Using a Community-Led Video Approach to Promote Maternal, Infant, and Young Child Nutrition in Odisha, India

Results from a Pilot and Feasibility Study

Using a Community-Led Video Approach to Promote MIYCN in Odisha, India (PDF, 1.11 MB)

Photo source: John Nicholson/SPRING

Digital Green Approach for Agriculture

Digital Green Foundation and Trust, a non-profit organization, uses information communications technology (ICT) with women’s and farmers’ groups to strengthen agriculture extension. The Digital Green approach for agriculture involves (a) participatory identification of content and local production of low-cost videos to improve agriculture practices; (b) group discussion that uses the videos as a basis for mediated instruction, where a mediator encourages the audience to discussthe video content; and c) follow-up home visits to support and monitor the adoption of the practices or behaviors being promoted through the videos. This approach builds on existing community organizations such as self-help groups (SHGs) and public systems and is aimed at amplifying their efforts at rural development. To date, Digital Green has reached 300,000 farmers across India, Ethiopia, and Ghana, and through collaborations with the Bill and Melinda Gates Foundation (BMGF), the United States Agency for International Development (USAID), and the Government of India, is slated for rapid growth.

In Odisha, Digital Green has partnered with the Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT) for the past three years to produce and disseminate videos focused on improved agricultural and livelihoods practices. Working in 130 rural villages in the Keonjhar District in northern Odisha, Digital Green and VARRAT have employed four full-time, community-based Community Resource Persons (CRPs) to develop, shoot, and edit short videos as well as 37 Community Service Providers (CSPs) to facilitate weekly or bi-weekly video screenings and discussions with members of village-level self-help groups (SHGs) and serve as a resource for individuals seeking to change their practices.

SPRING/Digital Green Collaborative Approach Pilot

The success of Digital Green in increasing the adoption of agriculture practices has attracted interest from other sectors, including nutrition. In October 2012, SPRING began a collaboration with Digital Green and VARRAT which resulted in a 12-month pilot intervention in 30 villages in Keonjhar district of Odisha. The goal of the pilot was to test the feasibility of leveraging the Digital Green approach for agriculture to promote maternal, infant and young child nutrition (MIYCN) related behaviors and care practices including child feeding, care during pregnancy, and handwashing.

The specific objectives of the pilot intervention were to:

build local NGO capacity in MIYCN with a focus on strengthening their capacity to produce MIYCN videos and facilitate effective MIYCN discussions during video dissemination sessions;
develop and disseminate 10 locally produced videos that motivate the adoption and promotion of recommended MIYCN behaviors; and
assess the feasibility of using the Digital Green approach for promoting MIYCN-related behaviors among participants in women farmer SHGs.

During the one year intervention, 10 locally produced MIYCN-focused videos were developed and disseminated in bi-weekly SHG meetings as part of an on-going Digital Green-VARRAT agriculture program.

The Feasibility Study

To address the pilot’s third objective, the International Food Policy Research Institute (IFPRI) initiated the feasibility study in June 2013. The study examined the feasibility of using the SPRING/Digital Green collaborative approach to promote select MIYCN practices over the course of the pilot intervention. The key research topics for the feasibility study focused both on processes and uptake. The key objectives of the study are listed below.

Process-Related Objectives:

Examine the capacity of VARRAT to produce MIYCN video content and facilitate MIYCN video dissemination, using the SPRING/Digital Green collaborative approach in an existing agriculture program.
Explore the key factors, both enabling and limiting, affecting the application of the SPRING/Digital Green collaborative approach to MIYCN promotion, focusing particularly on the transition in content, presentation style, time and workload issues, technical challenges, the process of adoption verification and scaling-up.

Uptake-Related Objectives:

Explore retention and comprehension of video content viewed by SHG members.
Assess the reception and acceptability of the MIYCN topics covered and practices promoted in the piloted videos for SHG members and other key stakeholders. Report on SHG members’ experiences with trials of new behaviors and identify their motivations for experimenting (or not) with new behaviors.
Understand intra-community diffusion of MIYCN messages promoted in the pilot MIYCN videos.

Methodology

Sampling

The 30 pilot study villages were stratified according to the predominance of scheduled castes (SC) and scheduled tribes¹ (ST): Highest (where SC/ST population was greater than 90%); medium (where the SC/ST population was between 50-75%) and low (where the SC/ST population was below 40%). From each of these strata, five villages were randomly selected: thus, the total number of villages that included in the study was 15. From each of the three strata, 10 SHG women were included in the study. These included pregnant women and two lactating women, mothers of adolescent girls, mothers with children between 6-24 months of age, and women that did not belong to any of these categories per stratum. Thus, to address the uptake-related objectives of the feasibility study, the final number of SHG study participants was 42, after oversampling to account for data quality and potential drop-out of participants from the study. In those households where SHG study participants had spouses and/or mothers-in-law, these were also included in interviews.

