Shifting Nutrition and Hygiene Behaviors in Sierra Leone Utilizing Trials of Improved Practices

Executive Summary

Cover photo: a mother in Sierra Leone bending down, carrying her infant child on her back as she uses a tippy-tap to wash her hands

The SPRING project, together with Helen Keller International (HKI), recently used Trials of Improved Practices (TIPs), a qualitative research methodology, to design social and behavior change communication (SBCC) efforts to improve the nutritional status of women who were pregnant or lactating and children under the age of 2 years old in Sierra Leone.

The TIPs approach provided an opportunity to pretest behaviors at the household-level before they were widely promoted. By focusing on behavior—what people do —rather than on knowledge — what people know or believe, TIPs provided an understanding of families' preferences and capabilities, as well as the barriers and enablers encountered in trying new behaviors. This methodology engaged people in dialogue and involved them as partners in designing the interventions that worked best in their lives to achieve positive health outcomes for themselves, their families, and communities.

In May of 2016, SPRING/Sierra Leone conducted TIPs research with 24 selected households in two chiefdoms in the Tonkolili region of the country. The analysis from TIPs assisted in the development of a grounded SBCC strategy and materials, and also provided guidance and understanding on the issues and practices raised for future development efforts, and an awareness of the TIPS methodology that can be replicated to other assessment topics.

The first step was to create and prioritize a menu of evidence-based behavioral options for: handwashing with soap at critical times; cleaning home/play environment, including safe disposal of feces; and appropriate complementary feeding of children 6–23 months. In addition, TIPs developed a methodology to test mothers' responses to the recommendations for improving infant and young child nutrition, WASH (water, sanitation, and hygiene), and other desired practices and determined which ones were most feasible and acceptable.

The selection of the menu of key behaviors was followed by three household visits, during which enumerators:

  • interviewed, observed, and understood the household’s context and current behaviors;
  • counseled and negotiated one to two new behaviors that the household was willing to try; and
  • followed-up to understand which behaviors households were able to do and to learn about the most important barriers and enablers to the suggested behaviors. The third visit also served to solicit suggestions from the participants about how to modify and promote the behaviors.

The dialogue and data from these three visits helped to develop tailored, contextually appropriate, and pretested messages for the promotion of these behaviors to the target audiences.

Creating handwashing stations and prioritizing soap for handwashing were some of the most tried and accepted interventions for the households in the study. One of the most common reasons that individuals gave for adopting this behavior related to the fact that TIPs team members explained the behavior and construction to participants, and the large water bottles needed to construct the simple handwashing stations were readily available.

In addition, behaviors agreed to be trialed for improved feeding practices included trying to find and buy pumpkin to feed their young child. The options for sub-practices to trial included: preparing pumpkin as a snack, combining pumpkin with other food, and cooking and mashing up pumpkin to serve as pap along with the less popular suggestion of buying a pumpkin with their neighbor to split. For the households that agreed to feed pumpkin a positive experience was reported although the availability throughout the year was reported as major barrier. Mothers were interested in feeding children colorful foods recognizing pumpkin as one of a few options.

However, not all of the behaviors were as likely to be adopted. Fourteen of the households interviewed were counseled on the importance of keeping their small child in a fenced-in clean, play area to protect them from contacting waste that could make them sick. While five households were interested in trying the behavior, none of the participants had actually built an enclosure by the follow-up visit. Many households preferred to continue the practice of periodically sweeping the home environment instead, providing crucial insight to design a WASH 1,000 intervention.

Although the TIPs methodology does not intend to provide statistically representative information about the greater populations we work with, it is an effective way to pretest new behaviors to better understand the factors that may impede or facilitate households’ adoption of a new behavior. By engaging in a dialogue with the same household members during three visits over the course of several weeks while the household was trying out a practice, the team was able to examine householders’ experience with each practice in detail. This detail helped the team to develop a specific SBCC strategy for each practice. Conversations with household members regarding a specific practice helped the team to identify the following SBCC strategy elements: influencers, those individuals whose opinion encouraged or discouraged the practice, perceived barriers and enablers to adoption, potential messages to encourage adoption, and potential noncommunication activities to promote adoption, such as increasing access to soap or potties at an affordable price. The rich data obtained during household visits played a key role in refining the choices of SBCC messaging, including drafting messages to capture or address the motivators or deterrents. (See Appendix 3. Behavior Change Frameworks.) Building on the specific SBCC actions, potential activities were suggested to detail platform and audience to increase uptake of each practice in Sierra Leone. This analysis shaped which specific practices to promote, and the instructions and key messages to employ to motivate adoption on a wider scale.

