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(Journal Article) Strengthening behaviour change communication in western Nepal: how can we do better?
01.10.2015
The Government of Nepal aims to achieve full water and sanitation coverage by 2017. The bilateral Rural Water Supply and Sanitation Project in Western Nepal (RWSSP-WN) works with local governments in 14 districts, aiming to declare them open defecation free. This behaviour change communications evaluation explored how to improve RWSSP-WN’s present practices to reach the diverse target population in the Terai districts, where more than 1 million people still defecate in the open. The study reviewed RWSSP-WN’s present behaviour change triggering tools and related communications strategies. Our findings suggest that availability of subsidies seems to change how people think about sanitation and tends to eliminate willingness to pay for a latrine. We recommended strong advocacy for a no-subsidy policy, and more attention paid to alternative financing options with targeted support to the poorest of the poor. The present behaviour change triggering tools do work as intended, but there is a need to develop pre-triggering and post-triggering strategies to increase the overall impact. The pre-triggering strategy would ensure that potential barriers to change are identified and addressed before the actual triggering event, and that the key stakeholders are prepared for the actual triggering event. The post-triggering strategy is needed to continue motivating households to change via messages that tap into the drivers of change, addressing also the barriers which may keep each household from changing behaviour. This paper provides a number of recommendations applicable for those working with local governments and communities to increase the scope and scale of behaviour change triggering. -
(Journal Article) Why do some behaviours change more easily than others? Water-use behaviour interventions in rural Nepal
01.10.2015
Water-sector development is inevitably based on changes in people’s behaviour. We analyse why some types of domestic water-use behaviours change more easily than others. Our case study is a water supply and sanitation intervention in remote and rural Nepal. We found that collective opportunities, degree of individual freedom, and individual incentives influenced the ease of the promoted behaviour changes. The enhanced individual opportunities, incentives, and collective tolerance enabled behaviour changes that were regarded as beneficial by the people themselves, whereas the existing social traditions in our case-study context often restricted those changes. Often, the individual agency and the collective traditions confronted one another. We suggest that this study can provide a design for predicting possible opportunities and challenges regarding behaviour changes in field operations, and for enhancing joint operation of individual and collective capabilities at local levels in the development intervention context. -
(Journal Article) Handwashing for menstrual hygiene management among primary schoolgirls in rural western Kenya
01.10.2015
Good hand hygiene contributes to the health and educational attainment of schoolchildren. Poor menstrual hygiene management (MHM) is recognized to impact on girls’ health, education, wellbeing and dignity, particularly in low-income countries. Identifying practical, affordable, and comfortable menstrual products to improve girls’ MHM is needed. One potential cost-effective product is the menstrual cup; however, provision of this insertable MHM product, in schools in low-income countries with challenging water, sanitation and hygiene (WASH) conditions, increases the need for assurance of good hand hygiene. This paper uses data from a randomized controlled feasibility study evaluating the acceptability, use and safety of menstrual hygiene products provided to schoolgirls in rural western Kenya. Here, we explore girls’ handwashing practices in school when using menstrual cups, sanitary pads or traditional items, examining the availability of WASH and the reported frequency of handwashing. Data generated from interviews with adults, girls’ private surveys, narratives from focus group discussions, and observational WASH surveys are explored. Reported presence of WASH was higher than that observed during random spot-checks. Overall, 10 per cent of girls never washed before, and 7 per cent never washed after, emptying or changing their menstrual item at school. Girls in cup schools were twice as likely to wash prior to emptying, compared with girls using other items. Handwashing among girls using traditional items was low, despite the same hand hygiene training across groups and a comparable WASH presence. Data highlight the need for sustained mechanisms to support schoolgirls’ handwashing practices for MHM. -
(Journal Article) Schoolgirls’ experiences of changing and disposal of menstrual hygiene items and inferences for WASH in schools
01.10.2015
