an audience-informed communication strategy for improving nutrition and WASH behaviour

and practices in the selected districts in Nepal.

The report is structured as follows:

Section 1 provides context and background to the project and research, and shows how poor

WASH is contributing to poor nutrition in Nepal. Section 2 documents the WASH behaviours

and practices of adults and children in households and in schools in the research sites, and

the barriers they face to taking up improved WASH practices. Section 3 summarises the

nutrition behaviours and practices present in the research sites, and the barriers families

encounter to ensuring adequate nutrient intake for adults and children. Section 4 documents

the findings of school observations and parents’ reflection on school meals. Section 5

presents research participants’ media preferences and their sources of WASH and nutrition-

related information. It also provides data on overall media usage in Nepal, including that

acquired outside of this piece of research and/or from other sources. Section 6 recommends

WASH and nutritional behaviours that could be prioritised in future communication strategies

and highlights drivers of change that can influence people to alter their existing practices. It

also outlines important considerations for developing such communication strategies and

offers suggestions on how media could contribute to these.

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1.1 Project background

1.1.1 Nutrition and WASH in Nepal

At the project’s outset, undernutrition was a very real prospect for many children in Nepal,

particularly for those living in the country’s food-insecure Mid and Far western regions.

Nepal’s most recent demographic health survey, conducted in 2016, showed that 36 per cent

of children under the age of five were stunted (much higher than 20 per cent, the level at

which stunting is considered a public health problemi), 10 per cent were wasted and 27 per

cent were underweight. Stunting was also more common in rural than urban areas (40 per

cent compared with 32 per cent), and in the mountain zone – and was least common among

children with more educated mothers and who were from wealthier families. Nonetheless,

both stunting and the proportion of under-fives that were underweight had declined since

the previous survey in 2001, falling from 57 per cent and 48 per cent respectively. Wasting

though, remained unchanged. ii

As regards WASH at the project’s outset, Nepal’s 2014 Multiple Indicator Cluster Survey

indicated that 93 per cent of households were using water from improved sources for drinking

water and that only 14 per cent of the households lacking access to safe drinking water were

treating their water to purify it. It also showed that: 60 per cent of households were using

improved sanitation facilities that were not shared; 48 per cent of children under the age of

two’s last stools had been disposed of safely; 72 per cent of households had a specific place

for handwashing where water and soap or another cleansing agent were present; and 95 per

cent of households had soap or another cleansing agent.iii WASH statuesque in schools is not

different – out of 27,174 public schools in Nepal only 21,437 have at least toilet facilities

Limited access to nutritious

food

Poor sanitation

and hygiene practices

Poor access to clean water

Stunting Wasting Underweight

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although those are often blocked and are not adequately maintained due to lack of skills –

skills that help in better management of water harvesting and skill to manage menstruation

hygienically – and budget in schools. Only 36% schools have separate toilets for girls and they

are often not user-friendly due to improper hygienic facilities. In addition, most schools lack

adequate facilities for handwashing with soap and for menstrual hygiene management.iv The

government of Nepal was visibly committed to improving WASH practices through its

National Sanitation and Hygiene Master Plan (2011-2017). Employing a community-led total

behaviour change approach, this plan aims to achieve hundred per cent total behaviour

change status across all of Nepal’s 75 districts by 2017.

Research has shown that undernutrition is mainly caused by inadequate intake and use of

essential nutrients from food. v When the quality and quantities of these nutrients are

inadequate, immune systems do not function correctly, making human bodies more

susceptible to a range of life-threatening illnesses, as well as impaired physical and mental

development.vi Inadequate diet itself results from: limited nutrition-related knowledge and

understanding, unsupportive attitudes and norms at the household/community level,

insufficient access to a variety of nutritious food,vii and lack of access to WASH infrastructure

and facilities.viii The latter encourages the transmission of a number life-threatening infection

in children and adults, (for instance diarrhoeal diseases, polio, influenza and lower respiratory

tract infections), and contributes to malnutrition. Existing evidence supports at least three

direct pathways – diarrhoeal diseases, intestinal parasitic infections and environmental

enteropathy – and several indirect pathways – e.g. expending energy when walking long

distances to collect water, and diverting a mother’s time away from child care – between poor

WASH and undernutrition.ix,x Indeed, experts have identified poor WASH as one of the main

culprits behind Nepal’s stubbornly high undernutrition rates. xi The World Health Organisation

(WHO) estimates that poor nutrition contributes, directly or indirectly to 45% of child deaths

worldwide, often through weakened immune systems and increased susceptibility to diseases.

Undernutrition has severe and life-long impact on children’s physical, mental and social

wellbeing. It lowers productivity and cognitive ability thus hindering social progress.xii

As such, in 1996 the government of Nepal, in collaboration with WFP, launched the NSMP.

This aimed to increase school enrolment, reduce hunger, decrease gender disparity, reduce

school attrition, and increase nutritional intake among schoolchildren to reduce nutritional

deficiency. Beginning in 2015, the current NSMP cycle is using schools as a platform for

improving nutritional outcomes; it is providing meals, improving sanitation and hygiene

infrastructure, and delivering education and behaviour change information. It thus

incorporates school-led total sanitation, a concept whereby schools are recognised and used

as a core entry point for promoting and creating awareness about improved sanitation

practices.

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Nutrition and WASH: key terms

WASH typically refers to the practices, behaviours and physical infrastructure necessary to maintain health and prevent illnesses or diseases, and comprises of the following three components:

1) Water. Access to sufficient amounts of water that is safe to drink, i.e. protected from faecal contamination and/or treated.

2) Sanitation. A clean environment: one in which human excreta (including urine and babies’ and children’s faeces) are hygienically separated from human contact and where solid waste is safely disposed.

3) Hygiene. Broader household and/or community-level cleanliness. Specifically, handwashing with soap at key times (e.g. after using a latrine or before feeding a child), safe food handling, storage and cooking practices.

Globally, improvements in WASH are measured by the proportion of a population with access to an improved drinking water source and an improved sanitation facility. However, as yet, there is no formal indicator for measuring improvements in handwashing. Instead, this is usually assessed by the number of people reporting handwashing with soap at certain important times.

Nutrition refers to the quality and quantity of food people eat in relation to the body’s needs. There are six types of nutrients that the human body needs to get from food: protein, carbohydrates, fat, fibre, vitamins and minerals. Fruits and vegetables rich in vitamin A (such as carrots, mangoes and sweet potatoes) should be eaten daily with meat, poultry, fish and eggs consumed as often as possible. Fats should be eaten occasionally.