Introduction

Despite increased donor attention, particularly in the wake of the 2014-2015 Ebola crisis, Sierra Leone remains one of the poorest and least developed countries in the world. This continued poverty has significantly contributed to stunting in the country’s most vulnerable population. As of 2014, 76 percent of children 6 to 59 months of age were anemic and 29 percent were stunted (SLMN 2013; SMART Survey 2014). In the Tonkolili district, stunting increased between 2010 and 2014 from 33 to 41 percent (SMART Survey 2010; SMART Survey 2014).

SPRING commenced work in Sierra Leone in January 2016. During the fall of 2015, BFS requested SPRING to conduct a nutrition assessment to inform the broader Feed the Future investments in nutrition-specific and nutrition-sensitive actions that would complement other donor and government investments to address stunting and anemia, especially among pregnant/lactating women and children under two years of age.

Following the assessment findings, SPRING commenced the development of small-scale approaches for improving stunting and documenting learning to inform longer-term programming. Given the short timeframe, SPRING placed an emphasis on maximizing opportunities for collaboration, learning, and adaptation during the eight month implementation period. Working through HKI, our international partner with an established presence in Sierra Leone, SPRING tested several approaches for increasing the demand for and consumption of diverse, nutrient-rich foods at the household level as well as increasing the access to and quality of nutrition-sensitive agricultural services.

Following the assessment findings, SPRING commenced the development of small-scale approaches for improving stunting and documenting learning to inform longer-term programming. Given the short timeframe, SPRING placed an emphasis on maximizing opportunities for collaboration, learning, and adaptation during the eight month implementation period. Working through HKI, our international partner with an established presence in Sierra Leone, SPRING tested several approaches for increasing the demand for and consumption of diverse, nutrient-rich foods at the household level as well as increasing the access to and quality of nutrition-sensitive agricultural services.

Methodology

Nutrition and WASH interventions often request households to change behaviors without much discussion as to why or how certain pre-selected behaviors should be adopted or how they affect specific members of a household. HKI and SPRING instead aimed to improve the uptake of select behaviors by consulting with families on which improved behaviors might be most feasible and acceptable for them to adopt. In order to improve on the nutrition and WASH practices, the program designed a research study using the TIPs methodology to test increased consumption of pumpkin, handwashing with soap, and keeping children away from feces within 1000day households.

TIPs makes provisions for practices to be selected and pretested at the household level. It provides an understanding of families' preferences and capabilities, as well as the barriers and enablers encountered in trying new behaviors and practices. TIPs focuses on behavior, that is, what people do, rather than on knowledge, that is what people know or believe. Through this assessment, the program learns directly from families themselves who trial the behaviors.1 The dialogue and data from the TIPs visits helps to select priority behaviors to promote and develop tailored, contextually appropriate, and pretested messages for the promotion of these behaviors to the target audiences.

In order to test approaches to increase demand for and consumption of diverse, nutrient-rich foods at the household level, SPRING/Sierra Leone first identified two commodities based specifically on identified nutrient gaps among women who are pregnant or lactating and children 6–23 months of age, The two commodities identified were pumpkin and fish. Pumpkin and fish are widely consumed in Sierra Leone but not necessarily by the target population. Pumpkin is rich in vitamin A and fish is rich in protein; both of which are deficient in the Sierra Leone diet. The team agreed to carry out three complementary formative research activities within the 1,000 days households: barrier analysis for fish and pumpkin consumption; TIPs for key critical WASH behaviors and infant and young child feeding practices; and an adapted value chain analysis to identify barriers and enablers within the food system for access to fish and pumpkin. The specific objectives of the TIPs research were as follows:

  1. Test mothers' responses to recommendations for improving infant and young child nutrition, WASH and other desired practices and determine which ones are most feasible and acceptable.
  2. Investigate the constraints on mothers' willingness to change feeding patterns as well as hygiene and other daily routines and their motivations for trying and sustaining new practices.

