Reference No: 16/05/02/003

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1 Consultant Scope of Work for Hygiene Consultant for Mother and Baby WASH and IYCF Thrive Project 1.0 Introduction Reference No: 16/05/02/003 Catholic Relief Services (CRS), the official international humanitarian agency of the Catholic community in the United States, was founded in 1943 by the US Conference of Catholic Bishops. CRS seeks to cherish, preserve, and uphold the sacredness and dignity of all human life, foster charity and justice, and embody Catholic social teaching as we work with local partners to promote human development by responding to major emergencies, fighting disease and poverty, and nurturing peaceful and just societies. CRS supports international relief and development work in 101 countries and territories spread across Africa, Latin America, the Caribbean, South and Southeast Asia, the Balkans, and the Middle East and in the completed fiscal year (FY14), our programs touched 85 million lives. While we seek to capitalize on our strategic advantages as a faith-based organization, all of our programs assist people on the basis of need, regardless of creed, ethnicity or nationality. CRS and our partners work with impoverished individuals and communities through programs that reflect the preferential option for the poor, reaching out to the most vulnerable and marginalized. As part of our agency health strategy, CRS invests in child health and wellbeing, benefiting children under the age of 17, while prioritizing interventions in early childhood development (ECD) and social service systems strengthening. We promote a holistic approach to health---with a goal of not only saving lives but also optimizing children s physical, emotional and cognitive development. Interventions are age appropriate and operate across multiple levels and actors facilitating multi-sectoral integration with agriculture, microfinance, education and health. 2.0 Project Goal and Objectives THRIVE project implemented by CRS and six of her partners is a two year project beginning January 2016, whose goal is to create a culture of care and support for HIV and AIDS affected children under two years and their caregivers in Kenya, Tanzania and Malawi. Funded by Conrad N. Hilton the project has developed a sustainable model for ongoing support to households so that caregivers of children under two practice early childhood stimulation; positive parenting; infant and young child feeding and water, sanitation & hygiene behaviours while incorporating into health facilities early stimulation, positive parenting counselling and maternal mental wellbeing in Kenya and Tanzania. The project targets an estimated population of 8,800 pregnant mothers and caregivers of children below 2 years in Kenya (2,640); Tanzania (2,640) and Malawi (3520) and has the following strategic objective and result areas. SO: Children under 2 years demonstrate increased attainment of age appropriate developmental milestones by 2017 IR 1.1: Increased adoption of key ECD practices (Early stimulation, positive parenting, IYCF, WASH) among mothers of children under 2 years IR 1.2: Strengthened mechanisms for the promotion of key ECD practices (Early stimulation, positive parenting) at the health facility level IR 1.3: Improved maternal mental wellbeing among mothers of children under 2 years

2 The key project strategy will be to organize pregnant women and caregivers of children under two years using the Care Group model and deliver messages on early stimulation, positive parenting, infant and young child feeding and water, sanitation and hygiene (WASH). Working with community volunteers, participants of the project will be supported using a social and behaviour change and communication strategy during care group sessions and home visits to enhance responsive caregiving practices. At the Health Facility, the project will establish ECD spaces and improve health staff counseling skills by infusing early stimulation and positive parenting messages to ensure a supportive environment for pregnant women during ANC and PMTCT clinic visits. Additionally, health personnel in Kenya and Tanzania, will have their skills built on maternal mental wellbeing. 3.0: Background of Assignment: WASH and its impact on Child Stunting Existing WASH interventions are failing to protect infants and young children from ingesting soil and feces at a critical growth and developmental stage. Interventions focusing on containing animals and prevention of exposure of children s hands from fecal bacteria, from contaminated floors and yard soil are just as, if not more important than hand washing and water treatment. Breastfeeding practices are another major risk factor since mothers frequently introduce water prior to six months of recommended breastfeeding, and they often prepare complementary foods unhygienically. Standard approaches to hygiene promotion - focused on educating people about germs and the value of using soap - have rarely resulted in positive, sustained behavior change (Curtis et al, 2003). It is now increasingly recognized that hygiene behavior is determined by a range of factors and is deeply-rooted in the environment in which the behavior takes place (Curtis, 2009). Although the perinatal period could be an opportune moment to change behavior, little is known about handwashing behavior in this population with regards to how, when and where a new mother fits handwashing into her daily activities and what barriers to optimal practice exist (e.g. fatigue, disruptions of baby to daily routine, etc.). This project will develop an integrated infant and young child feeding (IYCF) and Mother/Baby WASH approach to significant reduce risks of infection of excreta-based disease and test it in two countries over two years where CRS is implementing the Thrive ECD program, namely Tanzania and Kenya. The work will be carefully monitored though baseline and end line surveys to ascertain if infection for the first 1000 days of life is significantly reduced through comparison of villages within the Thrive project and those outside. It is proposed that this work be undertaken with Emory University. The hygiene consultant will collaborate closely with Emory researchers during the assignment. Stunting develops between 9 months before and 24 months after birth, termed the critical first 1000 days and its effects are irreversible. Improving the diets of young children can reduce stunting, though at best, only by about one-third. Frequent diarrheal illness has also been implicated. However, the effect of diarrhea alone on permanent stunting has been found to be relatively small, maybe because children grow at "catch-up" rates between illness episodes. Medical and epidemiological literature documents at least two mechanisms linking lack of sanitation to poor child health. Ingestion of fecal pathogens is well known to cause diarrhea. The second is enteropathy. The hypothesis (Humphreys, 2009) is that a major cause of child stunting and anemia is environmental enteropathy (EE). The hypothesis is that children suffering from enteropathy use much of the nutrients they eat to fight these chronic low-grade infections, using less nutrients from their diet for growing. Much of what is read about malnutrition focuses on food security and the related issues of availability, access, and affordability. The issue of absorption of micronutrients, and particularly the important role played by safe sanitation and hygiene, is frequently overlooked or underemphasized.