Malnutrition is most commonly used to refer to undernutrition. But, it can also refer to overnutrition, i.e. obesity or being overweight.

Undernutrition occurs when the body’s requirements for nutrients are unmet as a result of under consumption or impaired absorption of nutrients – both of the macro (fats, carbohydrates and proteins) and micro (vitamins and minerals) kind – and can be either acute or chronic.xiii

Indicators of nutritional status include:xiv

1) Stunting (low height-for-age) indicates chronic undernutrition. It usually occurs in the first five years of life and is permanent.

2) Wasting (low weight-for-height) indicates acute undernutrition. It can result in death and requires emergency intervention.

3) Underweight (low weight-for-age) indicates both chronic and acute undernutrition.

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1.1.2 How can media and communication improve health?

Media and communication can influence the factors that lead to changes in nutrition and

WASH behaviours and practices, the social norms that affect health, and the systems that

govern health policy. The body of evidence demonstrating this is ever expanding. For example,

a review funded by the United States Agency for International Development in 2014 found

that mass media campaigns can positively impact a wide range of child survival health

behaviours – particularly habitual behaviours such as washing hands with soap and

consuming foods rich in iron and vitamin A.xv Likewise, a recent systematic review found that

promotional approaches (including those containing media-based components) have been

effective in improving sanitation and handwashing behaviour both in the short and long

term.xvi

BBC Media Action’s own nutrition and WASH communication projects have also

demonstrated significant impact in changing periodical and habitual health behaviours in

different countries. For example, a TV drama and short factual discussion programme in

Bangladesh were able to reinforce knowledge, stimulate positive discussion and improve

motivation to take-up recommended practices related to maternal and child nutrition among

women and men in rural areas.xvii Similarly, a recent evaluation of BBC Media Action’s WASH

programmes in Kenya found that the radio shows improved knowledge and cultural attitudes

towards handwashing and resulted in the adoption of good WASH practices.xviii

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1.2 Project objectives and activities

BBC Media Action’s WFP-funded nutrition and WASH research and communication pilot

project sought to support local actors to create effective and evidence-based behaviour

change communication materials that would improve nutrition and WASH behaviours in

schools and households in Sindhupalchowk and Achham districts. Its ultimate goal was to

understand the barriers to and enablers of improved nutrition and WASH behaviours and

practices, and to make recommendations towards a communication strategy that would

shape audience-informed communication materials. The project focused on specific WASH

behaviours – such as handwashing with soap at critical moments, safely treating and storing

drinking water, and using latrines – and adequate nutrition for children aged five to 15 in

Nepal.

To develop understanding on how communications can support improved nutrition and

WASH outcomes in the project’s two sites, BBC Media Action undertook the following core

activities:

1. Formative research to identify children’s and communities’ existing WASH and

nutrition behaviours, and the barriers that existed to the uptake of healthier

practices in the two districts. This also sought to ascertain how the NSMP was

operating in schools in the study areas, and to identify communities’ perceptions of

this programme.

2. Ongoing training and mentoring of two local radio stations (Radio Ramaroshan in

Achham and Radio Sindhu in Sindhupalchowk) to support them in generating

audience-informed communication materials that would encourage communities to

take up improved WASH and nutrition practices. To date, the stations have produced

and broadcast eight public service announcements (PSAs) – all based on the initial

findings of the formative research – that will also be aired during school WASH clubs.1

In addition to these, BBC Media Action communication experts reviewed different

communication tools produced by various organisations working with WFP to

support NSMP and offered advice to improve those products.

1.2.1 Formative research methodology

BBC Media Action researchers designed the qualitative research and the study instruments.

It commissioned Nielsen Company Nepal Limited, a Nepal based research agency, to conduct

data collection and data management, and fieldwork was conducted in the two districts

between June and July 2017. This qualitative study used several data collection methods:

1 WASH clubs are groups established in schools and run by teachers and students jointly, to provide students with the information and skills require for improving their sanitation and hygiene practices.

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• Situational observations. School-based observation focused on understanding the

NSMP and associated operational issues in 20 schools and included observing: the

storage, preparation and distribution of school meals, the WASH facilities available in

the schools, and students’ WASH and nutrition-related practices. It also included

interviewing gatekeepers – such as members of school management committees,

food management committees and members of the WASH clubs – to validate

observational findings. Meanwhile, community-based observation involved transect

walk in the communities and household observation, as well as interviews with

parents and other childcare providers and with community health volunteers in two

communities to better understand households’ nutrition and WASH practices.

• Focus group discussions (FGDs) with parents of school going children from two study

sites. The agency conducted a total of 12 FGDs with mothers and fathers of children

from both districts.

• Key informant interviews (KII) with government official from the District Education

Office (DEO) and a member of FFEP ( Food for Education programme) unit to learn

more about their views of the NSMP.

BBC Media Action researchers analysed the data and produced this report. Any differences in

knowledge, attitudes, practices, norms and available facilities between study sites are

reported, while similarities are mentioned generally. Further detail about the research

methodology and sampling used is available in annex 1.

1.2.2 Strengths and limitations of the research

This research used the aforementioned qualitative methods to triangulate data and ensure

high-quality and meaningful findings. However, the findings documented in this report only

pertain to the practices of the research participants and cannot be generalised to the entire

population of the two districts. The research did, nonetheless, try to document the norms and

attitudes of wider communities where the data supported such analysis.

The school-based observations were conducted purely to gain a greater understanding of

WASH practices therein. The schools and their meals programmes were neither evaluated nor

monitored. It is important to note that many schools in Sindhupalchowk were still under

construction during the fieldwork and that this may have impacted the WASH practices of

children attending those schools. The research was limited to documenting families’ and

school-going children’s behaviour and practices related to the food they consumed and the

frequency of such consumption. The research methods utilised were unable (and not

intended) to assess the quantity of food provided to children, nor its ability to meet their

nutritional requirements.

BBC Media Action provided extensive training to all field researchers on data collection

techniques and child protection policy. However, a key learning of this research methodology

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was to ensure that research freelancers have enough and adequate thematic knowledge

before conducting research as there were some challenges with ensuring appropriate levels

of probing of respondents to ensure detailed data. Moreover, data management and

transcripts were prepared by the agency commissioned. IDIs in school and in the communities,

were conducted as part of situational observations. Those interviews were not recorded -

thus the transcripts were not produced. Findings of IDIs were documented in the observation

sheet and analysed along with all other observation data.

Although the study sought to conduct FGDs with parents of school going and non-school going

children, researchers struggled to recruit the latter as school enrolment was very high in the

two research sites. Thus, they were only able to carry out FGDs with parents of school going

children.