Process

The first step in the TIPs methodology was to create and prioritize a menu of evidence-based behavioral options using existing data and knowledge of the local context. This step also included a WASH technical advisory meeting which contributed to the selection of priority behaviors with district WASH representatives. This research focused on three key areas of WASH and nutrition behaviors that impact stunting during the first 1,000 days of life, or WASH 1,000: handwashing with soap at critical times; cleaning the home/play environment, including safe disposal of feces; and appropriate complementary feeding of children 6–23 months. Counseling cards were drafted depicting the key behaviors to assist interviews during the second visit. (See Appendix 3.) The selection of the menu of key behaviors was followed by three household visits, during which enumerators:

  1. interviewed, observed, and understood the household’s context and current behaviors;
  2. counseled and negotiated one to two new specific behaviors that the household was willing to try;
  3. followed-up to understand which behaviors households were able and not able to do and to learn about the most important barriers and enablers to the suggested behaviors. The third visit also served to solicit suggestions from the participants about how to modify and promote the behaviors.

Training of Enumerators

A three-day training introduced enumerators to the TIPs process, familiarized them with Themne2 translations of the forms, and prepared them to interview and subsequently negotiate the suggested practices with mothers and other members of the household. Five individuals (four men/one woman) were identified as interviewers and note takers and participated in the training along with the technical and logistic advisors. The two strongest counselors were selected as interviewers (one woman/one man) while two other trainees were selected as note takers (two men) to visit households in pairs. A half day of training was used to pretest the questionnaire to ensure appropriateness, understanding, and fluidity, and allow interviewers and note takers to practice in the field.

An additional day of training was provided immediately before the third household visits to review, finalize, and practice the third visit Follow-up Interview Guide.

Sample Selection and Size

The TIPs assessment was conducted in eight households in three communities Helen Keller International asked the District Health Management Team (DHMT) to facilitate household selection within communities with mixed religions and of varied size and distance from main roads. DHMT worked through Peripheral Health Units (PHUs) to identify households with children aged 6–23 months and various occupations of mothers. The three communities visited were Komrabia Junction, Kaimp Kakoloh, and Mododra within the two chiefdoms Malal Mara and Kholifa Mabang in the Tonkolili District. The communities were selected based upon distance from the main road varying from close to far as it would impact access to market. Within the households that were identified by the PHU was the occupation of the mother, a variety of those who were farmers, traders and those with disposable income as these were seen to impact on access to commodities. Pre-visits were made to ensure appropriateness and route, share our purpose, and confirm approval from the Village Headmen of each community. At the beginning of the first household interviews, interviewers asked to verify the child’s age with the child’s health card and the mother’s occupation was recorded. Three visits spread over two and a half weeks were made to each of the 24 households. One household was unavailable for the second visit, so the findings and conclusions reflect the 23 households who participated for all three visits.

Implementation Schedule

Each day of fieldwork, each of the two field teams visited four households (total of eight) within one community. During the first visits, interviewers offered the participating mothers (and members of the household the mother invited to join the interview) a brief explanation of the research, emphasizing that the team would visit two more times, and interviewed about household consumption of pumpkin as a complementary food as well as about specific WASH practices. Fathers were eager to be involved and some participated in all three visits and assisted with the trial of new practices. During the first visit to each village, the technical and logistics support persons also conducted transect walks of the villages and informal key informant interviews with village heads, in order to provide additional observational data to be triangulated with the interviews and help to develop trial recommendations.

Based on interview responses and observations, the teams analyzed the initial data to identify areas for improvement and to develop recommendations tailored to each household for the second visit a few days later. During the second interview, the interviewer counseled each family with targeted suggested practices based on the priority research behaviors and areas of improvement identified in the first household visit. More crucially, interviewers and families negotiated their selections from the menu of suggested practices, in order for mothers to express their preferences, concerns of practicality, modifications, and to agree to try the new selected practices for the period of the trial.

Approximately two weeks later, the third and final visits offered an opportunity to follow up with mothers to observe and discuss if and how mothers adopted the suggested practices, why or why not, if and how they modified the recommended practice and why, and their positive and negative reactions. Specific questions for mothers aimed to capture not only what made adopting the practice easy or hard and who in the household supported the adoption, but also if and how she would recommend the same practice to a friend. In some households, mothers had adopted and shared information for practices in addition to the ones that they had agreed to during the second visit.

