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Water, sanitation, hygiene and nutrition in Nepal Informing and motivating communities to pursue healthier practices in mid- and far-western districts RESEARCH BRIEFING // APRIL 2020 A journalist from Radio Doti pre-testing a PSA on malnutrition among female listeners/BBC Media Action Introduction This research briefing presents three case studies that demonstrate how BBC Media Action used insights from formative qualitative research to create public service announcements (PSAs) in 12 districts of mid- and far-western Nepal. BBC Media Action worked with local radio stations to target specific listener groups to influence individual, community and societal behaviour in relation to water, sanitation and hygiene (WASH), including menstrual hygiene and nutrition. BBC Media Action carried out the research and project activities in these districts between 2017 and 2019 under the nutrition and WASH communication project funded by the The United Nations World Food Programme (WFP) and the United States Department of Agriculture (USDA). Water, sanitation, hygiene and nutrition in Nepal Since 1990 Nepal has made significant progress in improving WASH and nutrition, but practices remain poor in the country’s mid- and far-western regions. Lack of resources is a major impediment to improving WASH and nutrition practices in these two regions, along with poverty and difficult terrain. Unsupportive attitudes and social norms at the household and community level are also drivers of inadequate hygiene practices and malnutrition.1 For example, discriminatory gender norms such as the practice of treating menstruating women and girls as “impure” and confining them to menstrual huts, the practice commonly known aschhaupadi ,2 still exists in isolated rural areas. Barred from bathing or washing clothes in communal water sources, it is very difficult for women and girls to maintain basic hygiene during their periods. 1 The causes of malnutrition are complex. Inadequate WASH practices can lead to malnutrition, in part because repeated bouts of diarrhoea make it impossible for people’s bodies to absorb the necessary nutrients from food and also through the introduction of parasites including worms. 2 Chhaupadi is a social tradition for Hindu women in western Nepal, which prohibits them from participating in normal family activities during menstruation because they are considered impure. The women have to stay out of the house and live in a shed. This lasts 10–11 days when a girl has her first period and 4–7 days for every subsequent period. After giving birth women are also confined for 10–11 days. 2 RESEARCH BRIEFING // APRIL 2020 // HEALTH Poor diets, resulting from limited nutrition-related knowledge and understanding, and insufficient access to a variety of nutritious foods, are also drivers of malnutrition in these two regions. Figure 1: WASH and nutrition challenges in Nepal3 10.8 3.5 million million 16% do not have access to of the population do not have access safe drinking water practises open to improved defecation 4 and clean water for sanitation household use 36% of children under 5 are 20% of government schools stunted (too short lack improved water for their age), an and sanitation indicator of chronic facilities malnutrition The role of media and communication Media and communication can play a key role in influencing people’s nutrition and WASH behaviours and practices, such as washing their hands with soap and consuming foods rich in iron and vitamins. Using media to shift people’s behaviour requires a sound local understanding of people’s perceptions, attitudes, concerns, beliefs, knowledge, practices and the wider environments in which they live, study and work. It also involves understanding exactly why they have not yet changed their behaviour and what may enable them to do so. BBC Media Action’s projects harness the power of communication to influence 10 key drivers of individual, community and societal health-related behaviour change, as outlined in Figure 2.5 3 Data from UNICEF (2019) Water and Sanitation (WASH) [online]. Available from: https://www.unicef.org/nepal/water-and- sanitation-wash [Accessed 22 November 2019]. 4 Improved sanitation includes facilities that hygienically separate human excreta from human contact. World Health Organization (WHO) (undated) Water sanitation hygiene key terms [online]. Available from: https://www.who.int/water_ sanitation_health/monitoring/jmp2012/key_terms/en/ [Accessed 9 January 2020]. 