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2. FINDINGS: WASH PRACTICES AND BARRIERS

Figure 1: Map of Nepal showing research sites

Achham district

Sindhupalchowk district

Note: Sindhupalchowk district is highlighted in yellow and Achham in red. Red circles in the district maps show selected VDCs where fieldwork took place.

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2.1 Water

Practice: communities’ water sources and collection methods

Observation revealed that residents in both project sites use water from improved sources;

in Sindhupalchowk communities mainly rely on piped water, and in Achham they mostly turn

to the river and springs. In some research sites in Sindhupalchowk and Achham, communal

reservoirs had been constructed near these water sources. FGD participants explained that

water is distributed from these sources to different community-level taps that are, in turn,

used by households. They described how households in some communities had arranged for

pipes to draw water from the communal taps directly to their premises. Participants also

noted that households, primarily adult women, mostly collect drinking water from the

reservoir using Ghagris (pots), which they store at home in a place accessible to both adults

and children. In Achham, participants said they collect water upstream of the sources to

ensure the water is not contaminated.

“The water sources are clean as they are situated uphill, far away from the

community. So, they are not contaminated by human and animal waste. Therefore,

the water we drink is safe.”

Fathers’ FGD participant, aged 32-40, Achham

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Knowledge and understanding: the importance of safe drinking water and water treatment

Research participants in both sites seemed to be aware of the salience of safe water,

particularly for drinking. Some parents in Achham also knew to use clean water for household

work such as cooking and cleaning. They mentioned gaining such awareness from different

WASH campaigns delivered by non-governmental organisations (NGOs) and government

bodies. Observation in both districts found that some of the households of communities

situated near to rivers and streams were using surface water for their animals, to wash clothes

and utensils, and in their toilets. However, they were not using it for drinking or cooking.

Participants were also generally aware that water can be contaminated by humans and

animals. To keep the reservoirs clean, their surroundings had been built from concrete, and

the reservoirs were covered or closed – thus, preventing animals from accessing them and

waste from polluting the water – and cleaned every three months. Participants reported using

different water sources for feeding and bathing livestock (mainly surface water) and not

disposing of human and animal waste into waterbodies. Men in the FGDs also reported that

drinking water sources (including those that are piped) in both districts become polluted and

unusable during the rainy seasons.

“The water source that we use for drinking is not usable during the rainy season.

So, we have to depend on another source, which is far [away from our village].”

Mothers’ FGD participant, aged 24-30, Sindhupalchowk

Research participants knew how to treat water to make it safe for consumption. All

participants listed boiling, others mentioned sunlight, and a few knew about purification via

tablets or chemicals and about filtration. Female respondents specifically mentioned using a

piece of cloth to filter water when collecting it from sources or taps. However, in practice,

many FGD participants did not know how to treat water properly (e.g. how long they should

boil or keep it in the sun for).

Many were also aware of the health hazards of drinking unsafe water. However, they only

reported diarrhoea as an adverse outcome.

“Drinking water should be filtered. If it can’t be filtered, it should be boiled or kept

under sunlight.”

Fathers’ FGD participant, aged 31-44, Sindhupalchowk

Knowledge and understanding: how water can become contaminated

Despite this, most participants were unaware of many of the ways in which the water they

drink every day can become contaminated. For example, many did not know about the

invisible threats (i.e. microorganisms) water contains, suggesting that their perception of

safety depends on the visible cleanliness of water sources and the water itself. Parents

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confirmed this during group discussions: several from Sindhupalchowk reported cleaning

reservoirs when they are dirty and using cloths to filter visible dirt from their tap water, and

only a few from one group in Achham mentioned that water contains invisible germs.

It is unsurprising then that some participants reported washing filtration cloths with water

collected from nearby (and unclean) ponds or canals for housework – a practice that can

induce contamination and make drinking water unsafe. Similarly, while respondents were

aware of the importance of collecting and storing water in pots, and of cleaning these

containers daily, they did not know that they should use safe water to clean such household

utensils if they are to avoid the threat of contamination.

Attitudes and beliefs: reluctance to treat water

Despite knowing that the water they consume may not be safe to drink and being aware of

different ways of treating this water, many parents reported not making enough effort to do

so and said that boiling and purifying water destroys its taste.

“Although we are aware that the source is not clean, we still don’t boil the water.

We drink it directly.”

Mothers’ FGD participant, aged 24-30, Achham

Findings from FGDs suggest that such reluctance to treat water may be based on a (somewhat

unfounded) sense of security garnered from the fact that generation after generation have

used water from the same source as themselves without becoming ill. Therefore, the belief

that there have been no major waterborne diseases in the recent past appears to be shaping

practice. It also suggests that participants do not consider diarrhoea, which occurs regularly

in their communities, to be a waterborne disease; such an affliction appears to have been

normalised due to its frequency of occurrence.

Lack of resources and time

Observation revealed that most men and women living in these two districts are farmers and

work hard to yield a good harvest. Thus, they have limited time for cooking and for other

household tasks such as boiling water. FGDs revealed that the majority of households in

Sindhupalchowk lost their taps in the 2015 earthquake and, as a result, spend far longer

collecting water than before. Consequently, they cannot afford further time to boil and cool

this water. The study also found that the cost of fuel is an additional barrier to boiling water,

and that participants only have limited stoves and prioritise using these for cooking meals.

Furthermore, because water filters and purification tablets are not readily available, nor are

they affordable for most, many people remain unaware of (and so do not use) these water

treatment options. Indeed, only a few research participants reported ever having used

purification tablets; this was when they had been distributed by NGOs after the earthquake.

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2.2 Sanitation

Practice: using improved facilities

All the communities observed during the formative research had already been declared ODF.2

As such, the core sanitation-related challenge they faced during the project’s lifetime was

ensuring they did not revert to open defecation in the aftermath of the earthquake that had

destroyed most houses and toilets.

Though research revealed that most households in the study sites have access to toilet, it also

found that open defecation remains to a certain extent. Participants saw no issue with

children defecating in the open – probably due to a lack of understanding that children’s

faeces are equally or more harmful than adults’ – and reported that adults working in fields

do the same as there are no nearby toilet facilities and going back home to use the toilet is

time-consuming.

“Even though people have toilets at home, sometimes while they are at work

they defecate in open.”

Mothers' FGD participant, aged 26-30, Sindhupalchowk

2 Achham district achieved this status in 2016 and Sindhupalchowk is due to follow suit by the end of 2017.

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Nonetheless, both observation and FGD findings suggest that people in the study sites

strongly prefer using toilets. For example, despite losing their toilets during the earthquake,

respondents from Sindhupalchowk reported avoiding defecating in open and instead sharing

toilets with their neighbours with the view to building their own as soon as they are back on

their feet.

