TERMS OF
REFERENCE
Terms of Reference for contracting an international consultancy to develop a Community Behaviour Change (CBC) Module using Participatory Learning and Action (PLA) methodology in Uzbekistan
UNICEF in Uzbekistan requires services of an individual consultant affiliated with a specialized consulting institution or center of excellence in the areas of Communication for Development, community work and/or civil society development.
The consultancy is required for the development, field-testing and introduction of a comprehensive Community Behaviour Change Module based on the Participatory Learning and Action (PLA) approach for adoption and sustaining five key mother and child caring behaviours in pilot communities of Namangan province and the Republic of Karakalpakstan of Uzbekistan.
1. Background and Justification
Steady progress has been achieved by Uzbekistan in improving health, nutrition and well-being of mothers and children since gaining the independence in 1991. The under-five mortality rate fell from 74 to 38 per 1000 live births between 1990 and 2008.[1] This has been achieved as a result of improved health care and progressive implementation of newborn and child survival interventions.
However, a number of challenges still need to be addressed. From the maternal and child health point of view, the neonatal mortality rate at 26 per 1000 live births is 2.5-3.5 times higher if compared to EU member states[2]. More than 79 per cent of infant deaths occur during the first 30 days of life due to avoidable causes like birth asphyxia, neonatal infection and diarrhea[3].
Although the Government pays attention to improving nutritional status of pregnant women and young children under the age of 5 years old, these groups remain vulnerable and suffer from multi-micronutrient deficiency disorders such as anemia and iodine deficiency disorder. Traditional practices of infant and young child feeding with food that is not mineral and vitamin rich worsen the situation. One third of children and 37% of women in childbearing age are anemic and only 53% of households consume iodized salt[4]. Child deprivation to nutrition is more widespread among the rural families and level of chronic malnutrition (stunting) is 19%. Around 5% of children are born low weight and 5% of children suffer from underweight.
Low coverage of exclusive breast feeding (26%), early introduction of less calories dense complementary food, ignorance of appropriate infant and young child feeding practices and illnesses due to diarrhea and respiratory illnesses are responsible for malnutrition in children.
Poor hygiene practices lead to high infestation with intestinal parasites. Coupled with poor sanitary conditions, infestations cause the high incidence of diarrhea, micronutrient deficiency (nutritional anemia), under nutrition and delayed cognitive development in children. In Uzbekistan the overall infestation with intestinal parasites is 7.8 times higher than other enteric diseases.
The early years, especially the first three years of life, are very important for the development of a baby’s brain. Everything she or he sees, touches, tastes, smells or hears helps to shape the brain for thinking, feeling, moving and learning.
Responding to the child’s needs by holding and/or talking soothingly to her or him will help establish a sense of trust and security. This kind of early bonding and attachment to the mother, father or other close caregiver helps a child develop a broad range of abilities to use and build upon throughout life. These include the ability to learn, be self-confident and have high self-esteem, have positive social skills, have successful relationships at later ages and develop a sense of empathy.
Early bonding with a child could also help decrease the level of institutionalization of children with disabilities and those from the most vulnerable families through creating close emotional link with the child.
While cost-effective, affordable and high-impact interventions implemented as part of the health care system reform initiated by the Government contribute in improving the situation and safe lives, they are not enough for long-term, sustained impact. No matter how efficiently medical services are provided, children will continue to die from preventable diseases, become malnourished and have their growth and development compromised, if their families and communities do not also care for, protect and nurture them more effectively.
Despite Government’s effort to raise population’s health awareness through the work of patronage nurses and community advisors, significant knowledge and practice gaps in terms of key health and protection household practices compromise the delivery of the continuum of care.
Part of the problem is that the communication interventions are very message-based and rely on issuing instructions with little or no emphasis on inter-personal communication skills of service providers. There is a need in strategies and approaches that will not only help provide caregivers and community members with the essential information, but promote a deeper understanding and collective deliberation about existing social expectations of families and their reference networks regarding the recommended behaviours, anticipated barriers to changing them and collective solutions to address these barriers. This participatory approach, which is new in Uzbekistan and to a large extent in the region, will help develop the self-efficacy and confidence of families and communities in taking informed decisions to adopt and sustain the recommended behaviours, to assure the health and well-being of their children and themselves too.
Therefore, following a consultative process, UNICEF in cooperation with the Ministry of Health (MoH), Women’s Committee and Makhalla Foundation identified key positive household behaviours to be promoted through a participatory process among caregivers of children under the age of five years. These are:
· Parents and other primary caregivers recognize and respond to ‘danger signs’ of childhood illnesses;
· Mothers are supported to practice exclusive breastfeeding (EBF) for at least six months of a baby’s life and provide complimentary feeding thereafter;
· Families take action to improve their food security and distribution to children, pregnant women and lactating mothers; they practice a balanced diet with nutritional variation;
· Communities practice proper hygiene behaviours with focus on hand washing with soap and water. Children and family members wash hands thoroughly with soap and water before handling food, after using the toilet or disposing of faeces, before feeding a baby and after touching domestic animals;
· Parents and other primary caregivers create early emotional bonding with young children, play with them and stimulate their cognitive development,
Brief description of the Community-based Behaviour Component:
The package of key behaviours will be piloted under the Community-based Behaviour Change Component of the Improving of Mother and Child Integrated Health Services Project Phase II (2013-2016), joint initiative of the Ministry of health, European Union and UNICEF. The component will be implemented and monitored in:
· 3 rural communities and 3 urban communities of Namangan province (with 1 rural and 1 urban control communities identified).
· 3 rural communities and 3 urban communities of the Republic or Karakalpakstan (with 1 rural and 1 urban control communities identified).