5 BBC Media Action (2015) The Pulse Guide: Inspiring Health Communication [online]. Available from: https://bbcmediaactionilearn.org/course/view.php?id=138 [Accessed 11 December 2019]. RESEARCH BRIEFING // APRIL 2020 // HEALTH 3 Figure 2: Key drivers of health-related social and behaviour change Knowledge and Accurate information is critical for individuals to understand which behaviours are positive understanding or risky for their health and to help them make informed decisions. Individuals’ feelings, thoughts, beliefs, perceptions and opinions are often deeply held Attitudes and beliefs (sometimes unconsciously) and can affect how they behave. People with a positive attitude towards new behaviour are more likely to practise that behaviour. These unwritten social and cultural rules in a society influence people’s behaviour, attitudes Norms and values. For example, they can define men’s and women’s roles in society, and shape what women and men do and what they think others expect them to do. Self-efficacy is an individual’s belief in their ability to do something, given the available Efficacy resources and any obstacles present. Collective efficacy refers to the beliefs held by a group about their combined ability to make something happen. The drive to do something. This is influenced by a person’s confidence and self-efficacy. Motivation Motivation for positive behaviour can be strengthened by many other factors, including perceived and/or real benefits and incentives. Broader than knowledge, skills can be both practical (such as knowing how to cook) Skills and psychosocial (such as decision-making, problem-solving, critical and creative thinking and communication). People learn how to behave, in part, by observing what others do and seeing the Observation consequences of their actions. Research suggests that people are strongly influenced by their peers or social circles and Discussion and dialogue often need to discuss a new idea or behaviour with others before they fully accept, adopt or reject it. Support and encouragement from family, friends, community leaders, and so forth, can help Support people to make behavioural changes. People need to be able to express their views and desires around issues (such as the way Participation WASH and healthcare services are provided) and participate in decisions affecting their lives. Girls washing their plates after a school meal in Bajura district/BBC Media Action 4 RESEARCH BRIEFING // APRIL 2020 // HEALTH The project BBC Media Action collaborated with WFP from 2017–2019 to deliver the nutrition and WASH communication project in 12 districts of mid- and far-western Nepal. The goal of the project was to improve nutrition and WASH behaviours in schools and households by encouraging parents and school staff to work together to increase the uptake of healthier WASH behaviours. BBC Media Action sought to achieve this goal through training and mentoring local radio station partners to create, produce and broadcast PSAs to encourage positive behaviour change among audience members. The PSAs targeted schoolchildren and their parents and caregivers, as well as the wider community. They were designed to increase women and men’s knowledge, risk perceptions, discussions and supportive norms around WASH and nutrition by using emotional motivators and simple local language. Each project delivered by BBC Media Action is firmly rooted in rigorous research, feeding into a strong theory of change (ToC) and a set of clear and action-focused communication objectives. Starting with a pilot project in 2017, BBC Media Action undertook formative research across three years in 12 districts (see Figure 3), all of which are in provinces 5, 6 or 7 in Nepal’s western regions (except Sindhupalchok, which is in the central region). Figure 3: Project districts Province No. 7 Humla Darchula Province No. 6 Bajhang Mugu Baitadi Bajura Dadeldhura Jumla Doti Achham Kalikot Dolpa Kanchanpur Dailekh Mustang Province No. 4 Jajarkot Kailali Rukum (W) Rukum (E) KATHMANDU Manang Surkhet Myagdi Bardiya Salyan Baglung Rolpa Kaski Province No. 3 Lamjung Rasuwa Banke Pyuthan Province No. 1 Gulmi Parbat Gorkha Dang Syangja Tanahu Palpa Nuwakot Palpa Sindhupalchok Dolakha Nawal Dhading Rupandehi Parasi Kapilbastu Nawal (E) Bhaktapur Parasi Chitwan Province No. 5 Makwanpur Solukhumbu Taplejung (W) Lalitpur Kavre Sankhuwasabha Ramechhap Okhaldhunga Parsa Sindhuli Khotang Bhojpur Terathum Bara Panchthar Sarlahi Udayapur Rautahat Dhankuta Ilam Mahottari Dhanusha Siraha Sunsari Morang Province No. 2 Saptari Jhapa In 2017 the pilot project focused on WASH and nutrition issues. In 2018 and 2019 the project also focused on menstrual hygiene as a part of WASH, as recommended by WFP. RESEARCH BRIEFING // APRIL 2020 // HEALTH 5 BBC Media Action developed a project ToC using insights gained from the research. This steered the development of a communication framework to guide radio PSAs, as well as training and mentoring activities for more than 100 producers and technical radio crew in 11 local radio stations.

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