However, other factors such as water scarcity pose a major challenge to maintaining

improved sanitation practices. During the dry season (November to May), water scarcity rises

and people prioritise drinking and other household needs over using water in their toilets.

Findings from both the observation and FGDs suggest that almost all toilets in the two study

sites lack running water and instead store the water they require for such activities in buckets.

Research participants in Achham highlighted that insufficient water is particularly problematic

in the school setting, leading to dirty toilets and, consequently, to students (especially boys)

resorting to urinating in the open.

“Our neighbours have toilet facilities but, due to insufficient water, some

people don’t use them.”

Fathers' FGD participant, aged 21-30, Achham

Table 1: Toilet facilities in the schools

Achham Sindhupalchowk

Available toilet facilities

In 7 schools - at least one functioning toilet

All 10 schools – at least one functioning toilet

Separate toilets for girls

In 5 schools In 9 schools

Toilet cleanliness In 3 schools – toilets were found clean

In 7 schools – toilets were found clean

Water facility in/near toilets

In 5 schools – Tap water in toilets In 2 schools – carry water form well or nearby sources In 3 schools – no water

In 6 schools – tap water in toilets In 4 schools – carry water form nearby sources

Handwashing materials in/near toilets

In 4 schools – soap in/nearby toilets In 2 schools – soap kept in the teachers room In 4 schools – no soap or handwashing materials available

In 4 schools – soap in/nearby toilets In 1 schools – use ash, no soap In 5 schools – no soap or handwashing materials available

Practice: safely disposing of children’s faeces

As aforementioned, children defecating in the open was observed across the research sites,

both due to societal norms and poorly functioning school toilets. Several households asserted

that infants’ faeces are normally disposed of in toilets, but acknowledged that sometimes

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they are too busy to do so and instead wipe the infant and throw the waste away. However,

researchers observed improper disposal of infants’ faeces around dwellings and washing

areas in all the research sites.

Knowledge, understanding, attitudes and beliefs: safe child stool disposal and children’s toilet

usage

Research participants were unaware of the importance of safely disposing of their children’s

faeces and of how to do so. Very few parents considered this as an important WASH practice,

incorrectly perceiving children’s faeces to be less harmful. This, in turn, appears to have led

to a norm of children defecating in the open and parents unsafely disposing of their children’s

faeces. Indeed, the research revealed that parents seemed reluctant to ensure their children

use toilets – perhaps because they are busy working in the fields and have entrusted childcare

to other (mainly older) members of the family. Nonetheless, some FDG participants felt

parents should endeavour to make sure their children do not defecate in the open and said

they needed to monitor their children’s practices more closely.

Practice and understanding: managing solid waste

The study found that most communities are aware of the impact of disposing waste

unsystematically and are endeavouring to keep their surroundings clean. For example, people

collect biodegradable waste in a pit separately, or along with animal excreta, to turn it into

manure. They also pile non-biodegradable waste in a pit near the house and either burn or

bury it. However, discarded waste was also visible in open spaces and, despite composting

being prevalent in the two research sites, respondents from Sindhupalchowk mentioned that

solid waste (especially that originating from markets) is often dumped near the river.

Visible dirt – especially solid waste and its impact on general cleanliness and hygiene – has

been a core part of the government of Nepal’s ODF campaign. Promisingly, researchers found

understanding of the faecal-oral contamination route present across the two research sites.

“Some people have cattle sheds right in front of their houses that are cleaner than

their houses. The municipality has [delivered] awareness programmes. It has taught

us that proper management [and/or] disposal of sewage [and/or] garbage makes

our environment cleaner and safer from airborne diseases carried by insects such as

mosquitoes. We are practising good habits for a safer, clean environment.”

Mothers’ FGD participant, aged 24-30, Sindhupalchowk

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2.3 Hygiene

Practice: washing hands with soap at home and in school

Observation revealed that people in two study sites are aware of the importance of

handwashing, largely due to the concerted effort of the media and to the community

meetings organised by family and community health volunteers and other NGOs, e.g. the Ama

Samuha (Mothers’ Groups).3 The study found that the traditional ways of washing hands (i.e.

using ash, mud or hay) have been mostly replaced by the use of soap, something most Nepalis

can afford to purchase. Many participants said they wash their hands if they are visibly dirty,

and most reported washing their hands with soap before eating and after defecating.

However, observation showed that the majority were not using soap at these critical

moments, nor after cleaning babies’ or children’s bottoms post-defecation.

Most parents in two study sites that participated in FGDs agreed that children do not wash

their hands unless their parents or other carers remind them repeatedly and monitor this

practice closely. As parents in both study areas work in the field during the day and have

limited time for child care, children rarely wash their hands at home at all, let alone use soap

for this purpose. Parents were confident that teachers reinforce and strictly monitor such

processes at school. However, researchers observed this was not the case: there was a strong

lack of handwashing in schools – both after using toilets and before eating meals – and

particularly poor or no monitoring of the practice by teachers.

3Ama Samuha sees women come together to form group and engage in development related activities, awareness creation etc.

23 | P a g e

Lack of resources

Observation highlighted serious gaps in terms of the availability of water and soap for

handwashing in schools. The location of handwashing stations and the presence of soap

varied (see table 1), with soap being available at designated handwashing locations in six

schools and at school offices in another two (though this was only to be used before meals).

Children primarily used water alone when washing their hands before meals; researchers only

observed handwashing with soap by most children in three schools.

Table 2: Availability of soap for handwashing in schools

Sindhupalchowk Achham

Soap observed near toilets/kept in an office 4 4 Soap used before meals 1 2 Handwashing occurred with water alone 8 5

Knowledge and understanding: the importance of washing hands with soap

Participants considered handwashing critical when dirt and odour were noticeable, after

using the toilet, before and after eating food, and after handling animal manure. However,

they were unaware of the following other key moments at which handwashing should take

place: after handling raw fish, meats and poultry; before and after preparing and serving food;

before feeding children; every time they clean a child’s bottom; and after blowing their nose

or sneezing.

For the most part, they also described handwashing as rinsing their hands with water. None

of the participants knew how to wash their hands properly with soap; for example, they did

not know how long to rub their hands with soap, nor that they needed to rinse their hands

with clean water. However, parents in Achham reported that schoolchildren are taught about

handwashing at school and thus have greater knowledge than them about handwashing

processes.