Findings

Characteristics of the Communities

Information on characteristics of each of the communities was gathered during the transect walks and key informant interviews with village heads.

Komrabai Station, Kholifa Mabang

  • 25 Houses – soon to be 29
  • 5 wells, 3 functioning
  • Maternal and Child Health Post (MCHP) – small with derelict facilities, no soap or water in Veronica bucket,3 nearby well dry
  • Primary school in village
  • Secondary school 4 miles away

Kiamp Kakolo, Malal Mara

  • 71+ Houses
  • River at one end of village
  • 5 wells, only 1 functioning (at the school)
  • MCHP – larger seemingly in good condition
  • Primary school in village
  • Told that pumpkins do not seem to grow well in village

Madora, Malal Mara

  • 64 Houses
  • 3 functioning wells
  • Primary school in village
  • No PHU in village
  • Community cassava factory & community rice fields
  • Fire destroyed numerous homes the week prior to TIPs visit

Ideal Practice 1: Feed Pumpkin to Children 6–23 Months at Least Two Times a Week

During the first household visits, interviewers inquired about current feeding practices within each family. The interview team found that most mothers were currently breastfeeding their child aged 6–23 months, while two mothers were still practicing exclusive breastfeeding and had yet to introduce complementary foods to their children who were aged seven months and 13 months. The majority of children were sick with diarrhea, fever, or vomiting at the time of or just prior to the first household visit. Few mothers had previously fed pumpkin to their children and identified current barriers to be lack of availability and the high price. Children of all ages and adults in the villages were observed frequently eating mangos, which were in season.

From the information gathered during the first household visit, the team created a targeted menu of behaviors specific to each household that would be recommended to mothers during the second visit. Based on the concerns about availability of pumpkin at the time of the TIPs assessment, interviewers discussed adapting the recommendation to promote both increased consumption of pumpkin and other colorful fruits and vegetables as complementary foods.

More mothers were interested in feeding their children colorful fruits and vegetables for the period of the trial than in finding and feeding their children pumpkin due to issues of seasonality. Of the 16 families counseled on feeding practices, 13 households agreed to try feeding their 6–23 month olds other colorful fruits and vegetables as complementary foods in place of pumpkin until it was available and nine households agreed to specifically try to find and buy pumpkin to feed their child. The options for sub-practices to trial for increasing consumption of pumpkin included: preparing pumpkin as a snack, combining pumpkin with other food, and cooking and mashing up pumpkin to serve as pap along with the less popular suggestion of buying a pumpkin with your neighbor to share. (See Appendix 1 for the analysis of sub-practices suggested and tried.). Mothers who did not choose this practice were asked why they were not interested in trying the behaviors, and one mother explained, “The unavailability makes it very hard and the cost also for now. And sometimes risky to send someone to go for it from a far distance for he/she might not come with your money.” For the two mothers who had yet to introduce complementary food, interviewers negotiated introducing complementary food including colorful fruits and vegetables and the mothers agreed to try. (See Table 1 below for a list of the commonest reasons for agreeing to try or adopt and commonest reasons for not agreeing to try or adopt a specific feeding sub-practice.)

Upon returning two weeks later for the third household visit, five of the nine households that agreed to try had fed pumpkin to their child. Many households had positive experiences providing pumpkin to their child: the child liked the taste (finished the bowl given), it alleviated the child’s constipation, it filled the child’s stomach, and after eating it, the child apparently disturbed mothers less (due to fullness): “Because I can see great improvement in her growth and she now stools freely and very active and disturbs less. So I will continue.”

For the 9 of 13 households that agreed to feed their children colorful fruits and vegetables, mangoes were provided most frequently as they were plentiful, along with bananas and papaya in some cases. Participants not successful in adopting the behavior referenced cost and availability issues; “It was hard to get the rice and the palm oil (cost) and banana and pineapple are not available.” One of the two mothers who agreed to introduce complementary food to her child had successfully tried the practice, while the other mother shared with the interviewer that she struggled to get the child to eat anything, despite having tried on multiple occasions.