Menstrual hygiene management (MHM) challenges during changing and disposal of menstrual items are important in low-income countries (LICs) where schools lack sufficient water and sanitation. Changing in poorly maintained latrines may expose girls to excrement and infection. We examine the frequency of dropping menstrual items and disposal of waste by schoolgirls in a menstrual solutions feasibility study in western Kenya. Drops when changing were reported in 17 per cent (20 per cent <16 years; 16.5 per cent 16 years plus; p=0.04) of girls’ reports overall. Differences by socio-economic status were not evident. Fifty-four per cent of girls dropped at least once. A quarter of girls using pads and cups reported drops in the first few months, reducing to 10 per cent over time, compared with ~30 per cent among traditional item users. One in four accidental drops occurred at school during the study. When dropped at school, most girls swapped the dropped item for a new one, but 24 per cent brushed/washed the item and reused it. While no clinical events occurred during this study, data suggest dropping within latrines could place girls at potential risk of exposure to infection. Disposal of items, or emptying cups, was mostly into the latrine. We conclude that accidental dropping of menstrual items while changing is common, including at school. Prevention will be helped by improving poorly constructed sanitation facilities, shelving, privacy, and staggering/increasing break time for girls to change. Provision of special garbage bins to prevent clogging and overflow of latrines is recommended. -
(Journal Article) Measurement of handwashing behaviour in Multiple Indicator Cluster Surveys and Demographic and Health Surveys, 1985–2008
01.10.2015
With this paper, we aim to describe handwashing worldwide, as measured in Multiple Indicator Cluster Surveys (MICS) and Demographic and Health Surveys (DHS) in low- and middle-income countries between 1985 and 2008, and to explain the strengths, weaknesses and evolution of this data collection to inform future survey development. We searched reports of DHS and MICS conducted before 2009 and analysed data on handwashing measurements. We examined data according to geographic region, as well as demographic characteristics such as wealth quintile, education of the household head, and rural/urban location. Before 2009, eight MICS and 40 DHS included handwashing-related measurements, using a variety of self-reports and rapid observations. Internal triangulation of findings from surveys that collected multiple types of measurement shows that self-reports to closed questions overestimate behaviour. Observation-based data suggest low handwashing rates in many low- and middle-income countries with high prevalence of water and sanitation-related diseases, and high inter- and intra-country disparities. However, due to the widely disparate nature of the pre-2009 handwashing-related measurements, much of the data cannot be compared between countries, and only an incomplete picture of global rates can be formed. Efforts to increase the prevalence of handwashing with soap and water need to be strengthened in many low- and middle-income countries, especially among poorer, rural populations and where the household head has less formal education. Closed questions asking for self-reports of handwashing behaviour should be avoided. Findings support instead the inclusion of uniform observation-based measurements, as were integrated as core modules of MICS and DHS in 2009. -
(Journal Article) Are burial or disposal with garbage safe forms of child faeces disposal? An expert consultation
01.07.2015
The importance of safe handling and disposal of child faeces given its potential role in disease transmission are increasingly recognized. Household surveys demonstrate that the burying of child faeces (‘dig-and-bury’) is common in several countries, especially in sub-Saharan Africa and South-east Asia. Disposal with garbage is widely practised in middle- and high-income countries and is becoming increasingly common in urban areas of low-income countries. The safety of these two approaches is difficult to assess given the limited evidence available and we therefore sought the opinion of experts in the field of sanitation to support advocacy around the topic. We report the findings of an anonymous expert (Delphi) consultation on the safety of these two child faeces disposal methods. There was almost unanimous agreement these should be considered neither safe nor improved. A range of arguments was provided to support this position, including proximity of solid waste and burial sites to the home and children’s play areas and that neither practice would be acceptable for adults. The consultation also highlighted gaps in the current evidence base that should be addressed to gain a fuller insight into the risks involved in these two forms of sanitation with a view to providing both programmatic and normative guidance. In particular further work is needed to assess the potential for exposure to faecal matter in solid waste in low- and middle-income countries and to elucidate the predominant practices of child faeces burial including proximity to the home or infant play areas as well as depth of burial. -
(Journal Article) Microfinance for sanitation: what is needed to move to scale?