Motivation and social norms: lack of perceived benefits

Some male participants in Achham reported that soap does not kill germs, but instead only

removes dirt. Thus, despite being able to afford soap, they – and many others in the two study

sites – do not feel it is a necessary expense; they perceive little to no benefit in using soap for

washing their hands.

Norms likely play a role in such perceptions. Participants mentioned that older family

members are particularly reluctant to use soap when washing their hands and, as these

individuals often provide childcare during the day, other people and children watch this and

learn that it is socially acceptable to do the same.

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3. FINDINGS: NUTRITION PRACTICES AND BARRIERS

Practice: food habits and preparation

Food habits were found to be similar across the research sites (see table 2), with female

members of households preparing food in the morning and evening. Firstly, they prepare food

for their children before they go to school and tea for the adults, as well as a light meal for

those working in the fields. Then they cook lunch (which is eaten around noon), light snacks

for the evening, and a larger meal for the night. Farming parents’ cooking practices are

determined by the time available to them; they reported being unable to invest time in

cooking several meals during the day. As such, children eat the same meals throughout the

day.

Table 3: Research participants’ dietary habits

Achham Sindhupalchowk

Food items regularly consumed

Morning: roti (bread made from wheat, millet, maize flour or beaten rice) Afternoon: rice and pulses with vegetables, maize and bhatmas (soya) Evening: bread with tea and bhatmas (soya) Night: rice and pulses with vegetables, ghee rotis and honey rotis

Morning: tea and roti made from local wheat flour (for those working in the fields) and rice and seasonal vegetables (for schoolchildren) Afternoon: rice, dhindo (a dish made from maize flour) and vegetables Evening/night: rice and vegetables

Weekly addition

Meat and fish Meat and fish

Food items prepared specifically for children

Infants: milk or curd Toddlers: softened pulses and rice

Infants: jwalo (porridge) and lito (a baby food made of flour, oil and sugar) Toddlers: milk and seasonal fruits, and doodh bhaat (rice with milk)

The study found that people in both districts mainly eat a carbohydrate rich diet with

vegetables, only consuming seasonal fruits occasionally, and derive their protein from pulses,

soya and legumes. They do not normally drink milk or eat dairy, and only occasionally or rarely

consume meat, chicken or eggs. Thus, animal protein, dairy and fibre, vitamins and minerals

from fruit constitute a major gap in their daily diet. Indeed, observation found that dairy,

poultry and meat are rarely available at local markets and, if they are, are very expensive. As

such, those who can afford to rear cows, goats or chicken to supply their family with milk,

25 | P a g e

eggs and meat, are frequently unwilling to sell these products. The variety of their diets is

further impacted by a lack of irrigation facilities that limits their ability to grow food items

during the dry season. Some FGD participants mentioned being able to grow a more limited

variety of vegetables compared to in the past; they did not state why this was. As the study

did not observe nor measure the quantity of food provided to children and adults (which is

also an important part of nutrient intake), it remains unclear if that poses an additional gap.

Knowledge, understanding, attitudes and beliefs: family nutrition

Almost all research participants were aware of ‘nutrition’ as a concept and had a positive

attitude towards family nutrition. During FGDs, parents particularly reported wanting to

ensure their children and family members eat nutritiously; women felt this more keenly than

men, likely because they are involved in cooking meals for their families.

FGD participants in two sites knew that different foods have different nutritional values and

named items they eat to acquire energy, protein, vitamins and minerals. Despite strongly

believing that their regular food habits provide them with adequate nutritional intake,

researchers found that participants’ meals were not sufficiently varied to do so. This suggests

that people are unaware of the importance of having a balanced and varied diet.

“We don’t know the names [of nutrients], but most of the products we eat give

us energy and [the] necessary nutrients.”

Mothers' FGD participant, aged 25-30, Sindhupalchowk

Research participants thought that the foods grown or available locally were adequate for

their nutritional needs. Many parents said they have been eating similar foods for generations

and have been healthy doing so. They perceived their children to be healthy, though only in

terms of their physical development; they did not comment on their children’s cognitive

development. Research participants were unaware of the prevalence of undernutrition in

their communities, only considering extreme illness (i.e. disability) as being related to

undernutrition. Generally, they did not know or understand that a lack of a varied nutritious

diet can lead to reduced immunity to illness, increased susceptibility to disease, impaired

physical and mental development and reduced productivity.

“I have raised five children and none of them are disabled; one is slightly weak

and was injured during the earthquake. Apart from that, they have no major

health issues; none of my children are weak. A rich person has a delicious meal

every day, but the poorer child that makes meal out of stinging nettle's root is

sturdier. A good meal doesn't ensure a fit body.”

Mother’s FGD participant, aged 39-44, Sindhupalchowk

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4. FINDINGS: THE NSMP IN ACTION AND PARENTS’ PERCEPTIONS OF IT

The NSMP is implemented through two approaches: a food-based project supported by WFP

and run by the Food for Education Project under the Ministry of Education (MoE), and a cash-

based project run by the MoE directly (see figure 2). The former is active in 10 districts and

reaches around 270,000 children, and the latter is present in 19 districts (though intends to

spread to 57) and reaches around 330,000 children.

Figure 2: How the NSMP is implemented

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4.1 Observation of the NSMP in action in schools

Researchers observed how the NSMP was being implemented in 20 schools within the two study districts (i.e. 10 schools in Sindhupalchowk and 10 schools in Achham).

Resources, training and menus

In Sindhupalchowk, WFP provides perishable and non-perishablexix4 food items to the schools,

and meals are prepared according to the menu WFP has provided and which has been

prepared with primary school children in mind. In the schools observed, WFP had also

provided: cooking utensils, chefs’ uniforms (to maintain hygiene), training, and chefs. The

NSMP is managed by two local cooperatives in two different village development committees

(VDCs) who strictly follow WFP’s menu. The cooperatives supply raw materials – usually

locally produced goods such as maize, soya beans and flour – based on need. There is at least

one cook in every VDC, although mothers’ groups (assisted by school assistants) also prepare

food in some schools.

In Achham, WFP provides schools with non-perishable food items (such as sugar, oil and flour

for preparing lito) and cooking utensils of various sizes. Every day, school assistants – some of

whom have been trained by WFP directly and others who have received instruction from

principals that WFP had trained – prepare 110g of lito (consisting of 90g of flour, 10g of oil

and 10g of sugar) for each student up to grade eight.