This practice was promoted because consuming vitamin-A rich foods such as pumpkin, mango, and papaya provides a critical micronutrient for children aged 6–23 months. The positive and negative input families shared during the research will inform the creation of SBCC materials to promote using these foods as complementary foods to be used in Tonkolili and surrounding communities.

Table 1. Reasons for Agreeing or Not Agreeing to Try or Adopt Specific Feeding Sub-practices

Table 1.1. UNAP Objectives and Strategic Areas

Suggested PracticeMost Common Reasons for:
Agreeing to TryTrying or AdoptingNot Agreeing to Try of Adopt a Practice
  • 1.1 Try feeding to child more than once before giving up.
  • 1.2 Encourage the child with active/responsive feeding.
  • 1.3 Cook and mash up the pumpkin for stews or pap.
  • 1.4 Combine pumpkin with other foods. Use clean bowl and spoon to mash pumpkin and serve on its own.
  • 1.5 Buy slice more often/when available and cook all so no rot/waste
  • 1.6 Buy a pumpkin with your neighbor to split
  • 1.7 Buy it on your own
  • 1.8 Increasing consumption of pumpkin by children aged 6–23 months
  • Counseling motivated mother
  • Pumpkin can make her child stronger and healthier
  • Child likes pumpkin and fills stomach; child disturbs less.
  • Child no longer constipated
  • Pumpkin not always available; expensive
  • 1.9 Prioritize other colorful fruits and vegetables as complementary foods
  • Counseling
  • Health benefits for child
  • Mangos plentiful, children like
  • Colorful fruits and vegetables are unavailable
  • Child did not like mango and other foods are expensive

Ideal Practice 2: Handwashing with Soap and Running Water at Five Critical Moments

The first interview included a number of questions on handwashing practices. Only one mother claimed to always wash her hands with soap, while two mothers indicated they never use soap, and the remaining 20 mothers sometimes use soap when washing their hands. Some mothers shared that ash was occasionally used to wash hands as almost all mothers perceived that it was hard for their family to have soap for handwashing, predominantly due to issues of affordability and availability at the village level. Four of the five critical moments prioritized for handwashing - before preparing food, before eating or feeding a child, after defecating, and after changing or cleaning a baby – had high frequency of ‘always’ and ‘sometimes.’ Handwashing after working with livestock/animals had the poorest responses with five ‘never,’ 15 ‘sometimes,’ and only two ‘always.’ There were no designated handwashing stations observed in any households, though culas4 were strategically placed (and moved often) around to rinse hands at various times. Similarly, household members were observed rinsing their hands often but seldom with soap. While few wells were functioning in any of the communities, respondents did not voice inaccessibility of water as a barrier to handwashing.

Eighteen households agreed to try an improved handwashing practice during the second household visit. Fifteen families agreed to trial keeping soap by the handwashing station, including instruction on making liquid in a bottle, after being counseled to do so. See Table 2 below for a list of commonest reasons for agreeing to try, trying or adopting and commonest reasons for not agreeing to try or adopt a specific handwashing sub-practice. Motivating factors included the counseling visit that households received and an increased perception of importance of soap to clean hands and to prevent hands from smelling of feces (“poo”). Along a similar thread, counselors negotiated with mothers to prioritize soap for handwashing as most families typically had it available and used soap for bathing and laundry but not for handwashing. Six agreed to trial. Also popular was the suggested practice of establishing a handwashing station using a “tippy tap.” The interviewers counseled and provided illustrated instructions on various types of tippy taps and also demonstrated for each family how to make one using an empty one-liter water bottle. After the demonstration, many families were enthusiastic to adopt this practice. While a variety of designs were presented to the families, the water bottle design was demonstrated – and was appealing to the families - because of the bottles’ availability and low cost and the fact that it all that was needed.

While a few mothers had previous knowledge of how to make soap, seven of the ten families who were suggested to make their own soap either alone or with neighbors, considered trying it. Yet only two agreed to try the practice. The issues voiced included the expense of materials to make soap and the challenge of organizing and sharing costs of purchasing with neighbors. The least popular recommended practice was buying soap and splitting it with neighbors to share costs as only one family of the nine counseled agreed to try the practice. One woman explained, “Buying soap with neighbor the problem there is the person sharing will think he/she should have more than the other. So this one won't work.”