3 Infant and young child feeding practices are pivotal for early childhood development. Even in resource poor settings, improved feeding practices can lead to increased intakes of energy and nutrients, leading to better nutritional status. Issues around infant and young child feeding also have been plagued by problems for years. Breastfeeding rates in most countries are decreasing as a result of rapid urbanization and women needing to work and leave their infants at home. Knowledge, however, is not necessarily the issue in influencing mothers to exclusively breastfeed until six months. Changing behavior in present breastfeeding practices requires considerable time and, therefore, the focus on environmental factors to ensure that contamination is prevented during feeding should receive far more importance within IYCF programs along with the focus on breastfeeding support for working women. The impact of helminth colonization on EE is has not been well studied, but considering that prevalence of intestinal worm infection is as high as 50% in children in certain parts of the world, this is a crucial issue that needs further attention (Korpe and Petri, 2012). 3. Purpose of the Consultancy The purpose of the assignment is to support the mainstreaming of an integrated hygiene strategy that focuses on infant and young child feeding, deworming and improved mother and infant hygiene practices to significantly reduce child stunting in ther THRIVE project in Tanzania. The strategy will be based in the THRIVE caregroup model, and be informed by behavioral theory, existing evidence, and formative research to be conducted by Emory study team. The proposed methodology to integrate the BCC campaign is on the premise that Family and community health outcomes are influenced by many factors. A comprehensive approach to social and behavior change recognizes that individual behavior change does not result from improved knowledge alone, and cannot be promoted in isolation from the broader social context in which it occurs 4. Proposed Strategy of Intervention An integrated package of interventions targeted at mothers and infants will be supported and monitored to improve child growth and reduce prevalence of diseases, and these specific interventions will be adjusted over time based on field research results from the partner University (Emory). The three essential objectives of the strategy are: New mothers and children over one years of age should be treated for helminth infections and receive multiple micro-nutrient supplementation, and this should continue until all their children have reached the age of two. Infants should also receive helminth treatment every six months until they reach three years of age. Mothers should ensure good hygiene practices focused on the young infant and for themselves and other direct caregivers in contact with the child. The purpose is to isolate as much as possible, animal and human pathogens from the infant. Mothers should take up improved and hygienic infant and young child feeding practices. This includes not only exclusive breastfeeding until six months but also the safe and hygienic preparation and storage of complementary foods as well as household water treatment and storage for the introduction of water to the infant after six months. 5. Specific Tasks and Outputs The consultant will focus on the following key messages for the development of the hygiene training component for the care group volunteers. Key messages will be theory and evidence-based and informed by research conducted by the study teams, with participation and feedback from the Hygiene Consultant.

