Thanks, Kristie. I would encourage those who have not watched the Go Baby Go webinar to take a look. It's quite helpful!

I like the Designing for Behaviour Change methodology and have used it and its predecessor (the BEHAVE framework) a number of times. I believe many NGOs know about the methodology and quite a few use it because it's well advertised on the CoreGroup website and has been promoted (rightfully so!) for some time now.

I'm looking forward to checking out Channels of Hope. When I worked at the Micronutrient Initiative, we considered using the Sesame Workshop in Bangladesh for a behavior change intervention but our target group (adolescent girls) was older. Too bad because they are a great group and we often forget the importance of fun in changing people's practices!

Thanks for reminding us of the complexities of making decisions about investments in water, sanitation, and hygiene. It's never quite as easy as it seems. In addition to your comprehensive list of considerations, I would also add epidemiological profile. So in South Asia where I've done most of my work, open defecation is a huge problem. Most statistics put open defecation in India, Nepal, and Bangladesh at about 50% of the population. Given the very high population densities, this results in what is essentially a thin layer of feces everywhere. In contrast, in Africa, the prevalence of open defecation is much, much lower (I've seen estimates ranging from 5-20%) and population densities are also much lower. This is all to say that there isn't a simple answer!

Thanks, Kirk! This is a great discussion.

Yes, World Vision has developed Go Baby Go, which is a key component to the ECD elements of BabyWASH. There are some great resources and a webinar recording on Go Baby Go here .

As you mention, we are also keeping a close eye on the results of the SHINE study, and we agree that the evidence of impact on EE is quite scant right now. We are hoping to see some results through BabyWASH that will contribute to building this evidence base, though, of course, that takes time.

As for SBCC strategies, World Vision uses the Designing for Behaviour Change methodology to discover the key determinants of behaviour change and to design activities accordingly. Sometimes the determinant is related to messages. Other times, it reveals the need for advocacy or engagement with key influences (household heads, faith leaders, etc.) to promote the necessary cultural approval for behaviour change. The aim is to work with a very targeted behaviour and design activities around only the most significant determinants with the aim to minimise activities needed and maximize the impact. We still have a lot to learn and improve upon in how we actually carry this out, but it is what we are moving toward

World Vision uses approaches such as Channels of Hope to engage faith leaders in behaviour change. I have just learned of a model used in WV Nicaragua called FECSA which sounds very similar to your description of GALIDRRA, combining household messages with practical application and practice of behaviour. We're starting to see some good results with our partnership with Sesame Street for hygiene behaviour change in schools. I don't have results to share yet, but anecdotally we're hearing some great results of household-level change resulting from what these children are learning in school. Stanford University is helping us to evaluate our initial pilot, so I hope I can have more to share in the coming months on that.

As for our team structure in Cambodia, I know they are united under joint leadership, but I don't have details on how that structure works, aside from shared leadership and budget. I can try to discover that.

For the toolkit, I'm attaching an introduction to it.

It is still a work in progress, and we're currently focusing on review and revision of the toolkit from our field-based colleagues in World Vision national offices, who will be the primary users of this tool. Rather than post more than the introduction of the toolkit here, if anyone is interested in learning or seeing me, they can contact me at This email address is being protected from spambots. You need JavaScript enabled to view it., I'll be happy to share more.

It'll be great to "see" you at our webinar. If anyone is coming to the UNC Water and Health Conference next week, we're having a side event on BabyWASH on Tuesday morning at 10:30 am, and it would be great to have some in-person discussions during the week!

Thanks, Kirk, for the question.

Your question is: If we do not have adequate funds for water, sanitation and hygiene, how would we allocate resources and why?

My thoughts:
(a) WASH sub-sectors are not homogeneous - the cost & incremental cost effectiveness ratio (ICER) are not the same for all contexts where WASH needs have to be addressed. For instance, the cost of WASH for a school with 500 children could be different from a WASH (even shared) facility for a 500-population small community. Similarly, the likelihood of behavior change communication (including follow-up) is perhaps more easily achieved in a school compared to general community because teachers could follow-up (this carries little additional program costs). However, the mortality due to diarrhea is highest in children aged below 5 years (not yet enrolled in school). So, the first step could be to (i) identify contexts where WASH needs have to be addressed, and (ii) costs & ICER for various types of existing status - do they already have toilets & only water/hygiene required or do they have water supply but no toilets or all three lacking as well as status of existing facilities viz., do they require overhaul.
(b) Multi Criteria Decision Analysis (MCDA) is a good way of identifying and deciding when there are multiple priorities involved (even when stakeholders have different priorities).
(c) From a funding perspective, it might be good to look at source of funding - which groups have assured funding (and gaps if any), modularity (individual / group decision & implementation required?), etc.
(d) What WASH combinations result in lesser incremental costs for a subsequent phase to complete the unfinished WASH goals.
(e) Are there interventions that can be combined with other sectors? For instance, hygiene by health and education sectors, sanitation is essentially taking up water sector's responsibilities, can logistics take up some of the sanitation sector needs in instances where funding shortages cannot be met in the short-term by allowing spare capacities to be utilized at subsidized costs, etc.