Upon returning for the third household visit, interviewers were pleased to observe improved WASH practices and hear positive experiences trying new practices from the majority of participants. Frequent responses included fresher and better smelling hands, “I like when you come from the latrine and wash hands with soap and water as I no longer have the smell of my poo.” While only six families had committed to prioritizing soap for handwashing, 11 families shared with interviewers they had adopted this practice, often citing the counseling during the second visit as the reason: “Through the counseling…that really motivated me because before I (did) not know the benefit of using soap.” Incorporating the messages and input from households will create stronger, contextualized messages and more effective SBCC materials.

For the practice of establishing a designated handwashing station, the 16households who planned to continue the behavior surpassed the 12 households that were initially willing to try. Four additional households not part of TIPs independently decided to construct tippy taps after seeing their neighbors use one even though some households targeted did not succeed. Families appreciated that the TIPs research team demonstrated construction and that materials needed to construct the simple handwashing stations were readily available. Many mothers felt that the handwashing station additionally “serves as a reminder to wash hands immediately after using the toilet or handling dirt or feces.” In many cases, there was strong male involvement as husbands, uncles, and fathers-in-law assisted in the construction and maintenance of the handwashing stations. For families that did not succeed in trialing and adopting the practice of designating a handwashing station, problems included lack of time, money, and the concern that children would destroy it.

While children wasting liquid soap was voiced as a concern, ten of the 15 households who agreed to keep liquid soap at the handwashing station adopted the practice and appreciated the benefit of their bar soap lasting longer when placed in a bottle with water to make liquid form.

The high uptake of building a handwashing station with liquid soap shows promise for future WASH interventions.

Table 2. Reasons for Agreeing or Not Agreeing to Try or Adopt Specific Handwashing Sub-practices

Suggested PracticeMost Common Reasons for:
Agreeing to TryTrying or AdoptingNot Agreeing to Try of Adopt a Practice
  • 2.1-2.2 Prioritize soap for handwashing and keep soap by the handwashing station - i.e. make liquid soap
  • Counseling and increased perception of importance of soap to clean hands; to prevent hands from smelling of poo.
  • Counseling and health benefits
  • To have clean hands; to prevent smelling or eating poo
  • Liked innovation of liquid soap
  • Expense and unavailability of soap and ingredients to make soap
  • 2.3 Home make soap yourself or with others (i.e. a mother’s support group).
  • Already know how to make soap and practicing
  • More cost-effective to buy ingredients and make larger amount than buying soap
  • Hard to organize and share costs with neighbors
  • Ingredients expensive
  • 2.4 Buy soap and split with neighbors to share costs
  • 2.5 Use ash instead of soap.
  • Had previously practiced
 
  • Sharing problematic
  • 2.6 and 2.10 Handwashing Station (Tippy tap or cula and scoop)
  • Counseling, ease of practice
  • Serves as reminder to wash hands
  • Counseling
  • To improve health and cleanliness of family
  • Materials readily available, others support it
  • No time or money to construct
  • Children destroy or waste

Ideal Practice 3: Keep Children Away from Feces

Animal feces were observed in all three communities and near most houses, along with trash, mango peels, and other debris. All respondents had seen human or animal feces on the ground around their house or compound. Most mothers knew and explained the fecal-oral route when probed about illness from feces. Two mothers reported placing their children on mats rather than directly on the ground, while other mothers shared that they regularly sweep the courtyard right outside their homes. Almost every household noted that they had a latrine, though many noted it was unusable and full. Even among households with latrines, they indicated that they also still used the bush to defecate. Approximately half of the children 6–23 months were using “poos” (child-sized potties), and mothers were observed teaching children to use poos at quite young ages (around ten months of age). Only two children wore “napkins” (diapers) which were typically cloth wrapped around the child’s bottom and sometimes covered by a repurposed plastic bag or sheet. Many mothers described regularly disposing of children’s feces in the latrine, but a high number of mothers described throwing their child’s feces behind the house or latrine, in the bush, in an open pit, or in a dustbin.

There was also a large number of animals who roamed freely in all the villages, including pigs, goats, sheep, ducks, chickens, dogs, and cats. Animals did, however, have pens and houses used at night to protect them from predators or theft. There were various types of fences observed in every village – around gardens, young trees, animal pens, protecting mosques - though rarely observed around household areas.