01.07.2015
The sanitation sector is gradually realizing that the effectiveness of approaches such as Community-Led Total Sanitation (CLTS) is limited by inadequate access to finance. Households are not able to construct durable facilities and sanitation services are unable to develop so as to respond to demand. At the same time, there is fierce competition among microfinance services providers that is pushing institutions towards more remote customers and to offer innovative products. In addition, the rise of mobile banking and digital finance has lifted many poor people out of financial exclusion. These factors have created a nexus between microfinance and sanitation with high growth potential. However, the sanitation microfinance market remains small to date. Since 2010, the SHARE research consortium has investigated global experiences and lessons for using microfinance to develop sanitation services. A SHARE action-research in Tanzania triggered selected financial institutions to offer financial products for sanitation and generated lessons for scaling up sanitation microfinance. This article presents the findings from the SHARE research, in the context of broader developments in the microfinance markets and key findings from other donor-led initiatives. -
(Journal Article) Fostering economic opportunities for youth in Africa: a comprehensive approach
01.06.2015
Youth unemployment and working poverty are large and growing development challenges. The barriers faced by young women and men in accessing sustainable livelihoods are many, so supporting their successful transition into employment and entrepreneurship requires a comprehensive and holistic approach. This article reflects on the evolving approach of The MasterCard Foundation-supported programmes in sub-Saharan Africa, within the broader context of wider research and evidence. It suggests that combining training in a range of market-relevant skills, with access to job and business opportunities and appropriate financial services, can foster economic opportunities for youth. It emphasizes the importance of recognizing the role of mixed livelihoods in contexts where formal jobs are lacking, and of supporting youth engagement in agriculture and agribusiness as viable livelihood opportunities. And it highlights that the challenge can only be adequately addressed via the meaningful engagement of a range of stakeholders, including the private sector, government and civil society, and, especially, youth themselves. -
(Journal Article) Improving the food security of the extremely poor by linking them to markets
01.03.2015
This article draws lessons from ACDI/VOCA, CARE, and World Vision-implemented food security programmes to answer three questions: how can push/pull activities better integrate the extremely poor into 1) output and 2) input markets? And 3) how can push/pull programme activities help improve intra-household gender dynamics and financial decision-making to improve the food and nutrition security of household members? In output markets the lessons include: 1) that market development and savings group interventions can be implemented by the same officer; and 2) projects should move early to have a private sector provider take over the village savings and loan associations. While there are constraints in the input markets, there are also push strategies for increasing production, including direct delivery of inputs to farmers, vouchers to increase demand, and Farmer Business Group development to increase collective input buying and pull strategies such as linkages with buyers for the selling of products and tapering down subsidies. Intrahousehold gender equitable decision-making can positively impact the food security of the household members. Mixed gender Village Economic and Social Associations are efficient in tackling intra-household decision-making. This allows the provision of flexible and efficient financial services as well as an opportunity to engage husbands and wives in gender-related dialogues. -
(Journal Article) Making markets work for women: how push and pull strategies can support women's economic empowerment
01.03.2015
In many countries, the inability of women to negotiate pervasive social, legal, and cultural barriers inhibits their participation in the productive sphere, particularly their entry into market systems as producers and entrepreneurs. The paper draws on case studies from projects implemented by the Mennonite Economic Development Associates (MEDA) in Ghana, the Entrepreneurship and Community Development Institute (ECDI) in Pakistan, and Zardozi in Afghanistan to show how practitioners can maximize ‘push’ and ‘pull’ strategies to increase the scale, impact, and sustainability of women's economic empowerment programming. Despite differences in country contexts, value chains, and sectors, the authors illustrate the importance of ‘push’ strategies in helping women to overcome the persistent gender-based discrimination that undermines women's understanding of markets, access to networks, self-confidence, and business success. They also show how deliberate ‘pull’ strategies that use commercially based incentives can increase women's incomes and business sustainability. The authors conclude that a blend of push and pull strategies will provide the most reach and impact for women's economic empowerment projects, ensuring income growth and gender equality dividends for families and communities. -
(Journal Article) Empowerment in action: savings groups improving community water, sanitation, and hygiene services
01.03.2015