4 a) Promotion of the Seven-Point Plan, namely: 1. Mother and baby hand washing and drying at key times (before food preparation, infant feeding and after defecation); 2. Promotion of a protected hygienic play environment for the infant, i.e., away from chickens and other sources of contamination (safe areas); 3. Hygienic infant and young child feeding including introduction of hygienic and nutritious complementary foods after six months of exclusive breastfeeding; 4. Improved household toilets with hand-washing station; 5. Safe disposal of infant and young child feces; 6. Household water treatment targeting the infant; and 7. De-worming campaigns for children over one year and women of child bearing age, including pregnant women in the second and third trimester and lactating women. Details of each message are listed below: 1. Mother and baby hand washing and drying at key times (before food preparation, infant feeding and after defecation) To significantly reduce infection, interventions must directly target the infant to reduce the frequency and intensity of diarrhea and other intestinal infections. With malaria, bednets are targeted at mothers and infants but prevention of other common diseases has been somewhat neglected and the focus has been heavily slanted to treatment. For example, diarrhea is addressed through ORS and chronic infections with antibiotics. In order to reduce the impact of disease upon the child efforts need to focus on reducing the number of episodes of disease and the debilitating impact this has on the nutritional status of the child. Key messages will be developed, pre-tested and targeted for caregivers to protect their child from infection and from themselves passing infection to the child. 2. Promotion of a protected hygienic play environment for the infant, i.e., away from chickens and other sources of contamination (safe areas) It is extremely important that infants in poor communities be protected from exploratory ingestion of chicken feces, soil, and dirt for optimal child health and growth. E. coli (fecal contamination) intake from ingestion of chicken feces is 4000 times greater than that from either untreated drinking water or soil (Ngure, 2013). Children are frequently exposed to fecal bacteria by crawling on cow dung smeared kitchen floors, on bare soil, and on chicken feces in the yard. Chicken coups will be built to prevent contact with children or the construction of a play area with fencing for the child. 3. Safe disposal of infant and young child feces There is a far higher prevalence of pathogens in children s feces. Tailoring messaging to caregivers is essential, for example, placing emphasis on disposing the feces into a toilet/latrine for children not developmentally able to use a toilet and promoting the use of clay pots for infant defecation. The project will promote the manufacture, selling and use of locally made potties for disposal of children excreta and advocate for its safe disposal. 4. Hygienic infant and young child feeding including introduction of safe drinking water and hygienic preparation, feeding and storage of nutritious complementary foods after six months of exclusive breastfeeding Mothers often lack autonomy for food purchasing and nutritional decisions because of the power exerted by husbands and paternal grandmothers. All mothers should have access to skilled support to initiate and sustain exclusive breastfeeding for six months and ensure the timely introduction of adequate and safe complementary foods with continued breastfeeding up to two years or beyond. Promotion about the

5 acute versus chronic malnutrition distinction is essential, and counselling will focus on building family skills and practice for accessing, preparing, feeding, storing nutritious and hygienic complementary foods. The use of story-telling / scenarios, hygienic preparation demonstrations, recipe trials, community based recipe contests will be promoted. 5. Improved household toilets with hand-washing station The combined strengths of technical assistance and sanitation marketing will increase the number of households who will want to construct new toilets or upgrade existing shared toilets to reach a ratio of one hygienic toilet per household. Even the poorest will have the possibility to build their own toilet as an effective sanitation marketing strategy will stimulate pro-poor financing mechanisms for sanitation and enhance the local supply for affordable products (Sanitation Marketing, World Bank, 2014). Practical implications include influencing social norms toward positive sanitation behaviors (i.e., everyone uses a latrine ) and promoting awareness of actual latrine costs, coupled with messaging that underlines positive product attributes (O Connell, World Bank, 2014) However, continued use of toilets will not be of health benefit unless these are regularly cleaned and smells are kept to a minimum, thus reducing flies. A sanitation campaign will be supported for construction of hygienic toilets at the household level with no subsidies. 6. Household water treatment targeting the infant, after exclusive breastfeeding for six months for drinking and preparation of complementary foods Even when the water source itself is safe, water used for drinking and cooking is often contaminated because of poor water-handling practices and unsafe storage. Household water treatment and safe storage and handling will be promoted for the safety of domestic water since it has been shown to have a significant impact on the prevention of diarrhea, especially in young children. One of the major problems in many countries is the introduction of water to the infant before six months of age. If the water is contaminated then the project will promote options for the treatment of water at the household level, relying on household investment to ensure sustainability. 7. De-worming campaigns for children over one year and women of child bearing age The strategy will actively promote targeting of all mothers and children over one year as a minimum with suitable deworming medication at six monthly intervals for two years. This medication will also be provided to one control group not targeted with the project s hygiene campaign, for more effective comparison of interventions. a) The consultant will review the Thrive project and the levels it operates, including: I. Households and care groups: A targeted behavior change campaign needs to target men, women and children as distinct target groups and determine the best methods to motivate the necessary IYCF and hygiene changes. Most hygiene education efforts will be targeted through the care groups. II. Health Facility: Improved infant and young child feeding and hygiene practices will be promoted through the clinics and ECD spaces through training of health facility personnel and community health workers running the ECD spaces. b) The consultant, in close collaboration with Emory University, will conduct the following tasks: 1 Review data of present practices in the THRIVE areas regarding these seven behaviors and analyse information collected from the baseline survey undertaken. 2 Work with health staff to review the present hygiene and IYCF curricula for community health workers.

