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. Using this framework, the radio producers and BBC Media Action’s mentoring team worked together to develop concepts and characters that matched the preferences of specific target groups. Appropriate drivers of change (see Figure 2) helped to simplify communication objectives and identify appropriate stories and behaviour change triggers for the PSAs.

Figure 4 illustrates how researchers, mentors and partner radio stations worked closely to produce and broadcast 79 PSAs on WASH and nutrition issues over the duration of the project.

Figure 4: Connection between project research and PSA production

RESEARCH • Formative research • Sharing research findings with production team • Communicating research findings with radio stations • Developing ToC and communication framework

STORY DEVELOPMENT • Finalising issues based on research findings • Content development, highlighting drivers of change • Scripting, music and dialogue

RECORDING • Casting • On-location recording • Studio recording

POST-PRODUCTION AND PRE-TEST • Editing • Pre-testing PSAs with target audiences • Incorporating feedback from pre-test • Finalising PSAs for broadcast

PSA BROADCAST

• Radio stations collecting feedback from audiences

6 RESEARCH BRIEFING // APRIL 2020 // HEALTH The research The formative research sought to gain a nuanced understanding of existing knowledge, practices, attitudes and social norms regarding WASH and nutrition within communities, families and schools, and menstrual hygiene practices. It aimed to identify the barriers to healthier WASH and nutrition behaviour and how these could be reduced and/or removed. The research involved using qualitative methods of data collection among the different target populations, as outlined in Figure 5.

Figure 5: Formative research data collection methods

Focus group Key informant Observations discussions (FGDs) interviews A total of 34 rural A total of 52 FGDS A total of 34 and urban primary were conducted representatives of and lower secondary with mothers and district health offices, schools were observed fathers of school-going community-based to understand the WASH children and adolescent organisations and WASH facilities available in girls and boys. officers were interviewed school, and WASH and to understand the overall nutrition practices. nutrition and WASH scenario within the districts.

Why radio? Although radio listenership in Nepal has decreased over the past few years (from 60% of the population accessing it daily in 2013 to 30% in 2018), it is still the most popular form of media available to women and men who live in the country’s western and far-western districts. In fact, it is often the only media form they access.6

With a proliferation of local language FM radio stations that are also available on smartphones, radio is one of very few ways to reach Nepalese people in their own dialect or language. Research also showed that adolescent girls and boys – key target groups for this project – have access to their parents’ and elder siblings’ mobile phones, and access to radios at home.

Radio PSAs were chosen as the preferred format as they can be produced relatively quickly and in multiple local languages. And their brevity means they can be incorporated into any outreach work in media “dark” areas.

6 Sharecast Initiative Nepal (2018) Nepal Media Landscape Survey 2018 – Topline Findings [online]. Available from: http://www.sharecast.org.np/224-2/ [Accessed 22 November 2019].

RESEARCH BRIEFING // APRIL 2020 // HEALTH 7 Case studies

1: Challenging harmful traditional practices around menstrual hygiene

Research insight The research showed that restrictive menstruation practices are entrenched in mid- and far-western Nepal. Girls described not being able to use family toilets and water taps for up to seven days a month, having to walk several hours to fetch water and having to defecate outside. They spoke of having to re-use cotton pads when menstruating, but appeared to have little knowledge of the consequences of inadequate menstrual hygiene, such as increased infection risk, if pads are not washed and dried thoroughly. As a result, girls reported that once they start their periods, good hygiene is much more challenging.

While both girls and boys feel chhaupadi practices are not right, they fear bad or evil consequences for their community if they do not abide by such restrictions. They are also uncomfortable about disobeying older relatives and community members who support this practice.

When my periods started my mother quickly took me to a chhaupadi hut, where I stayed for seven days, and I was barred from my regular activities… I was not allowed to use the toilet as normal and had to walk half an hour to the river to defecate and wash the used cotton pad. Teenage girl from Doti district

Research highlighted that role models are an effective way to address harmful traditional practices around menstruation.

Action based on research Radio Bajura used a real-life female role model to challenge harmful practices and norms around menstrual hygiene.

Target audiences: Women and girls, including community leaders Communication objective: Inspire women and girls to have the confidence to discuss their challenges during menstruation with their families and communities Motivator/enabler: Amplify the voice of an influential and trusted local role model to inspire women and girls to challenge traditions around menstruation

The Radio Bajura team developed a PSA featuring the real-life experience of the influential deuda7 singer and local Bajura politician Suna. In the PSA, Suna shares her experience of beginning to menstruate at the age of 16 while she was milking a cow. She recalled her initial concern that something bad could happen to her loved ones or community if she continued to touch and milk this sacred animal during this “impure” time.

7 Deuda (geet) is a Nepali genre of song and dance – the most popular genre in the project regions.

8 RESEARCH BRIEFING // APRIL 2020 // HEALTH However, she explained how she allowed her family to drink the milk and observed no bad consequences. In the PSA, she questioned the validity of traditions around menstruation that have been deeply rooted in religious beliefs for generations. As a political leader and role model, she discussed the importance of hygiene and of consuming a nutritious diet that includes dairy, meat and fish during menstruation.

A Bajura radio listener called the station and shared her opinion of its PSAs produced for this project:

I like the PSAs, especially on child nutrition, menstrual hygiene and sanitation. They are informative, entertaining, and because [they are] in our local language it is easy for us to understand. In the past, [because of embarrassment] we used to hide the cloth we used during menstruation in… the walls of our homes. After listening to the PSAs we are now aware of the risks of using unhygienic cloths and have started leaving them out in the sun to dry. Female radio listener, West Rukum district

2: Encouraging and motivating young women to nourish themselves adequately

Research insight Women, who are primarily responsible for preparing food in households, reported that they lack knowledge on the importance of food diversity and good nutrition. For example, young adult women are familiar with the word “nutrition” but they do not really understand what it means. They can link it to certain foods, for example the fact that spinach contains vitamins, but they do not connect how eating this can benefit their health.