Table 4: Food items prepared for and served to students

In Achham In Sindhupalchowk

Mahankal VDC Thulosirubari VDC Sun – Fri: Lito (a baby food made of flower, oil and sugar

Sun: jaulo (porridge) Mon: puri (deep-fried bread) and curry Tues: maize, soya beans and curry Wed: fried rice with mixed vegetables Thurs: roti (made from millet flour) Fri: meat and beatenn rice

Sun: boiled potatoes and curry Mon: jaulo Tues: maize, soya beans and curry Wed: meat and beaten rice Thurs: fried rice with mixed vegetables Fri: roti (made from wheat flour) and curry

4 Perishable foods include: meat, poultry, fish, milk, eggs and many raw fruits and vegetables. All cooked foods are considered perishable. To store these foods for any length of time, they need to be kept in a refrigerator or freezer. If refrigerated, they should be used within several days. Staple or non-perishable foods, such as sugar, dried beans, spices and canned goods, do not spoil unless they are handled carelessly. However, they will diminish in quality if stored over a long time, even if stored under ideal conditions.

http://food.unl.edu/safety/chart#refrigeratorhttp://food.unl.edu/safety/chart#pantry

28 | P a g e

Storage

Observation found that some schools receive supplies that will last a week, but that others –

particularly those that are in hard-to-reach areas, such as Urleni School in Sindhupalchowk –

receive supplies intended to last for as long as a month. As most schools lack separate storage

facilities, it also found that raw materials (both perishable and non-perishable) and utensils

are usually stored in wooden boxes that are placed in the corner of schools’ offices.

Preparation, serving and eating school meals

None of the schools researched observed have proper kitchen facilities and, thus, food is

predominantly cooked on traditional stoves located in open spaces outside (see figure 3).

Once cooked, the food is covered with a lid and kept near the stove. There are several

exceptions. Firstly, Kalika Adharbhut School in Achham keeps cooked food in plastic bags

because they lack serving dishes and have to cook meals in two shifts due to their pans being

so small. Secondly, some schools do not cover cooked food at all.

Students queue to receive food and are usually served on plates. Some schools provide

spoons, others do not. None of the schools observed have designated eating areas and, as a

result, children tend to eat wherever they can find space – including in classrooms.

Hygienic practices

Observation revealed that most schools’ cooks do not wash their hands with soap before

preparing and serving food. This is despite many of them in Sindhupalchowk mentioning that

WFP had provided them with such training. Researchers also found that plates and spoons

are not cleaned before meals and that food distribution is, in general, not hygienic enough.

Figure 3: Preparation, distribution and eating of a school meal

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4.2 Parents’ perceptions of the NSMP

Parents, particularly those who lack the time to prepare food during the day, said they

appreciate the NSMP as it helps them ensure their children receive adequate food and do not

feel hungry. Indeed, many parents were happy that the meal provided through the NSMP has

enabled their children – many of whom go to school without having had a proper breakfast –

to finish the school day, rather than leaving at lunchtime as they did previously. Parents from

Sindhupalchowk also said they like the different menu that the NSMP offers.

“Children prefer lito [to their old lunches]; they do not need to carry extra lunch with them. Children used to complaint about stomach aches, but now they are fit.”

Fathers’ FGD participant, aged 32-40, Achham

Overall, parents are positive about the nutritious food that the NSMP provides as they could

not afford to provide the same every day in their households. Parents in Achham also liked

that there appeared to be no gender-related discrimination in terms of the quantity of food

provided; age determines the amount of food children receive. Parents in both districts

particularly appreciated that the NSMP’s food management committees (FMCs) regularly

check to ensure about the food’s quality. Observation found that, in some schools, school

management committees (SMCs) invite parents to be involved in discussing and ensuring the

quality of school meals. However, FGDs revealed that many parents had not personally

inspected the food’s quality.

“Because schools provide nutritious foods (among other things), this encourages our children to go to school.”

Mothers’ FGD participant, aged 39-44, Sindhupalchowk

Parents also reported having been influenced and motivated by the NSMP. For example,

mothers said they know more about nutrition thanks to their children sharing learnings from

school with them.

Despite being satisfied with the NSMP, some parents raised concerns about how school meals

are cooked and thought that the food had caused ringworm in their children. Others

expressed concern about schools’ lack of storage facilities and the associated risks of

contamination (from rats or insects). Several parents who had accepted SMCs’ invites to

review schools’ cooking facilities reported being dissatisfied with the amount of smoke the

traditional stoves produced, citing fears that it could pose health hazards to children. A few

parents were particularly unhappy that children were involved in collecting the firewood used

for cooking school meals during their school hours.

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5. FINDINGS: NEPALIS’ INFORMATION SOURCES

5.1 Nepalis’ access to and consumption of media

People in the study areas have access to different traditional and new media platforms (see

figure 6). Radio is the most popular, and is the only platform available to many people who

live in remote hill areas. TV ownership is limited to wealthy families, resulting in low

viewership; however, those with access to a TV prefer this platform to others. Access to

newspapers is limited to those who are highly educated, while access to and usage of mobile

phones and the internet is growing fast among all sections of society.

Participants in the FGDs in Sindhupalchowk reported listening to Radio Melamchi and Radio

Sindhu the most, while their counterparts in Achham said they tune into Radio Ramaroshan

and Radio Triveni. Most participants in both sites reported listening to radio in the morning

(between 7 and 9am) and in the evening (from 7pm until they go to bed), though women tend

only to tune in in the evening as they are busy with housework earlier in the day. Female FGD

participants mentioned that they like to listen to entertaining content, such as dramas and

music programmes, while men listen to these as well as the news.

Figure 4: Overview of media access of Nepal’s adult populationxx

Source: nationally representative survey (n=4,000), 2016.

5.2 Sources of information about WASH and nutrition

FGD participants highlighted that media is an important source of WASH and nutrition

information. They recalled listening to PSAs about handwashing during advert breaks

between radio programmes, as well as tuning into the radio programmes that discussed

WASH and nutrition, such as Bhanchin Ama (Mothers’ Know Best).

They additionally mentioned that NGOs’ campaigns (such as the large SUAAHARA nutrition

project) had played a vital role in providing people in two sites with information on WASH and

nutrition, especially post-earthquake. So too had health workers in Achham, who had

organised community meetings – e.g. the Ama Samuha (Mothers’ Group) – and undertaken

door-to-door visits to disseminate such information. Interestingly, research participants from

Sindhupalchowk did not mention these as information sources.

Parents said schools were valuable sources of information on handwashing, reporting that

their children brought the improved WASH behaviours they had learned in school back to

home and, in so doing, influenced parents and other family members. Researchers observed

97% have access

90% have access

83% have access

49% have access

37% have access

31 | P a g e

information, education and communication (IEC) materials – such as posters on handwashing

– in the schools they visited. However, they concurrently witnessed students practising poor

WASH behaviours.