The component will use a holistic communication strategy to promote positive health, nutrition, hygiene and child care practices in households. The strategy will use a mix of communication approaches from mass media to inter-personal communication to community participation for reaching individuals and their families in the pilot communities.
The key element of this strategic mix is Participatory Learning and Action (PLA). Through PLA approach individuals/families will receive information, analyze it collectively, and identify issues of concern and perceived need for change in behaviour or practice. The PLA process would enable neighborhood community groups to also identify barriers to changing existing behaviours or adopting new ones. This would enable them to internalize jointly negotiated solutions, weigh the consequences or benefits of positive change and negative outcomes or risks of not changing behaviour practices. The participatory process would also create support groups within the community that would conduct informal monitoring, keep families motivated for change and contribute to sustain change by engaging with family members and those who influence them.
In terms of participant groups (or target audiences), interventions under the community-based component will address the primary audience at the household level whose behaviors are intended to change as well as secondary participants who would support or reinforce the change through an array of actions and channels. PLA methodology will be used for initiating, reinforcing and sustaining the intended behaviour outcomes and monitoring behaviour change.
PLA participants will be trained in community-based monitoring of behaviour change using indigenous community resources – human and material. Through the PLA process the community influencers will assist the communities in promoting and sustaining behaviours at the household level.
PLA sessions for each community will be conducted for four days. During these four days participants will analyze the health, nutrition and child care situation in their communities and families (particularly those with newborns and children under 5 years old. They will also monitor progress against identified indicators and benchmarks for expected behaviour change related to the five behavior outcomes as well as the facilitating factors and barriers associated with the targeted change.
On the fifth day following the 4-day PLA training, a smaller volunteer group of influential people in the community (men, women, young people and school children) will be assigned specific tasks for following up with the PLA participants, mobilizing them to continue practicing the behaviours and ask questions when confronted with doubts or a desire to seek additional information. They will mobilize teams and conduct appropriate activities to encourage practicing of new behaviors and sustain their outcomes. They will also be responsible for community-based monitoring of new or modified household practices following the PLA and supporting activities against agreed behaviour change indicators.
Patronage nurses from the Ministry of Health side and community advisors from Women’s Committee side will be trained as PLA facilitators. They have full access to households within the communities. They will be supported by health promotion doctors and nurses from the Institute of Health and Medical Statistics at the district level.
The facilitators are the backbone of the PLA exercise and the success of the component depends to a large extent on their ability to engage participants, to create an enabling environment for them to participate in the dialogue process – identify issues, problems, share their endogenous knowledge, beliefs, family influences as well as difficulties, voice their doubts, contribute to the joint analysis of problems and explore solutions jointly in as open and free a manner as possible. They will be trained to listen to the community members actively, encourage them to speak and participate and jointly agree on action to be taken in the interest of the community through a 5-day PLA Facilitators’ Workshop.
Currently, the KAP research is underway to: 1) collect baseline information on 5 key mother and child care and protection behaviours; 2) identify and understand existing social norms and potential motivations for the adoption and sustained practice of key behaviours; 3) identify relevant sources of information and channels, power dynamics, groups and social networks that can influence household and community behaviours and practices.
Findings of the KAP study along with other available information sources will be used in developing the Community Behaviour Change Module.
All activities under this consultancy will be undertaken in close consultation with the Ministry of Health, Women’s Committee and Makhalla Foundation.
2. Purpose of the Assignment
The overall purpose of consultancy is to develop a Community Behaviour Change Module, implementation methodology based on the PLA approach, identifying the required training materials and schedules to enable selected communities of Namangan province and Karakalpakstan to adopt and sustain key positive practices. The module and implementation methodology should be accompanied by a clearly outlined community support and sustainability component also linked to creating demand for quality services and optimum use of community resources. The methodology should have a strong monitoring component for the performance of facilitators as well as for measuring change in knowledge, attitudes and practices at the household and social normative levels.
It is expected that the consultancy will be implemented in two phases (detailed tasks for both phases are listed in point 9 of the ToR).
The consultant will:
· Review and use existing KAP study findings to inform the CBC module design.
· Conduct additional analysis using social norms diagnostic tools to build in social expectations of the community regarding the recommended behaviours and their endogenous knowledge about these behaviour practices.
· Apply existing international best practices in developing the participatory learning and action methodology.
· Develop a facilitation module and brief guidelines on how to use it.
· Ensure that the module includes the following chapters:
1) Profile of the facilitators (skill set and professional time requirement);
2) Community information gathering and situation analysis focusing on empirical expectations (perception of how others will act) and normative expectations (perception of how others expect one to act) with regard to the package of key behaviours;
3) Collective deliberation about normative issues and problems in addition to personal beliefs and customs that create barriers in practicing the recommended behaviours;
4) Analysis of other barriers related to infrastructure, socio economic factors etc.;
5) Exploring solutions jointly. Community action plan development, collective declaration / commitment with regard to the package of key behaviours;
6) Community action plan implementation mechanisms;
7) Establishing community support groups to prevent relapse and provide motivation to communities;
8) Community-based monitoring: methodology and collective reflection;
9) Collective reflection, self-sustainability planning to establish an enabling normative environment for recommended behaviour practices (implementation, monitoring and maintenance of behaviour practices, documentation, and information/feedback to Makhalla and district authorities.
· Develop the list and concept of behaviour change communication (BCC) materials to be included into the PLA toolkit to create an enabling social normative environment and promote the package of behaviours.
· Assist in field-testing of the module and PLA toolkit materials.
· Co-facilitate the training of 80 local facilitators in the use of the PLA module and toolkit (two 5-day workshops) and develop a refresher training schedule and performance monitoring indicators.