6 3 Review present methods of integrating behavior change aspects into the THRIVE program and make recommendations for improvements. 4 Examine the following factors: a. What incentives, what factors (in the broadest sense) exist that would help motivate people to change their behavior? b. Why are some people currently doing it and others not (ie. positive deviants)? What makes the difference? c. What activities can you include in your program that would help you to address those factors that you ve identified as most influential in changing the behavior? d. Do you need materials to support those activities? e. Which products have been used successfully? 5. Develop training modules for hygiene behavior for the THRIVE program based on influencing improvements in the seven key behaviors. 6. Liaise with Emory University for the behavior change communications methods used for integrating the seven key hygiene behaviors into village health campaigns outside of the care group sessions and ECD spaces. 7. Assess the performance of the health workers and care group volunteers in motivating changes for the seven key behaviors. 8. Design the most suitable hygiene campaign including recommendations for support materials most suitable in the national context. TIMEFRAME: Consultancy is expected to take no more than 45 working days commencing from the day of award of the consultancy. 6. Work Relationships He/she will work under the supervision of the CRS Tanzania Director of Health Projects and she/he will liaise closely with Emory staff conducting the operational research study. The consultant will liaise with Emory University for the detailed assessment of the hygiene behavior campaign, which will test the three key strategic objectives and the seven hygiene behaviors for their maximum impact on improved nutritional status, especially reduction of stunting. 7. Expected Profile of the Consultant The consultant is expected to hold the following qualifications in order to be eligible for this position: Masters degree or PHD (from a recognized university) in public health, international development, or related social science (e.g., community development) Sound knowledge of major development issues, especially on child health and nutrition issues. Extensive experience in maternal & child health/nutrition, and/or hygiene behavior programs, and experience working in Tanzania. Experience in safe / hygienic preparation of infant and young child feeding practices Experience with behavior change theory and practice Experience conducting and analyzing qualitative data Excellent analytical and report writing skills Experience with curriculum development A demonstrated high level of professionalism and an ability to work independently and in highpressure situations under tight deadlines. Strong interpersonal and communication skills High proficiency in written and spoken English Familiarity with Tanzania culture and norms.

7 8. Expression of Interest Catholic Relief Services would like to hire consultancy services for the assignment for a period of 45 days which includes desk review, preparation, implementation, report writing and would like the assignment to commence in June Interested candidates are requested to submit their application detailing the following: i) A capability statement: State the individual s experience relevant to the assignment, curriculum vitae, appropriate references and relevant testimonials Please state your availability on the relevant dates of the assignment. ii) Technical Proposal: Provide an understanding and interpretation of the Scope of work, proposed time and activity schedule for the proposed activities and outline of deliverables. iii) Financial proposal: Include all proposed costs in Tanzania Shillings comprising of a detailed budget of clearly defined activities (i.e. consultation fees as well as operational costs), activities prepared in Excel sheet clearly identifying each item cost and narrations, with figures and totals clearly calculated. Others: i) CV of the Lead consultant and researchers showing experience conducting similar researches. ii) CV for all the team members and proposed capacity of any complementary staff. iii) Referees: the consultant should provide three referees including their full names, addresses (physical address and contact person), and telephone numbers. iv) Copy of registration certificate, VAT and TIN. (where applicable) These documents need to be submitted for CRS as part of the application package. 9. Submission of Proposals The proposal can be sent to the address below or e mailed so as to reach the undersigned by May 20 th 2016 to: Human Resources Manager Catholic Relief Services Tanzania Program Note: Please indicate the Reference Number on the subject. 10. Evaluation and Award of Consultancy CRS will evaluate the proposals and award the assignment based on technical and financial feasibility. CRS reserves the right to accept or reject any proposal received without giving reasons and is not bound to accept the lowest, the highest or any bidder. Only the successful applicant will be contacted. CRS does not charge any fees from applicants for any recruitment. Further, CRS has not retained any agent in connection with this recruitment

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