Adaptation in rural water, sanitation, and hygiene programs: A qualitative study in Nepal.

Adaptations are modifications made to programming to improve effectiveness or contextual fit, and are important for program improvement. However, adaptations can be detrimental if they do not preserve an intervention's underlying theory of change. We present a case study of 45 adaptations made to rural WaSH programming in Nepal, identified through qualitative interviews with implementers conducted in June through August 2019. For each adaptation, we characterized its target outcomes and implementers' motivations for making the adaptation, and we assessed the adaptation's intended and unintended effects on program quality. Participants described adaptations to both interventions (e.g., changes to hygiene promotion messages) and implementation strategies (e.g., sanctions to enforce toilet construction, such as denying work permits to households without a toilet). Adoption was the most common target outcome, specifically increasing toilet construction. Other target outcomes included feasibility of program delivery, acceptability of messages or WaSH products, reach of program activities in the community, and sustainability. Implementers were commonly motivated by intense pressure to meet national open defecation free targets. Most adaptations achieved their target outcomes. However, sanctions adaptations had substantial unintended negative effects. Implementers reported that sanctions were unpopular with communities and had poor sustainability. In contrast, non-sanctions adaptations that targeted outcomes of feasibility, acceptability, and sustainability had few unintended negative consequences. Our findings suggest that adaptations to promote rapid adoption of toilet construction do not consistently achieve sustained behavior change. Furthermore, adaptations to improve feasibility of program delivery or cost and acceptability of WaSH products can indirectly improve adoption even when it is not an explicit target outcome.

Non-compliance to the Tobacco Control and Regulatory Act among Vendors in the Vicinities of Schools of a Metropolitan City: A Descriptive Cross-sectional Study.

Introduction: Tobacco use is the underlying cause of ill health, preventable deaths, and disabilities worldwide. The Tobacco Product Control and Regulation Act 2011 prohibits the sale of tobacco in public places including educational institutions but non-compliance to the law had not been assessed. This study aimed to find out the prevalence of non-compliance to the Tobacco Product Control and Regulation Act among vendors in the vicinities of schools in a metropolitan city. Methods: This descriptive cross-sectional study was conducted in a metropolitan city in August 2018. Ethical approval was taken from Institutional Review Committee [Reference number: 23(6-11-E)2/075/076]. A convenience sampling method was used to recruit vendors within 100 meters radius of secondary schools. The data were collected through face-to-face interviews using a semi-structured questionnaire. Point estimate and 95% Confidence Interval were calculated. Results: Out of total 217 vendors, non-compliance to the section 3 of section 11 of Tobacco Product Control and Regulation Act was found in 195 (89.86%) (85.84-93.88 at 95% Confidence Interval). Among the non-compliers, 110 (56.41%) were selling both smoked and smokeless tobacco products, 78 (40%) were selling smoked and 7 (3.59%) were selling smokeless tobacco products. Conclusions: The non-compliance with Tobacco Product Control and Regulation Act's prohibition of tobacco sales within 100 m of schools in Kathmandu Metropolitan was similar with other studies conducted in similar settings. Keywords: government regulations; primary schools; vendors.

Successes, challenges, and support for men versus women implementers in water, sanitation, and hygiene programs: A qualitative study in rural Nepal.

INTRODUCTION: Women's active participation is important for inclusive water, sanitation, and hygiene (WaSH) programs, yet gender roles that limit women's access to formal education and employment may reduce their skills, experience, and capacity for implementation. This paper explores differences between men and women implementers of rural WaSH programs in implementation approaches, challenges, and sources of support for implementation, and success in achieving program quality outcomes. METHODS: We interviewed 18 men and 13 women in community-based implementation roles in four districts of Nepal. We identified challenges and sources of support for implementation in four domains-informational, tangible, emotional, or companionship-following social support theory. We assessed successes at achieving intermediate implementation outcomes (e.g., adoption, appropriateness, sustainability) and long-term intervention outcomes (e.g., community cleanliness, health improvements). RESULTS: Women used relational approaches and leveraged social ties to encourage behavior change, while men used formative research to identify behavior drivers and sanctions to drive behavior change. Women experienced stigma for working outside the home, which was perceived as a traditionally male role. Companionship and emotional support from other women and male community leaders helped mitigate stigma and lack of informational support. Women were also more likely to receive no or low financial compensation for work and had fewer opportunities for feedback and training compared to men. Despite lack of support, women were motivated to work by a desire to build their social status, gain new knowledge, and break conventional gender roles. CONCLUSIONS: Both men and women perceived that women were more effective than men at mobilizing widespread, sustained WaSH improvements, which was attributed to their successes using relational approaches and leveraging social ties to deliver acceptable and appropriate messages. Their skills for motivating collective action indicate that they can be highly effective WaSH implementers despite lack of technical experience and training, and that women's active participation is important for achieving transformative community change.

Severe acute malnutrition and its associated factors among children under-five years: a facility-based cross-sectional study.

BACKGROUND: Despite consistent efforts to enhance child nutrition, poor nutritional status of children continues to be a major public health problem in Nepal. This study identified the predictors of severe acute malnutrition (SAM) among children aged 6 to 59 months in the two districts of Nepal. METHODS: We used data from a cross-sectional study conducted among 6 to 59 months children admitted to the Outpatient Therapeutic Care Centers (OTCC). The nutritional status of children was assessed using mid-upper arm circumference (MUAC) measurement. To determine which variables predict the occurrence of SAM, adjusted odds ratio was computed using multivariate logistic regression and p-value < 0.05 was considered as significant. RESULTS: Out of 398 children, 5.8% were severely malnourished and the higher percentage of female children were malnourished. Multivariate analysis showed that severe acute malnutrition was significantly associated with family size (five or more members) (Adjusted Odds Ratio [AOR]: 3.96; 95% Confidence Interval [CI]: 1.23-12.71). Children from severely food insecure households (AOR: 4.04; 95% CI: 1.88-10.53) were four times more likely to be severely malnourished. Higher odds of SAM were found among younger age-group (AOR: 12.10; 95% CI: 2.06-71.09) children (0-12 vs. 24-59 months). CONCLUSIONS: The findings of this study indicated that household size, household food access, and the child's age were the major predictors of severe acute malnutrition. Engaging poor families in kitchen gardening to ensure household food access and nutritious diet to the children, along with health education and promotion to the mothers of young children are therefore recommended to reduce child undernutrition.