All Digital Green and VARRAT technical staff directly involved in relevant field operations were included in the sample. These included 12 CSPs and four CRPs (VARRAT), as well as key informants from VARRAT, SPRING, and Digital Green. The sample also included seven protagonists who were featured in the nutrition videos and one Anganwadi worker (AWW) and one Accredited Social Health Activist (ASHA) per each of the three strata (a total of six frontline workers).

Data Collection Methods

The data collection was led by Development Corner (DCOR), based out of Bhubaneswar, Odisha. For process related objectives, in-depth interviews were conducted with CSPs, CRPS and other technical /operational staff and key informants from SPRING, Digital Green and VARRAT. The CSPs and CRPs were also administered a nutrition knowledge test (NKT) which was a closed-ended questionnaire aiming to capture the knowledge of the key frontline staff on topics related to the 10 videos on MIYCN to assess their capacity. In addition, 10 structured observations of dissemination were conducted. The structured dissemination observation guide was an adapted version of the structured observation tool that Digital Green routinely uses for monitoring dissemination. In-depth semi-structured interviews with frontline workers and the protagonists (i.e. the featured actors in the videos) supplemented further information on program processes (as well as uptake) related objectives.

For uptake-related objectives, SHG study participants were interviewed using in-depth semi-structured interview techniques. In addition, they were administered NKTs as well as a structured questionnaire to assess the diffusion of messages espoused in the MIYCN videos. Short in-depth interviews with mothers-in-law and husbands were also conducted.

Results and Recommendations

The results of this study show that the approach is highly promising and offers an excellent opportunity to respond to key human development needs in nutrition and agriculture. The Digital Green videos are shown to be one of the key sources of nutrition-related information within the communities. The demand for videos is high and acceptability of the intervention by SHG members and their families as well as the frontline health workers is strong. The frontline workers view the intervention as complementary to their role. The SHG members’ knowledge of the nutrition messages promoted in the videos is high on infant and young child feeding, but weak on care during pregnancy and use of iron and folic acid supplements (although it is beyond the scope of this study to attribute this solely to the intervention). Despite the fact that the intervention is nascent and this study was not designed to measure behavior change, there are distinct indications of trial of behaviors promoted in the videos as well as some sharing of the video messages with other non-viewers of videos. The key results and the implications for the next phase of the intervention development are presented below in Table A.