Respondents from Sindhupalchowk were keen for information on: locally available nutritious

foods, practices that could be adopted in rural areas to improve nutrition-related outcomes,

and seasonal produce. They also indicated that they prefer to acquire information via

interpersonal communication than from radio programmes. Research participants from

Achham, meanwhile, wanted information on how to: clean their surroundings, treat their

water, keep their children clean, and cook and prepare nutritious food for their children.

The sources of health-related information that participants in the two research sites trust the

most are health workers, medical professionals and community elders. They mentioned that

including such individuals in media programming will help ensure the credibility of

information that is provided. Participants also indicated that inviting popular personalities

and local celebrities who have relevant backgrounds to disseminate health-related

information could be effective.

Figure 5: Trust on national and local institutions as sources of information on current affairs and politics xxi

Source: nationally representative survey (n=4,000), 2016.

Findings from a different (but also recent) surveyxxii that BBC Media Action commissioned

suggest that Nepalis trust their family members and friends most for information on current

affairs and politics, followed closely by their local chiefs or village elders (see figure 5). They

also indicate high trust in government officials – which perhaps supports this formative

research’s findings concerning trust in health workers – and relatively high levels of trust in

media sources (barring the internet).xxiii

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6. RECOMMENDATIONS

6.1 Behaviours to prioritise and drivers of change to target

These formative research findings have highlighted the key drivers of change that media and

communication can influence to lead to improved WASH and nutrition behaviours and

practices in Achham and Sindhupalchowk districts. Thus, this report suggests the following

behavioural and communication objectives are pursued:

1. Encourage families and school officials to treat water before drinking by:

• Shifting their perceptions around natural source equals clean water by increasing their

knowledge and understanding about what makes water dirty (i.e. visibly clean water

does not mean that it is safe water)

• Increasing their knowledge and understanding around the links between drinking

clean water and health – specifically, that safe water can prevent illness and diseases

• Increasing their knowledge and skills around how long to boil water to make it safe for

drinking (i.e. one minute is enough unless one is living at elevations above 6,500 feet,

in which case this rises to three minutesxxiv) and other alternative water treatment

methods (e.g. purifying tablets etc.)

• Motivating them by showing them that the cost of treating water outweighs the cost

of treating illness related to drinking unclean water

• Motivating them by portraying a sense of pride in looking after their families’ health

• Motivating them to use improved cook stoves by showing them that boiling water

using one of these will reduce their fuel consumption and improve their health

because it produces less harmful smoke

• Showing other people in their community purifying or boiling their water before

drinking

2. Encourage families to use cleaner and safer water for all household activities by:

• Increasing their knowledge and understanding around the links between open

defecation and unsafe disposal of faeces and contamination of surface water

• Increasing their knowledge and understanding around the links between using

surface water that may be contaminated with faeces for cleaning their

house/household items and illness and diseases

• Enabling community discussion on the issues and solutions around water access and

usage

• Providing a platform that enables participation by community members in the way

water services are delivered so that they can express their views and needs

3. Enable families and school officials to ensure that children do not defecate in the

open and to safely dispose of younger children’s faeces by:

• Shifting the perception that children’s faeces are less harmful than adults’

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• Shifting the norm that it is acceptable for children to defecate in the open by role-

modelling families like them ensuring that their children always use the toilet because

of the benefits to their health and wealth

• Increasing their knowledge and understanding about the dangers of children

defecating in the open or not disposing of a young child’s faeces properly on their

health and environment

• Increasing their skills around how to clean a baby’s or young child’s bottom properly

and how to dispose of the waste safely

• Motivating them by showing them the benefits (i.e. health and pride) of children using

toilets

4. Encourage communities to safely dispose of solid waste by:

• Increasing their knowledge and understanding about the dangers of unsafe disposal

of solid waste on their health and their neighbours

• Motivating them by showing them the benefits (i.e. pride and wealth) of disposing of

solid waste safely

• Increasing their skills around how to safely dispose of solid waste

• Enabling discussion between communities and leaders on the issues and solutions

around safe disposal of solid waste

5. Enable parents, teachers and children to wash their hands with soap at all the critical

times5 by:

• Increasing their knowledge and understanding around what the most important times

for handwashing with soap are

• Increasing their knowledge and understanding that not washing their hands with soap

(i.e. water alone is not enough) at all the critical times (i.e. not just after defecating or

before eating) can cause sickens such as diarrhoea, colds, coughs, skin infections etc.

• Showing that other people in their community and school are washing their hands

with soap at all the critical times

• Motivating them by portraying a sense of pride in looking after their hygiene

• Enabling discussion between children and parents and children and teachers about

handwashing with soap at critical times

• Providing reminders (e.g. songs, posters, stickers etc.) so that they remember to wash

their hands with soap at all the critical times

• Increasing their skills around how to wash their hands properly

5 Critical times include: after using the toilet and after cleaning the bottom of a baby or child who has just defecated; before preparing, serving or eating food and before feeding children; before and after handling raw meat, poultry or fish; and after blowing one’s nose or sneezing.

34 | P a g e

6. Encourage parents and teachers to always have soap available at designated

handwashing areas by:

• Increasing their knowledge and understanding that ensuring soap is always available

at designated handwashing places at school and at home is key to ensuring that

everyone can wash their hands properly

• Motivating them by showing the benefits (i.e. pride and health) of monitoring that

children always wash their hands with soap at all critical times

7. Encourage teachers to ensure school meals are prepared and served in a hygienic

way and using utensils by:

• Increasing knowledge and understanding of school staff and parents involved in

preparing school meals around hand washing with soap before preparing and serving

food

• Motivating teachers and parents by highlighting the benefits (i.e. pride and health) of

cleanliness and hygiene practices around food preparation

• Motivating teachers and parents to use improved cook stoves by highlighting dangers

of smoke to children’s health

• Increasing skills of school staff in serving food in hygienic way and using proper utensils

and encouraging new habits

8. Enable families to eat a more varied diet by:

• Increasing their knowledge and understanding around the different food groups (i.e.

which these are and their nutritional values)

• Increasing their knowledge and understanding that including different types of food

in their children’s diet will ensure that they grow and thrive

• Enabling discussion around healthy eating, food, and financial and agricultural choices

• Motivating them by portraying a sense of pride in looking after their families’ health

• Building on their current cooking practices by increasing their skills in safely handling

and preparing a variety of food from local sources

• Showing how other people in their community prepare a variety of food from local

sources, for the whole family

• Motivating them to use improved cook stoves by showing them that using one of

these will help them cook a variety of food quickly

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6.2 Building a media and communications strategy

The previous section gave examples of the types of communication objectives that could

underpin a response to the behavioural barriers identified in the study. However, effective

WASH and nutrition communication needs to move beyond the idea of health communication

as top-down “messaging” to something that encompasses dialogue and respects the opinions

of those most affected. The best behaviour change communication interventions carefully

analyse and strategically design responses that consider many other factors. As such, this

section provides an overview of factors that need to be considered when designing SBCC

content, and makes practical recommendations for what effective communication might look

like in Achham and Sindhupalchowk.

