Understanding How to Increase Uptake of WASH, Nutrition and Maternal and Child Health Services

"Respondents highlight that having the support of family members and key influencers, in particular husbands and mothers-in-law, to engage with available services would enable them to adopt more positive WASH [water, sanitation, and hygiene], MCH [maternal and child health], and nutrition practices."

This report, published by BBC Media Action, summarises the findings of formative research conducted with mothers, families, and key influencers (husbands and mothers-in-law) to address the water, sanitation, and hygiene (WASH), nutrition, and maternal and child health (MCH) needs of communities in Afghanistan. The qualitative research was designed to inform the Driving Action for Well Being to Avert Mortality (DAWAM) project, which seeks to contribute to decreased morbidity and mortality in women and girls and high-risk groups, including persons living with disability, in Afghanistan. The study sought to identify Afghans' information needs, the barriers and enablers to accessing services and adopting practices, and the key issues for communication to address. The data were collected between December 2023 and February 2024 through 13 focus group discussions with pregnant and lactating women and 30 in-depth interviews with husbands and mothers-in-law in seven provinces.

The findings show that participants had a limited understanding of when and how to treat water to make it safe to drink and limited knowledge of sanitary methods of disposing of household waste and rubbish. While these people have first-hand experience of the various illnesses caused by drinking unsafe water and unsanitary practices, they lack awareness of other options or solutions. Good handwashing and menstrual hygiene practices were also hindered by the limited availability of facilities and materials (such as soap). Knowledge of key WASH, nutrition, and MCH practices among participants is also limited and generic. While participants demonstrate some knowledge of recommended practices, they lack understanding of the importance and/or benefits. This fact means that knowledge is not necessarily translated into practice. 

In addition, knowledge around ideal nutrition for newborns, children under five, and pregnant and lactating women is prone to distortion by traditional beliefs. This situation can lead to some potentially harmful practices, such as giving newborn babies animal fat alongside colostrum and supplementing breastmilk with herbal medicines. While respondents can list nutritious foods that mothers and children under five should consume, in practice it is budget, rather than need, that dictates the type of food that is available to the household. While participants were aware of the benefits of institutional delivery, those living in remote areas often chose to give birth at home, partly because of accessibility issues but also because of prevalent attitudes and social norms.

Many of the perceived barriers to people accessing and availing WASH, nutrition, and MCH services are largely consistent. Key informants and participants reported that the overarching barriers are the lack of access to clinics, hospitals, and services; financial constraints; lack of knowledge and awareness; unhelpful social norms and traditional practices; and a lack of availability of essential medicines and hygiene materials.

The study also showed that the current operating environment for humanitarian organisations in Afghanistan is particularly challenging. Factors include the imposition of restrictive policies under the de facto authorities, such as those preventing women from travelling alone, and practical barriers to the delivery of services, plus the associated decline in donor funding available for the public health sector. As such, access to WASH, nutrition, and MCH services and support, particularly for those living in remote rural areas of Afghanistan underserved by the public health system, is increasingly challenged.

Based on the findings, the report offers recommendations for the way forward, which, in brief, are:

• Address gaps in knowledge and understanding about key WASH, nutrition, and MCH principles, with a focus on understanding the importance and benefits of the uptake of positive practices and available services.
• Dispel traditional beliefs and highlight practices that continue to cause harm. Interventions should sensitively address the issues associated with traditions around WASH, nutrition, and MCH.
• Provide support to overcome practical barriers to accessing services and support, such as by addressing transportation issues for families needing to access health centres by encouraging people to save money for transport or emergencies or providing examples of how communities can support people to access health care when they need it, helping people to engage with mobile health workers and vaccinators.
• Engage remote rural communities directly via face-to-face sessions on WASH, nutrition, and MCH, harnessing the support of trusted local stakeholders and influencers. Utilise effective platforms including schools, mosques, and community shuras for awareness-raising and knowledge-sharing sessions. These initiatives should be supplemented with media content, via radio and television, to reinforce learnings and reach audiences on a broader scale.