Table A. Key Findings of the Feasibility Study and Recommendation

Uptake-Related Research Objective	Key Findings		Recommendations
Working well	Current challenges
Examine the capacity of VARRAT to produce MIYCN video content and facilitate MIYCN video dissemination, using the SPRING/Digital Green collaborative approach in an existing agriculture program.	CSP and CRPs are enthusiastic on taking nutrition onboard. They have an amicable relationship with community members, and are regarded as credible sources of knowledge related to health and nutrition (regardless of the sex) by SHG members, mothers-in-law, husbands and frontline workers interviewed. CRPs are capable of producing nutrition videos, with technical backstopping from SPRING. CSPs and CRPs articulated specific challenges (technical, knowledge, and protagonist issues) in taking MIYCN onboard, but are able to innovate and overcome many of these.	The quality of CSPs’ communication and facilitation during dissemination sessions appears to be mixed. Encouraging feedback from earlier sessions, encouraging the group to generate ideas and providing appropriate responses to questions raised by SHG members during the dissemination sessions are particularly weak. CSPs had accurate knowledge of optimal breastfeeding practices. But their knowledge on optimal. complementary feeding practices, care during pregnancy and handwashing requires further strengthening. In some cases, CSPs we reported to have poor skill in the local dialect.	Invest in ongoing nutrition training to continue to improve MIYCN related knowledge and skills among CSPs and CRPs. Invest in further training in communication and facilitation skills for CSPs and videography for CRPs The above trainings must be tailored to equip CSPs and CRPs with problem-solving capabilities, especially on challenging issues when producing and disseminating MIYCN videos. Provide opportunities for peer-to-peer learning (for example, strengthen the nutrition focus of the bi-monthly meetings; regular interactions with frontline workers). Ensure that the language/dialect skills of the SHGs members and CSPs match.
Explore the key factors, both enabling and limiting, affecting the application of the Digital Green approach to MIYCN promotion, focusing particularly on the transition in content, presentation style, time and workload issues, technical challenges, the process of adoption verification and scaling-up.	The videos are one of the key sources of nutrition information in these communities. The strong technical collaboration with SPRING is valued by Digital Green and VARRAT staff (including CSPs and CRPs). SHG members underscore the following as the key strengths of the video dissemination sessions: the pace, the flow, the mediation and (sociocultural) familiarity with the cast. The proactive efforts to build strong synergies with government’s frontline workers (in training, choosing topics, storylines and the cast, and casting them as protagonists) is valued both by VARRAT and the frontline workers. Frontline workers view the nutrition videos as job aids, reinforcing their efforts at promoting MIYCN within their communities.	Unlike agriculture, the abstract nature of the topic as well as the sociocultural beliefs makes it difficult for people to relate to cause and effect, which in turn affects comprehension, willingness to try the disseminated practices and share information. Content identification and selection of MIYCN messages to be disseminated is more challenging given the intangible nature of the topic. Production of videos is more complex from technology, storyboarding and shooting points of view. Nutrition videos have several people complicating the requirement for the film shooting venue, voice modulation and lighting. Several women, especially young mothers, are usually too shy to talk on the camera. The current process of adoption checks/verifications is challenging for nutrition. Verification of adoptions rely on self-reporting and CSPs rely on probing and triangulation. Relying on probing and triangulation using proxies and other techniques by the CSPs, whose MIYCN knowledge is also fairly rudimentary, is problematic.	Continue with strong technical collaborations on MIYCN. Sustained and committed investment in strong MIYCN resource persons at VARRAT/frontline level is critical for technical accuracy, local relevance of the messages and scaling-up. Resolving several of the challenges elucidated here will require investing in CSP and CRP trainings and on-going support as elaborated above. Strengthen the follow-up visits to households to reinforce messages and maintain community engagement rather than for adoption checks. Test various nutrition monitoring approaches for adoption verification. Continue the fruitful synergies with existing government systems and frontline workers.
Explore retention and comprehension of video content viewed by SHG member attendees. (Note: the idea here is to assess if mothers have accurate knowledge of the messages disseminated in the videos. The results not attributable to the intervention)	Majority of the mothers accurately demonstrated handwashing; but only a third could recall all the 3 critical times for handwashing. Knowledge regarding breastfeeding is high. Over a three-quarter of the mothers possess accurate knowledge of timely initiation of liquids and semi-solid foods.	Knowledge of use of iron folic acid (IFA) supplements during pregnancy and adolescence is low. Only about half of the mothers interviewed have appropriate knowledge of care during pregnancy (rest and an extra meal/day).	Increase exposure to the messages by repeating the videos and creating new videos to disseminate these messages. Reinforce the messages through other mechanisms (e.g. discussions during other SHG meetings, village health and nutrition days; through frontline workers and through other SHG members).
Assess the reception by SHG members and other key stakeholders of the MIYCN topics covered and practices promoted in the piloted videos. Report on SHG members’ experiences with trials of new behaviors and identify their motivations for experimenting (or not) with new behaviors.	Belief in the topics and messages presented was extraordinary high: in effect, all household informants emphasized to interviewers that they found the messages disseminated during the pilot to be highly believable, and this finding was supported by responses from frontline workers and CSPs. Acceptability of the intervention by SHG members and their families is strong; Husband and mothers-in-law generally support women’s participation in dissemination. The frontline workers responded affirmatively to the positive influence of nutrition videos and are optimistic in their view of the nutrition education this approach.	Trials of behaviors are taking place, but economic constraints and entrenched sociocultural taboos remain significant barriers to behavior changes (This is also to be expected given that the intervention is nascent and behavior change requires long-term investments). Supply-side constraints could also limit behavior change (for example, poor quality food supplements by the government; or lack of stock of IFA in health clinics).	The content and the style of the future MIYCN videos need to be further responsive to local livelihood-food systems and sociocultural issues to inspire behavior change. The videos should identify solutions that are locally feasible and improve MIYCN problem solving skills among SHG members. Strengthen SHG institutions themselves to: Champion the cause -- a critical step to alter community norms. Assist mothers in adopting optimal MIYCN behaviors (for example helping negotiate sociocultural norms; peer-to-peer support groups). Resolve supply-side issues by building (or using if they exist) constructive mechanisms of grievance and redress. Engage other mechanisms (such as local governments and committees, doctors and traditional healers, schools) to bring MIYCN on the community agenda.
Understand intra-community diffusion of MIYCN messages promoted in the pilot MIYCN videos.	Over two-thirds of the interviewed SHG members shared information on any of the videos they viewed with at least one other person. A third of the sharing resulted in second degree diffusion to a third individual.	Social tensions between community members, lack of time, and the perception that the community was already aware of the information presented in the videos were cited as reasons why information was not shared outside of the immediate family. While agriculture videos are immediately relevant to a wide section of the population, the nutrition messages pertain primarily to young girls, pregnant women and mothers of young children—a group that is a minority in the SHGs. The participation of mothers of newborn children could be problematic for two reasons. Mothers tend to spend time in maternal homes during late pregnancy and early lactation periods; they spend most of their time with their newborn child at home. Thus unlike agriculture, wider adoption of practices to promote MIYCN hinges on diffusion of the messages.	Improve facilitation to encourage women to share information and encourage explicit commitments to share information. The above recommendations of strengthening the SHGs are also critical of diffusion of messages. Investigate the necessary and sufficient conditions under which SHGs could be the change-agents for MIYCN (SHGs have successfully harnessed to reduce infant and maternal mortality in India, including Odisha).

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Footnotes

1 Scheduled caste and scheduled tribes are officially recognized by the Constitution of India as historically disadvantaged groups.