With 748 million people worldwide lacking adequate water, sanitation, and hygiene (WASH) services (WHO/UNICEF, 2014), increased access to these services is a significant global challenge. Savings groups (SGs) combined with social empowerment strategies can be used to engage communities meaningfully in addressing development challenges such as access to clean water and a functioning latrine. As participants in PCI's SG initiative entitled Women Empowered (WE), women have independently identified WASH needs in their communities and have organized and carried out collective actions to improve their situation. This paper highlights results from a qualitative study in which PCI looked at SGs within two international development programmes in urban and rural Guatemala. The paper explores key opportunities in implementing an integrated, social and economic empowerment strategy and how changes in self-efficacy and leadership can lead to positive community impact. PCI found that participation by women in rural and urban Women Empowered SGs contributes to increased decision-making abilities and leadership, as well as increases in collaborative, collective actions at the community-level. Moreover, when one integrates SGs as a component of larger, multi-intervention development programmes, one can create a facilitative environment which encourages SGs to participate as active development partners rather than passive development recipients. -
(Journal Article) Microcredit: from hope to scepticism to modest hope
01.03.2015
After its introduction in the late 1980s and its fast expansion thereafter modern microfinance, and specifically microcredit, raised the hope that it could combine access to (semi-) formal credit for the poor with financial sustainability of the new microfinance institutions, and that it would contribute to increased micro-entrepreneurial activity, consumer welfare, and the empowerment of women. More recently scepticism about the operation of microfinance institutions and their impact has arisen. Based on the literature, we discuss the possibility of combining outreach to the poor with financial sustainability, microfinance crises, and the findings of recent impact studies. Our conclusion is that microfinance is not a panacea for development, but that it is a tool poor households can use in their fight for survival. -
(Journal Article) Bringing together push and pull through local entrepreneurs
01.03.2015
Despite significant efforts in agriculture market development, millions of smallholder farmers remain isolated from markets, due to remoteness and low farm productivity. Push/pull approaches to market development suggest a dual strategy for bringing smallholders into agricultural markets: 1) reduce producer vulnerability and build capacities, based on market requirements; and 2) facilitate relationships for producers to deal in consistent, growing markets. While simple in concept and effective as an approach, the execution of push/pull is complex. In particular, it is difficult to connect push (producer capacity) and pull (market) elements, resulting in unsustainable market linkages. When applying a push/pull approach in areas where the Aga Khan Foundation (AKF) works, AKF has noted that local entrepreneurs can link push and pull effectively and for the long term. This case study reviews how entrepreneurs link push and pull in AKF's market development programme in southern Tanzania. It outlines learning on how local entrepreneurs bridge gaps between producers and firms, taking the case of remote farmers accessing inputs (seed, fertilizer, implements, and pesticide) from larger suppliers. The paper describes the challenge of linking push and pull, outlines AKF's experience in southern Tanzania, and follows with points for discussion on incorporating local entrepreneurs into push/pull programmes. -
(Journal Article) Adolescent schoolgirls' experiences of menstrual cups and pads in rural western Kenya: a qualitative study
01.01.2015
Poor menstrual hygiene management (MHM) among schoolgirls in low income countries affects girls' dignity, self-esteem, and schooling. Hygienic, effective, and sustainable menstrual products are required. A randomized controlled feasibility study was conducted among 14-16-year-old girls, in 30 primary schools in rural western Kenya, to examine acceptability, use, and safety of menstrual cups or sanitary pads. Focus group discussions (FGDs) were conducted to evaluate girls' perceptions and experiences six months after product introduction. Narratives from 10 girls' and 6 parents’ FGDs were analysed thematically. Comparison, fear, and confidence were emergent themes. Initial use of cups was slow. Once comfortable, girls using cups or pads reported being free of embarrassing leakage, odour, and dislodged items compared with girls using traditional materials. School absenteeism and impaired concentration were only reported by girls using traditional materials. Girls using cups preferred them to pads. Advantages of cups and pads over traditional items provide optimism for MHM programmes -
(Journal Article) Putting the men into menstruation: the role of men and boys in community menstrual hygiene management
01.01.2015
This paper examines how men and boys have an essential role in effective menstrual hygiene programmes and describes an initiative to engage men and boys in Uttar Pradesh, India. Cultural norms around menstruation are rooted in gender inequality and compromise women's ability to manage menstruation hygienically and with dignity. While there has been significant progress in developing comprehensive approaches to menstrual hygiene management (MHM), the role of men and boys in supporting menstrual hygiene has been lacking. In India, WaterAid and Vatsalya have targeted men and boys to address this gap in a programme that started in December 2011. Groups of men and boys were established and sensitized. Male teachers and masons were also trained to provide MHM services in school. Regular monitoring of software and hardware components, focus group discussions with male and female community members, and analysis of attendance registers has been undertaken to assess the emerging outcomes of the programme. As a result of the initiative, men and boys have begun to talk about menstruation more freely and are better able to support the MHM needs of women and girls within the household, community, and school. -
(Journal Article) Developing games as a qualitative method for researching menstrual hygiene management in rural Bolivia
01.01.2015