Overall, I think it is not possible to have a one-rule for prioritizing WASH sub-sectors from a resource allocation perspective. It depends on the context (school/community, equity, women's rights, economics - costs & ICER, etc).

Personally, if I had to make a choice, I would go for sanitation. People anyway fetch water for household purposes (including WASH) - the cost of status quo is essentially opportunity cost (hours & health lost). Hygiene - with tippytap option available, additional resources is mostly communication & followup - which can be clubbed with sanitation implementation. In contrast, if OD continues, there is no way to stop disease spread & the resultant morbidity / mortality - real costs. If ecosan technologies are not adopted, no way to close the nutrient loop in the agricultural cycle or lower energy needs - again, real costs.

Again, the above is only my personal opinion. It is neither desirable nor feasible for everyone to adopt the same resource allocation methodology. Simply because we need to gain evidence for decision-making as well as research to develop technologies/other interventions - in all the WASH sub-sectors. In that sense, we need to differentiate between resource allocation for technology development, approvals & pilot, scaling up, etc.

A yet another aspect is funds available with an entity (our entity - be it individual, NGO, private company or govt) and others in each of the three sub-sectors. If hygiene is over-funded, it might be better to invest in water or sanitation. So, it is also important to know the extent of funding and projects planned/under implementation in the specific geography for deciding resource allocation between the three sub-sectors.

Regards,
Sowmya

Thanks for your input, Kurich. World Vision developed the Go Baby Go initiative if I’m not mistaken. Is that the ECD component of your BabyWASH strategy? We’d love to hear a bit more about your joint WASH and health teams in Cambodia. In Nepal, our technical teams in Kathmandu had more difficulty integrating multiple sectors than field workers who seemed to understand that you don’t focus on WASH on Monday, agriculture on Tuesday, nutrition on Wednesday, etc.

I’d love to see the BabyWASH field facing toolkit when it is ready. The challenge with evidence as I see it is that while there’s quite a bit of evidence about the importance of clean environments and for our purposes in particular, environmental enteropathy, there’s not a great deal of evidence about what works to reduce EE. There’s some nice work coming out of the SHINE project and the WASH Benefits study and MAL-ED work will shed even greater light on the topic. I’d be curious to hear what other major studies you and others have run across.

Kurich, what SBCC strategies does World Vision use during home visits (beyond message sharing)? My projects have used several—though not as much as we’d like for WASH (we generally use them for nutrition only). One is GALIDRAA which provides CHWs a structure for engaging the mother in a discussion about hand hygiene, for example, to find out what her current practices are, the barriers she faces, etc. The CHW then provides mothers options she can try and the mother picks one she’ll put into practice over the next week or two. The CHW then checks back with the mother in a couple of weeks to see how things have gone and praises her for engaging in the behavior (or helps the mother identify a different behavior if she was unable to adopt the agreed-upon practice). Regardless—we focus on small, doable actions; not all of hand washing, just some small component (e.g., putting a bar of soap next to the latrine one week, locating water near the latrine the next, etc.) to give the mother confidence she can change a complex behavior over time, a little at a time. GALIDRAA goes by other names as well including negotiation for behavior change. There is an excellent manual online called Make Me a Change Agent. What I really like about this approach is that it can work for multiple sectors—not just WASH and nutrition. As long as there is a repeated behavior (e.g., NOT early initiation of breastfeeding since it’s a one-time event), negotiation can likely be used to change practices.

Another approach we’ve piloted in Nepal (again, mostly for nutrition but with a bit of WASH) is “action cards.” The premise is that families get all too many messages. The CHW walks away from the home visit having given the mother a message about hand washing. The mother knows hand washing is important and wants to wash her hands but can’t do so for a variety of reasons. Action cards are similar to counseling cards but with a twist. Using the first card in a set, the CHW presents the ideal behavior. Subsequent cards depict barriers. For example, one card in the set might show lack of soap; another, a lack of water; yet another, lack of time or disapproval from the husband, etc.). These cards are developed ahead of time, along with the cards that show the ideal behavior. The most common barriers in a given locale can be identified through formative research, the DHS, special studies, etc. The CHW then presents the ideal behavior and asks the mother what barriers she faces when washing hands. The CHW then pulls out the corresponding barrier card and the CHW and mother discuss what the mother might do to overcome THAT barrier. While we only piloted the approach, it seems like this strategy might work better than simply sharing a message. Have others used a similar approach (or perhaps something better than what we’ve thought of)?

