Terms of Reference: Knowledge Attitude and Practice study WASH and IYCF
Reducing malnutrition and improving access to water, sanitation and hygiene are key development targets as set in the SDGs 2.2, 6.1 and 6.2. Growing evidence has accumulated the positive impact that improved behaviors on sanitation and hygiene have on reducing stunting.
In Mozambique, nutrition, hygiene and sanitation are lagging behind. The national figures show that 43% of the under-fives are stunted. It is estimated that 47% of the rural population practises open defecation and only 8% have access to a functional handwashing station with water and soap. This national figure is even worse in certain provinces, and in Zambezia province open defecation in the rural area is estimated at 72.1%.
Government of Mozambique has programs on water, sanitation, hygiene and nutrition aiming to improve the access to services and the adoption of improved practices. The rural water and sanitation programme (PRONOSAR), has set explicit targets for sanitation, including the elimination of the practice of open defecation by 2024. Subsequent investments in promotion activities with the use of Community Led Total Sanitation (CLTS) method have been made. Since 2008 the Government is certifying Open Defecation Free (ODF) communities in an incremental manner and a total of 4,989 communities have been declared open defecation free.
Despite these investments made, the current reduction rate of open defecation only stands at 1.4 percent points a year and at current trendline it would thus take another 24 years to eliminate open defecation. To meet international commitments of the Sustainable Development Goal (SDG) 6.2 by 2025, and acceleration is required. From a decentralized perspective this need for acceleration is even greater, as there is a large variation between provinces. At current pace the worse performing province Zambezia is only expected to meet this SDG by 2070.
The UNICEF in collaboration with the EU and the Government of Mozambique have launched a project, targeting reduce undernutrition of children under five in the provinces on Zambezia (41%) and Nampula (49%) to 35%. The project targets the two provinces, but activities are focused in 7 districts( Zambezia:
Gurue, Lugela, Pebane and Molumbo districts, Nampula: Ribaue, Monapo, Nacalha Velha districts).
Activitirs in these three districts cover; improved service delivery on water supply and health services and by promoting behavioral change. The behavioral change component aims to increase of sanitation coverage by 8 percent points, handwashing by 30 percent points, and increase exclusive breastfeeding for infants under six months and increase the proportion of children receiving a minimum diverse diet diversity by 7 percent points.
This behavior change is to be achieved by social behavioral change communication (SBCC). The effectiveness of this SBCC depends on its alignment with the current knowledge, attitude and practice (KAP) of these rural communities. Understanding the drivers and bottlenecks for the uptake of improved behaviors, mapping the communication channels that communities have access to and investigating the strength and trust people place in these communication channels will further inform these SBCC messages.
There are some studies available on this subject to give some insights on this subject.
(1) Baseline study on Social and Behaviour Change Communication (SBCC) in Manica in 2017 by WFPi covering quantitative and qualitative aspects of knowledge and practice on handwashing, sanitation.
(2) Social Norms study on open defecation by UNICEF in 2016ii gives some quantitative information on the social norms on sanitation in declared ODF communities in four districts in Zambezia and Tete and maps the key influencers.
(3) Knowledge, Attitude and Practice study by MCSP Mozambique covering Nampula and Sofala in 2017iii provides quantitative information on nutrition and water treatment practices and access to handwashing and sanitation.
(4) Qualitative study on norms, attitudes and practices in small towns in Inhambane, Tete and Manica commenced by UNICEF in 2015 iv, provides qualitative information on the perception and practices on sanitation and hygiene by households specific to these towns.
(5) Qualitative Knowledge Attitudes and Practice study on parenting in three provinces of Zambezia, Tete and Nampula, UNICEF 2018v . The study covering one district per province, being qualitative, gives few inputs on the current sanitation and hygiene practices of families with under 2 year old children. The study does not cover knowledge and attitudes on sanitation and hygiene.
(6) Stunting baseline study and behavioral drivers in Nampula province by BigWin 2018, collecting qualitative data on nutrition practices, including sanitation access and practicesvi.
The above studies give some insights in the current practice and access levels on hygiene and sanitation from selected locations. Access to household sanitation is typically available from large surveys like IOF 218. However, less is known about attitudes and knowledge levels. Studies typically collected from few key informants. Quantitative data on knowledge and attitudes is minimal and is not representative.
Bottlenecks and drivers on behavioral change related to sanitation and hygiene are not documented.
Social norms studies have only been studies in ODF communities and not been investigated in the more typical communities where open defecation is widely practiced.
Understanding and quantifying the knowledge levels and attitudes on sanitation and hygiene at the household level is foundational for any SBCC strategy and messages, and should actually be conducted on a regular basis to understand the changes SBCC activities are having, and monitor the progress on the behavioral change ladder. Understanding the drivers and bottlenecks will allow messages to, go beyond knowledge transfer, and provoke action and move people on the behavioral change ladder.
Understanding the current social norms of rural communities on open defecation will further strengthen changing these norms in order to achieve and sustain open defecation free communities.
The stunting reduction project by UNICEF and EU does has strong monitoring component and three surveys will be conducted to understand the baseline, midline and endline. These surveys are to be undertaken by vanderBilt University, and will focus on measuring the progress in access to services and to some extent the behaviors of households with children under five in these two provinces overall and specifically in the 7 focus districts. The survey does not cover knowledge and attitudes questions in the households survey, excludes households without children under five, and excludes focal group discussions.
Hence there is a need to undertake a comprehensive study on the knowledge, attitudes and practices in the provinces of Nampula and Zambezi, to quantify the current knowledge, attitudes and practices. This study should include identifying the drivers and bottlenecks associated with the behaviors, and should also include a mapping and analysis of communication channels.