The onset of menstruation has proven challenging for girls in school, with absenteeism, missed class time, reduced participation, teasing, fear, shame, and risky adaptive behaviours among the most commonly noted impacts in many settings. In 2012, Emory University and UNICEF conducted a multi-country formative study to gain a global perspective of girls' experiences. A compendium of tools was created to ensure investigation of common themes across all settings. This paper describes the process of adapting the focus group discussion (FGD) tool for Bolivia into a board game as a method to ease girls' discomfort discussing menstruation and elicit richer data. We describe the development of the menstrual hygiene management game, including structure and strategies for adapting FGD questions that increased interaction, stimulated detailed responses, and diversified participatory activities. A discussion of lessons learned will highlight elements of success and areas for improvement in future game adaptations. The paper discusses games as a research method for other topics and their applications for programme design, monitoring, and skills-based learning. -
(Journal Article) Unpacking the policy landscape for menstrual hygiene management: implications for school WASH programmes in India
01.01.2015
Menstrual hygiene management (MHM) relates to how girls and women manage their monthly period, and require access to information about menstruation, clean and safe menstrual absorbents, and amenities and facilities such as toilets and water, and waste management to maintain hygiene. In general MHM is poor in India, with low levels of knowledge and many misconceptions, varied use of menstrual absorbents, and unhygienic practices among adolescent girls. With almost 50 per cent of school age girls enrolled in schools, creating a conducive environment in schools to promote MHM is imperative. This policy scoping exercise examines how select policy initiatives implemented by the Government of India address MHM, especially in the context of schools. This document review found that adolescent girls are a focus of most policy initiatives addressing MHM, with a focus primarily on the hardware (i.e. infrastructure, sanitary napkins) or software (i.e. health education) components. Most programmes are implemented at the school level, though guidelines for implementation are not always explicit. Programmes suggest convergence with other government programmes, yet operationalization of convergence mechanisms is lacking. -
(Journal Article) Learning, acting, and learning (LAL) research on schools' menstrual hygiene management (MHM): Pakistan
01.01.2015
UNICEF Pakistan adopted a conceptual framework for global qualitative research to advance their ongoing exploratory research work on menstrual hygiene management (MHM) in 2013-14. The findings of qualitative research informed the design of certain interventions in schools to improve MHM. These interventions were implemented as action research so that the benefits of these interventions can be studied. Qualitative research gave an in-depth understanding of girls' needs and their preferences to address MHM-related issues. Data analysis of qualitative research helped a team of sanitation practitioners and social scientists in understanding different factors influencing MHM in girls' schools. A few simple and focused interventions were hence designed and implemented. Six weeks after the implementation of hard and soft activities on the ground the results were studied. Results showed significant improvement in MHM conditions in girls' schools. Girls and teachers welcomed the initiatives and there were indicators for future sustainability. Areas of improvement were also noted by UNICEF before taking these interventions to scale. This research was documented as ‘learning, acting, and learning’ (LAL: literally meaning ‘Red’ in the local language, Urdu) research. -
(Journal Article) Uncovering the challenges to menstrual hygiene management in schools in Mali
01.01.2015
There is limited information on girls' menstrual hygiene practices and experiences at school in francophone sub-Saharan Africa. We conducted qualitative research to determine the challenges faced by school-aged girls in Mali, a culturally diverse and largely Muslim country. Research activities were conducted in eight urban and rural schools across the Sikasso and Koulikoro regions, including in-depth interviews with 26 girls and key informant interviews with 14 teachers and school directors. Results describe girls' practices for managing menstruation at school, their support systems and information channels, and their voiced recommendations for school WASH and education improvements. -
(Journal Article) Towards a sustainable solution for school menstrual hygiene management: cases of Ethiopia, Uganda, South-Sudan, Tanzania, and Zimbabwe
01.01.2015
African schoolgirls face considerable challenges as a result of the real biological phenomenon of menstruation and its management. Menstruation is seen as a secret and is regarded as taboo. As a result girls are not receiving adequate support from home, schools, or the community. They are left on their own to address the challenge which consequently affects their school performance. Development interventions that deal only with the supply of materials cannot resolve the problem in a sustainable manner. We need to have a comprehensive approach that can improve: knowledge, attitude, and practice of girls, parents, and the community; sanitary materials supply; the policy environment; and the physical infrastructure. The issue of menstrual hygiene management is gaining recognition as part of the development agenda for improving girls' school participation. But there is little research and few practical case studies have been conducted to inform policy and practice. SNV Netherlands Development Organization is addressing menstrual hygiene under its WASH in School programme in Asia, Africa, and Latin America. This article highlights baseline survey findings of the current menstrual hygiene management practices in the project areas of Ethiopia, South Sudan, Uganda, Tanzania, and Zimbabwe and recommends the approach piloted.