During the second household visits, interviewers counseled 14 families on various suggested practices to keep children away from both human and animal feces. Out of the households interviewed, 14 households were counseled on the importance of keeping their small child in a clean, enclosed area to protect them from coming into contact with waste that could make them sick, yet only five were interested in trying a suggested behavior related to this. See Table 3 below for a list of commonest reasons for agreeing to try, trying or adopting and commonest reasons for not agreeing to try or adopt a specific sub-practice to keep children away from feces. At the follow-up visit, neither of the two participants who said they were interested in building a fenced in play area had actually done so. When asked why they were not successful with adopting the behavior, they said that their children were not used to their movement being restricted and they expected that their children would cry or not find the behavior appealing, despite any initial interest in this practice. Four of the 12 families counseled to try placing their child on a clean mat or lapa rather than directly on ground agreed to try, and only one family was successful in trying the practice “child(ren) that have started movement cannot be easily penned or put down on a lapa because they will move off from the penned area or lapa.”

Many households preferred to continue the practice of periodically sweeping the home environment instead, explaining, “Seeing my child play with feces and dirt, especially now that she crawls, motivated me to be sweeping regularly.” This is crucial information to have when designing a WASH 1,000 intervention. As evidence suggests that clean play spaces, free from human and animal feces, for children is a high priority behavior that impacts nutrition. SPRING and partners will use this deeper understanding as we continue to investigate how to further contextualize this suggested behavior and adapt the suggested practices to make them more acceptable.

Table 3. Reasons for Agreeing or Not Agreeing to Try or Adopt Specific Sub-practices to Keep Children Away from Feces

Suggested PracticeMost Common Reasons for:
Agreeing to TryTrying or AdoptingNot Agreeing to Try of Adopt a Practice
  • 3.1 Put child on a clean mat or lapa inside the home and outside.
  • Counseling
  • To keep child clean and healthy
  • To improve health and cleanness of child
  • No mat/lapa to use or money to buy
  • Child moves too much to stay on mat/lapa
  • 3.2 Put child in a penned area that is clean.
    • -Keep the child entertained with homemade toys, siblings, and games.
  • Keep child healthy and safe
 
  • Child not used to movement being restricted
  • Too unfamiliar, not appealing
  • Difficult to construct; others unable to assist
  • 3.3 Collect feces on the ground and dispose of it immediately in latrine/pit/bury far from house (animal and other).
  • To improve cleanliness and health
  • Counseling
  • To improve cleanliness and prevent sickness; improve appearance and smell of home
  • Not enough time at home (at farm during the day), difficult to maintain
  • 3.4 Organize with community for a clean shared play area for all children.
  
  • Too difficult to organize, too unfamiliar
  • 3.5 Help your child use a ‘poo’ (baby toilet) or teach them to use poo on their own. Properly dispose of poo in latrine or bury with ash.
  • Counseling; nicer than child defecating on the ground
 
  • No money to buy a ‘poo’
    3.6 Use cloth napkin; clean your child immediately after defecating, pouring dirty water in the latrine or bury it with ash.
    Counseling
  • To improve cleanliness and health of child; avert smell of poo and rash for child
  • No cloth to use for napkins
  • Prefer teaching child to use ‘poo’, washing napkins a lot of work

The inclusion of men, mothers-in-law, and other members of the household in all three household visits seemed to help facilitate the adoption of practices and encouraged full household participation in the various practices, especially the construction of the tippy tap. Recommendations that necessitated community or neighborly sharing were not widely appealing nor commonly trialed. Overwhelmingly, participants told the research teams that they would continue all trialed practices, though there was no mechanism to verify the long-term adoption of practices.

Although the TIPs methodology does not intend to provide statistically representative information about the greater populations we work with, it is an effective way to contextualize and pretest recommended behaviors to better understand the factors that may prevent or encourage households from adopting a new behavior. This methodology engages people in dialogue and involves them as partners in designing the interventions that work best in their lives to achieve positive health outcomes for themselves, their families, and communities. SPRING is using the results from this research and other complementary research initiatives to inform the development of a social and behavior change strategy to guide the nutrition and WASH 1,000 activities implemented by SPRING and collaborating local partners.