In general—and to the extent that we are able to do so—it would be good to share materials on ECD, WASH, nutrition, etc. If there are no proprietary issues related to sharing materials, perhaps folks can send links to materials you’ve developed or attach files to your message. As usual, we’d want to know what has worked and not worked in your experience. It goes without saying that none of us should simply take materials and use them in our own context with no adaptation, no discussion with the organization that developed the materials, and no acknowledgment of their contributions!

Thanks for the invite to hear Dr. Neal. I’ll definitely participate in the webinar!

Thanks for your thoughts, Sowmya. If I understand your point correctly, it is better to have your lead sector provide a tangible outcome or product as opposed to something less concrete, correct? This fits well with what I know about behavior change. People change their practices when they see a direct (and hopefully, fairly immediate) benefit. This is often NOT the case for things such as immunizations, stunting (though not underweight), empowerment, and so on.

Also--and perhaps this is a separate discussion--when push comes to shove and you don't have enough money to invest in water, sanitation and hygiene, where do you invest resources? Looking at the scientific literature, I don't think there's a definitive answer. I just finished analyzing data on the impact of toilets and water on stunting and underweight (unfortunately, we didn't have information on hygiene). Our data come from Young Lives--a cohort study going on in Ethiopia, India, Peru, and Vietnam. Our results suggest a markedly greater impact of improved toilets on stunting (though not underweight) than improved water.

We also looked at access to improved water and toilets and children's performance on tests of cognition. We found that access to improved water and toilets has independent associations with children’s test scores (we used the Peabody Picture Vocabulary Test) that often remained significant with adjustment for covariates that you'd expect would influence cognition as well. Our findings suggest that the effects of WASH may go beyond sub-acute and acute infections and physical growth to include children’s language performance, a critical component of cognitive development.

This is all to say that there is some evidence that toilets may be more important than water for some child development outcomes. I'm just wondering when your programs don't have enough money to invest in water, sanitation, and hygiene, what interventions do you pick and why?

Hi Everyone,

I think Krischan has a valid point. That it may sometimes be difficult to balance between (a) having to integrate several sectors at the time of planning itself and (b) selecting one sector has the advantage of providing clear guide for planning and gaining stakeholder participation quickly.

Some suggestions for a middle path:

1. In the case of sanitation, we know that the sanitation SDG is inter-linked with other SDGs by target wording as shown in Kim Andersson's post #14864 (will also need to consider implementation aspects - sorry, but the table does not cover the toilet superstructure which requires the use of sustainable building materials for achieving goal 11, 13, etc relating to sustainable cities and climate change - important when we consider the number of toilets that needs to be built).
2. For each sector, there could be a guide which states what needs to be integrated in sanitation for achieving other sector goals regarding each programmatic aspect - at the planning, implementation, supervision, M&E, impact evaluation stages in sanitation.
3. We could select sanitation as the lead sector or, it could be housing as well. Generally, just my opinion, the focus (of powerful actors - policy makers, NGOs for transparency & governance, even funding agencies) is probably on sectors that require expenditure for goods. This is simply because the expenditure will come under audit and there are several regulatory & accountability mechanisms, etc that already exists for expenditure. This is a historical trend (public expenditure accountability became priority before scrutiny over equity or other human rights aspects). Another important reason is that it is easier to achieve development goals through passive interventions compared to those requiring active behaviour change (lower handwashing rate compared to toilet use amongst people who have access to toilets, for instance). Therefore, if we have to select "lead" sectors, it would probably have to be a sector that requires expenditure on goods. Therefore, between sanitation and women's rights, sanitation would probably have to be the "lead" sector, with sincere apologies to all the women's rights activists. What is important is to complete the analysis above (which sectors are inter-linked) and identify sectors, such as, women's rights which may not get adequate priority in the usual procedure and ensure its inclusion in the lead sector's planning, implementation and M&E.
4. It is also important to see the source of budget. In case of sector integration, we will have to achieve goals of multiple sectors but the source of funding may be coming from one sector - unless specific measures are put in place for pooled funding. Even in those cases, some sectors such as women's rights may not have a budget adequate enough to contribute to sanitation. Probably, historically, development programmes were vertically planned (as independent sectors) which was appropriate at that time - more focus when systems resources (IT, manpower, etc) are scarce to achieve at least the top priority goals. For integrated achievement of goals of multiple sectors, we will need to adopt a pooled funding approach on all aspects - stakeholder discussions, programmatic aspects, etc - even if funding comes from only one sector. It would be great if this discussion thread includes content from some publications (by the Overseas Development Institute, for instance) regarding lessons learnt from pooled funding in development aid.