Women also felt they have limited time to prepare varied meals because they bear the heavy burden of household chores and agricultural work. Younger women wanted to learn more about good nutrition, rather than being guided by traditional beliefs or practices.

Action based on research Radio Saipal in Bajhang district used drama to challenge the norm that women should put their family’s health and nutrition needs before their own.

Target audiences: Adult women Communication objective: Increase knowledge and understanding about the critical importance of consuming a diverse diet Motivator: Evoke a sense of empathy and reflect the real lives of Bajhang women to empower them to nourish themselves adequately

The Radio Saipal team developed a PSA that featured a short drama involving a young woman and her late mother who appears to her in a dream, concerned about her daughter’s poor health and diet.

RESEARCH BRIEFING // APRIL 2020 // HEALTH 9 The daughter explains that she prioritises her family and farm rather than her own well-being, so she has no time or energy to prepare nutritious food. Her mother shares her own experience of how she also struggled to nourish herself properly, leading to suffering during menstruation and perhaps also contributing to her death while giving birth.

The mother advises her daughter to use her home-grown greens and grains to make tasty and nutritious food for herself and her future children. When she wakes up, the daughter plans to discuss what she has learned with her family.

3: Informing communities about water contamination risks

Research insight Most communities use water from improved sources8 such as community reservoirs for drinking, washing, cleaning, cooking and bathing. But some communities fetch water directly from a natural source such as a spring well (locally known as a naula, kuwa or muhan) or river.

Project research highlighted that most people in the targeted communities were not aware of the possible risk of water contamination if it is not stored or managed correctly. Therefore, they did not recognise the value of ensuring the cleanliness of water reservoirs, pipelines and collection vessels.

Action based on research Radio Sudur Awaj of Dadeldhura district developed a PSA in the form of a short drama to raise awareness of the risks of unclean water.

Target audiences: Rural parents and caregivers Communication objective: Inform target audiences about possible points of water contamination, from the water source to the household Motivator: Amplify the voice and influence of an informed family to motivate community members to take collective action

The PSA drama showcased different members of a family experiencing the impacts of unclean water. In the drama, a farmer returns home from work to discover there is no fresh drinking water. His 14-year-old daughter tells him the water pipe is broken and the water tank is full of decayed leaves and animals such as frogs so the water is unsafe to use.

The mother arrives home carrying water she has collected, which she also says was dirty. The farmer links a recent diarrhoea outbreak in the community with the dirty water. He agrees to start a village discussion to motivate people to take action. The PSA’s concluding catchline is, “From spring water to home and from tank to the storage pot – maintain cleanliness at all possible points of water contamination.”

8 Water sources that, by nature of their construction, adequately protect water from outside contamination, in particular from faecal matter. 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]

10 RESEARCH BRIEFING // APRIL 2020 // HEALTH A local radio station in Achham district recording a PSA/BBC Media Action

Conclusions n Using research to understand different audiences and their specific WASH and nutrition practices and attitudes in the different project districts was highly beneficial. It meant that a strong ToC and actionable communication objectives could be generated, so that the final PSAs produced with partner radio stations were highly specific and relevant to the populations they aimed to reach. n Collaborating with local partners is an important factor in project effectiveness. In this project, the local media partners that produced the PSAs with BBC Media Action had an in-depth understanding of the target communities, which was further strengthened by the research insights. n The PSAs were able to make full use of the research for creative ideas as it explored not only existing WASH and nutrition practices and barriers to healthier behaviour but also identified what would motivate and trigger people to make positive behavioural changes. The research also helped to identify specific creative devices to motivate audiences and challenge norms, such as role modelling, personal testimonies and featuring diverse real-life stories. n Short PSAs are an effective format when working with partners who have few resources. They can also be used beyond the project lifecycle – including for outreach activities by other stakeholders, such as WASH officials and health professionals. Some stakeholders have already shown interest in contacting local radio stations to produce similar PSAs.

RESEARCH BRIEFING // APRIL 2020 // HEALTH 11 Acknowledgements This research briefing is part of the nutrition and WASH behavioural change communication project funded by WFP and USDA. Its content is the responsibility of BBC Media Action and any views expressed should not be taken to represent those of the BBC itself or any donors supporting the work of the charity.

The authors would like to thank all the respondents who participated in the research. They are also grateful to local radio staff, school staff, WASH facilitators and local government staff who provided unconditional support in collecting data in the 12 districts. Particular thanks go to Sabina Pradhan, Seema Gurung, Caroline L Sutcliffe, Emebet Wuhib-Mutungi and Shobhana Pradhan at BBC Media Action, and Umesh Chaudhary and the WFP Nepal team who provided significant support to the research and production of this report. Thanks also go to the rest of the BBC Media Action Nepal team for their valuable feedback. For more detailed results from the project, please contact BBC Media Action Nepal team.

Authors: Sanjib Saha, Astha Siwakoti and Bhabasagar Ghimire Contributors: Sally Gowland and Seana Lama Commissioning editor: Sonia Whitehead Editor: Katy Williams Copyeditor: Lorna Fray Designer: Marten Sealby

Cover image: A village in Doti district, Nepal/BBC Media Action

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Tel: +44 (0) 20 7481 9797 Email: [email protected] Web: bbcmediaaction.org

©BBC Media Action 2020

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