Audience segments

It is important to consider who a project’s specific influencers are and, therefore, which group

a project is going to target with which communication objective. For example, an objective

that is trying to influence mothers’ behaviour will use a different approach to one trying to

influence teachers’.

Based on the formative research’s findings, this report recommends that parents, as the

primary caregivers of children and decision makers of family nutrition, should be targeted as

a key audience segment. As the research also found that other caregivers (such as older family

members) influence family nutrition and that teachers play a critical role in instilling WASH

behaviours in children and ensuring hygiene routines are implemented at school, this report

advises that such segments are also targeted as part of a holistic WASH communication

intervention.

Messengers

People need information from trusted sources. As different people trust different people, it

is important to consider who is giving the message in SBCC content in order to ensure they

are likely to gain traction with the target audience. Depending on the message a project is

trying to provide and the approach it has chosen to take, this could vary from religious or

community figures to friends or family.

As participants in the study areas trusted health workers, medical professionals and

community elders the most to provide them with health-related information, these should be

the primary messengers of SBCC materials. It is likely that the additional influence of family

and friends recommending particular practices would increase the impact on day-to-day

practice of the behaviours being targeted by SBCC materials, so such individuals could be

helpful in reinforcing messaging.

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Motivational and emotional drivers

The motivational and emotional drivers that might inspire or encourage a project’s target

audience to adopt different practices are critical for behaviour change. The most commonly

used motivator for WASH communication at the local level is still ‘health’, which, although

sometimes important, is rarely a sole trigger for behavioural change. In fact, communication

based on germs and health have, in many cases, been found to be ineffective.xxv Furthermore,

evidence from formative research studies conducted in various countries shows that social,

physical and emotional drivers (e.g. pride, loss of face, convenience, comfort, habit etc.) are

some of the more important determinants of latrine usage.xxvi

BBC Media Action’s approach to health communication

BBC Media Action believes that health is influenced by many factors – some of which communication can influence, some of which it cannot. People’s health is determined by where they live, their society and their socio-economic position within it, as well as the health services that they can use. Critically, BBC Media Action believes that health behaviours are affected by people’s own attitudes and knowledge, as well as those of others around them. Its approach to health communication projects and research draws on academic and practitioner literature and guidance, as well as organisational experience in this field, including audience research. Further detail on the approach can be found in the organisation’s health communication guide, The Pulse.xxvii The drivers of behaviour change BBC Media Action’s projects harness the power of communication in diverse ways (from face-to- face, community-based interventions to mass media programming and digital), and often seek to influence the following 10 key drivers of individual, community and societal level health-related behaviour change: 1. Knowledge and understanding. What people know can lead to change and is

influenced by the information that they gather via media and communication. Accurate information is critical for individuals to understand which behaviours are positive for or risky to their health and to help them make informed decisions.

2. Attitudes and beliefs. Individuals’ feelings, thoughts and beliefs, perceptions and opinions are often deeply held (sometimes unconscious) and can affect how they behave. People with a positive attitude towards an improved behaviour are more likely to practise that behaviour.

3. Norms. The unwritten social and cultural rules and beliefs around behaviour,

attitudes and values that can influence what people do and men and women’s roles in society.

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4. Efficacy. Self-efficacy refers to one’s belief in his/her ability to do something given the resources available to and the potential obstacles facing him/her. Collective efficacy refers to the beliefs held by a group about their combined ability to make something happen.

5. Motivation. The drive to doing something. This is influenced by one’s confidence and self-efficacy. Motivation can be strengthened by many other factors, including perceived and/or real benefits and incentives.

6. Skills. Some behaviours (such as eating nutritiously) depend on having know-how and

skills. Broader than knowledge, skills can be both practical (such as knowing how to cook) and psychosocial (such as decision-making, problem-solving, critical and creative thinking and communication).

7. Observation. Humans learn and imagine how to behave, in part, by observing what

others do and the apparent consequences of those actions.

8. Discussion and dialogue. Research suggests people are strongly influenced by their peers/social circles and often need to discuss a new idea or behaviour – either in a one-to-one, small group or more public setting – before they fully accept, adopt or reject it.

9. Support. Individuals are easily and directly influenced by what those around them

think and do. Group support and encouragement around an issue that may just affect the individual is important for them to change lifestyle and habits such as giving up smoking or eating healthy.

Participation. Participation connects populations with service providers and policy-makers. Populations need platform to express their views and desires around issues (such as the way WASH and healthcare services are being provided) and, information and skills to participate better in decisions affecting their lives.

People are strongly influenced by what other people around them are doing or what they

think they are doing. These are the social or cultural norms that influence people to engage

with a particular behaviour, even when they do not agree with it. Indeed, this study found

that even when communities have knowledge about healthier WASH behaviours, they are

often not practised because the new practice is against the current accepted norm. Thus, this

report strongly recommends disrupting acceptance of existing norms around disposal of child

faeces, latrine use and times at which handwashing takes place, by using a strong emotional

driver and supporting and promoting social acceptance for the new norm and disapproval for

the old.

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Strong creative approaches

The creative approach and quality applied to communications, is much more important than

usually given credit for because it means that communications stand out in a market that is

saturated with health programming. It is what makes people take notice and discuss issues

with their peers. Creative approaches that often succeed in attracting and retaining attention

include: comedy, religious or moral sentiment, curiosity, novelty, authority or reverence,

and/or a strong emotional pull.

Therefore, this report recommends that any SBCC outputs take into account the creative

approach that will most attract the attention of the particular audience segment being

targeted. When planning a creative approach, this report recommends asking questions such

as: what motivates or moves this audience in their day-to-day lives?

Platforms and timings

Platforms determine how and when a project reaches its audience. Different platforms are

effective at achieving different things. For example, mass media, such as radio can be a good

way to introduce new ideas to large numbers of people, whereas face-to-face

communications can encourage sustained dialogue and discussion which is central to

achieving changexxviii and be effective at making an information or idea seem very personal to

s