Regards,
Sowmya

Thanks for this great topic and provoking questions, Kirk! I look forward to reading other posts!

1. How have you integrated your WASH activities into nutrition (or other) interventions? What worked? What didn’t?
We are beginning to develop core “BabyWASH” interventions designed to help fill programming gaps focused on mothers and children in the first 1000 days of life. BabyWASH focuses on the integration of WASH, nutrition, MNCH and early childhood development (ECD). Currently, we have some strong programmes that integrate maybe three of the above interventions, but seldom all four. For instance, we have village-based child nutrition programmes in Rwanda, for example, that combine ECD interventions with nutrition and hygiene empowerment for mums with young children. In Cambodia, our WASH and health teams are joint teams with shared goals that empower integration. In many areas, our WASH programmes work through community health workers, enabling joint messaging and monitoring.

World Vision’s traditional development programmes are organized into area programmes which introduce a degree of integration or at least concurrent implementation of programmes within the same geographic area. We are often challenged by more siloed funding streams and/or implementation targets.

2. What strategies have you used to secure buy-in and support from government officials and project staff who aren’t experts in a field outside their own (e.g., nutritionists approaching development from a “WASH perspective” and vice versa)?
The SDGs are helping World Vision to grow in integration. It is pretty clear that we can’t achieve these goals unless we work better together. And the growing body of evidence that interventions that cross sectors have the greatest impact is a very compelling argument for integrated programmes. World Vision is building our new BabyWASH field-facing toolkit on emerging evidence of the links between WASH, nutrition, MNCH and ECD. Because we are focused on evidence-based programming, that evidence helps with securing buy-in.

3. In multi-sectoral development work, how many sectors are too many? In Nepal, our programs included nutrition, WASH, reproductive health, agriculture, and gender. We found that focusing on so many sectors from day one was both confusing and overwhelming for staff.
This is a great question to explore. I’m not convinced there is a magic number, but I think it is better to start relatively small and focused to establish your norms and practical ways of working, learning and measuring success. With BabyWASH, there has been a large temptation to add in other sectors into our toolkit, but we have refrained, not because these other sectors aren’t important, but because the evidence of integration isn’t as strong, and we don’t want to overly dilute programming and make it essentially impossible to implement or monitor. So, for us, we’re starting with four. As we learn and refine, we may consider adding others.

4. As experts in WASH, do you think we picked the two highest priority WASH behaviors (wash hands before preparing meals and before feeding the child) or would you recommend one (or more) of the other critical behaviors instead?
Handwashing before preparing meals and before feeding a child is highly critical. I would also add handwashing after defecating or changing a nappy, plus safe faeces disposal, can’t be emphasised enough.
I think it’s important to consider how we engage in behaviour change interventions as well. How do we move from short-term behaviour change to long-term habit formation? If you’re familiar with Dr David Neal, he talks about this idea in The Science of Habit . We’re hosting a webinar on 20 October with Dr Neal to explore this idea further, if anyone in this discussion would like to join us! You can find out more here .

[Sorry for the late post! This is my first time as a moderator.]

For those of us working to improve the nutrition of women and children in Southern countries, there have been several recent, watershed moments that point to the importance of incorporating WASH in nutrition programs. In particular, there have been three publications worth mentioning. Dewey and Adu-Afarwah reviewed 38 intervention studies and found that even in the best nutrition programs, promoting good foods addressed only one-third of the average deficit in stunting (chronic malnutrition) experienced by Asian and African children. This study reminded us that food alone does not solve the challenge of poor nutrition. Jean Humphrey’s 2009 Lancet article suggested that toddlers’ poor hygiene and sanitation—including frequent exposure to and ingestion of animal feces—contributes to environmental enteropathy which, in turn, is associated with greater morbidity and poor growth. In Zimbabwe, as part of the SHINE project, Ngure and colleagues found that infants living in unhygienic environments ingest large amounts of animal faeces when they are left on their own to play.

These studies point to the need to approach nutrition from a more holistic perspective. As I’ve designed integrated nutrition projects in Nepal (Suaahara) and now in Tanzania (ASTUTE), I’ve been inspired by these studies and by growing program experience about how to integrate WASH and nutrition from a practical standpoint.