Application of the Findings

To employ these findings to create stronger, contextualized behavior change materials for Sierra Leone, the team developed a modified behavior change framework for each recommended practice to guide analysis and the development of social and behavior change materials. Tracking the number of households that were counselled on each practice, that agreed to try the practice, that did try the practice, and that intend to continue the practice, provided the first indication of acceptability and practicality of each suggested practice (See Appendix 1. TIPs Ideal Practices/ Suggestions Tracking.) Following the completion of the fieldwork, the team entered the responses from all three visits and findings were sorted by each behavior. For each practice that was trialed by households, modified behavior change frameworks were developed to analyze responses from both those who did try and did not try the suggested practice.

The behaviors that were identified to be promoted were those that were trials and found acceptable and feasible to participating households. However, the practice of restricting movement of the young child was not popular, but has been kept as a behavior to be promoted. This is due to the fact that the consumption of animal feces is a critical issue and the promoted behavior to address was new and unusual, but no other option currently exists to address this gap so the team felt it was worth moving forward.

The frameworks were adapted from the Designing for Behavior Change Framework.5 Within each framework, the team classified reported motivators for trying or not trying the behavior under commonly used behavioral determinants.

The team identified specific SBCC actions to address each determinant based on TIPs findings, including drafting messages to capture or address the motivators or deterrents. (See Appendix 3. Behavior Change Frameworks.) Building on the specific SBCC actions, potential activities were suggested to detail platform and audience to increase uptake of each practice in Sierra Leone. This analysis shaped which specific practices will be promoted and the instructions and key messages that will be employed to motivate adoption on a wider scale. Specific messages and images were developed directly from the TIPs findings.

Conclusions

Following up with each household on the specific nutrition and WASH practices over a three week period allowed the team to capture impressions and interest in trying new behaviors, and also to understand the day-to-day realities that facilitated or impeded the adoption of a specific practice in target households. This analysis not only assisted in the development of strategic SBCC strategy and materials, it also provided guidance and understanding on the issues and practices raised for future development efforts and an awareness in Sierra Leone of the TIPS methodology that can be replicated to other assessment topics.

Beyond identifying which specific practices householders find acceptable and feasible, TIPS constituted a crucial step in framing SPRING’s SBCC efforts. By engaging in a dialogue with the same household members during three visits over the course of several weeks while the household was trying out a practice, the team was able to examine householders’ experience with each practice in detail. This detail helped the team to develop a specific SBCC strategy for each practice. Conversations with household members regarding a specific practice helped the team to identify the following SBCC strategy elements: influencers, those individuals whose opinion encouraged or discouraged the practice), perceived barriers and enablers to adoption, potential messages to encourage adoption, and potential noncommunication activities to promote adoption, such as increasing access to soap or potties at an affordable price.6

The rich data obtained during household visits played a key role in refining the choices of SBCC messaging. Examples of impactful findings include the following:

  • Building/using tippy taps and liquid soap were accepted much more enthusiastically than expected. As a result SPRING developed four different counseling cards on handwashing with soap: Critical times to wash, building a tippy tap, creating liquid soap, and steps for proper handwashing.
  • In the communities, many individuals associated the foul smells of feces with ill health (much more so than perceptions of germs.). The images and messages in the counseling cards emphasize the elimination of bad smells as positive consequences of handwashing with soap, keeping the courtyard free of feces, and proper disposal of children’s feces.
  • For keeping children away from feces, informants showed discomfort and unfamiliarity with the idea of placing a child in a pen to prevent contact between the child and animals or other sources of contamination. Householders preferred to sweep the courtyard more frequently since sweeping seen as part of traditional role of women. However, conversations showed that extra sweeping may divert a mother’s time and energy from needed self-care and care of children. Therefore the materials developed promote regular sweeping, but also contain less prominent images of a child in a pen to slowly help familiarize community members with the practice.
  • Household members who reported difficulty in obtaining pumpkin to feed their child showed enthusiasm when the team suggested they substitute mango (which was plentiful at the time and also a good source of vitamin A). Based on these observations, the team is exploring the use of seasonal calendars to promote different locally available vitamin A-rich foods during the season when each is most plentiful.

Such findings would have been difficult to obtain through other formative research methods.

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