In our first year of programming in Nepal, we focused on five practices, including two WASH behaviors: 1. Wash hands before preparing food and before feeding the child, and 2. Keep toddlers out of the dirt by placing them on mats. We used support groups, home visits, community radio, and other strategies to improve these behaviors.

In Nepal, approaches we think worked include: 1. Focusing on just a few behaviors (and, for hand washing, limiting program emphasis to just two critical points) 2. Getting buy-in through two-day district orientations that included government authorities from a variety of sectors, not just nutrition, and 3. Bringing technical as well as community-based staff up to speed on WASH. So for instance, staff who promoted homestead food production were very knowledgeable about agriculture but didn’t have much experience in WASH. However, their efforts were critical to the success of the program overall; so, as part of their “agricultural” work, they promoted caging chickens. Doing so led to healthier poultry. But caging small livestock reduced children’s exposure to animal feces as well. The reverse is also true: WASH experts at all levels can benefit from exposure to agriculture and other disciplines.

The evidence from Suaahara’s baseline and midline surveys suggests large improvements in a variety of behaviors. I’ll talk about our programming experience in Tanzania in the next post. In the meantime, here are some questions:

1. How have you integrated your WASH activities into nutrition (or other) interventions? What worked? What didn’t?

2. What strategies have you used to secure buy-in and support from government officials and project staff who aren’t experts in a field outside their own (e.g., nutritionists approaching development from a “WASH perspective” and vice versa)?

3. In multi-sectoral development work, how many sectors are too many? In Nepal, our programs included nutrition, WASH, reproductive health, agriculture, and gender. We found that focusing on so many sectors from day one was both confusing and overwhelming for staff.

4. As experts in WASH, do you think we picked the two highest priority WASH behaviors (wash hands before preparing meals and before feeding the child) or would you recommend one (or more) of the other critical behaviors instead?


References:

Dewey KG, Adu-Afarwah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Maternal and Child Nutrition. 2010;4:24–85.

Humphrey JH. Child undernutrition, tropical enteropathy, toilets, and handwashing. The Lancet. 2009;374(9694):1032–35.

Ngure FM, Humphrey JH, Mbuya MN et al. Formative research on hygiene behaviours and geophagy among infants and young children and implications of exposure to fecal bacteria. American Journal of Tropical Medicine and Hygiene. 2013;89(4):709-16.

Wasn't aware that it is a hot topic right now, as it has been talked about for years it seems (not always called "integration" though, for example "nexus" is a similar idea etc.).

I am currently part of multi-year recovery program that was planned with tight integration of the Shelter, WASH & DRR components (and to a lesser extend with a livelihood component).

My (personal) lessons learned are that integration has to be done right from the start as trying to merge together components later on is almost impossible. And even with a program like ours that was planned to be integrated from the start, this is harder than it sounds as (especially in the early recovery phase) there are always good reasons for one component to rush ahead and not wait for a proper integrated assessment etc.

Furthermore it is helpful to select one sector as a (first under equals) leader that takes precedence over the other sectors to some limited extend. This give the integrated program a bit of a clearer guide and can help solving contradictory priorities that always come up at some point. For us it was the Shelter construction sector which probably made sense in the beginning. However in retrospect it would have probably been better to have DRR link everything together (Now DRR is sort of an afterthought). However WASH is usually pretty good in adapting to other sector needs I think.

In addition there is definitely also a work relationship problem with integrated programs as the experts from every sector want to prioritize their specific focus (and often ego ) and this can lead to conflict and less integration then desirable.

My personal opinion is that integration is probably more of a buzz-word than actually something new. In the end it is something like 60% common sense, 20% joint planning, 20% integration of M&E and other tools.

Integrated programming is a hot topic right now, but that does not make it a new topic. Many organizations have been attempting to integrate sectors for years, with varying levels of success. In this topic, we want to hear all about the successes and failures your organization has had with integrating multiple sectors (two, three, four or even more). By sharing together, we can start to discern common themes and common pitfalls to integration.

I am pleased to introduce our expert to help me moderate this topic: Dr. Kirk Dearden. Dr. Dearden currently serves as the Senior Advisor for Research and Quality Assurance at IMA World Health in Tanzania. He has worked with many NGOs over the years designing, implementing and evaluating development programs, and has considerable experience in social and behavior change communications. He has used his experiences to teach the new generation of public health students through courses at Boston University School of Public Health and others. He brings a wealth of programming experience from Asia, Africa and Latin America and will be a key voice in this discussion.