Participatory Communication Campaign Approaches in
Transcription
Participatory Communication Campaign Approaches in
Participatory Communication Campaign Approaches in Improving Health Practices in India An Impact Assessment of DFP’s Programme for Improving Mother and Child Health in Selected States Sponsored by: Directorate of Field Publicity Ministry of Information & Broadcasting Government of India Conducted by: Department of Communication Research Indian Institute of Mass Communication Aruna Asaf Ali Marg, JNU Campus, New Delhi – 110067 Web site: www.iimc.nic.in; Email ID: [email protected] Research Team Project Coordinator : Professor (Dr.) Gita Bamezai Project Team : Prashant Kesharvani B.N. Ambade Anupriya Roy Jyoti Ranjan Sahoo Manushi Shashi Chhetri Cover Page Design : Shashi Chhetri Secretarial Assistance : Jai Raj General Assistance : Sanjay ‘It is health that is real wealth, and not pieces of gold or silver’ Mahatama Gandhi Contents Acknowledgment i Preface ii-iii Glossary iv Executive Summary v-xii Chapter 1 Participatory Communication Campaign Approaches in Improving Health Practices in India 1-12 o o o o Introduction Review of Literature Aims and Objectives Methodology Chapter II Impact of DFP Campaign o o o o Socio-Demographic Profile and Entry-Exit Respondents Changes in Behaviours Contingent upon Positive Knowledge & Attitude Differences in Knowledge and Attitude due to Campaign Assessment of Campaign by Health Functionaries and Evidence from Service Utilization Data Chapter III Assessment of DFP Campaign Activities o o o o 13-29 30-49 Pre-Campaign Activities Field Campaign Activities Additional factors pertaining to campaign activities Content analysis of campaign Chapter IV Charting New Frontiers and Way Forward 50-55 o Conclusions & Recommendations Bibliography Annexure o Research Instruments o Content Analysis of Print & Outdoor Material 56-57 I-XXIX Acknowledgement We express our sincere gratitude to the Directorate of Field Publicity, Ministry of Information and Broadcasting for entrusting IIMC with the onerous task of conducting this study. The scope of this assignment was challenging since the field work spanned a vast geographical area, encompassing eight districts in four states including the north-eastern state of Assam. It was possible to witness the campaign in strategically important regions of the country and visit remote villages and learn about the life that they face. Equally important was the exposure to the work carried out by DFP personnel in these extreme and disadvantageous situations and learning first-hand enterprising work handled by them. We would like to acknowledge the support we got from the Delhi head-office of Directorate of Field Publicity, especially Sri. Mohan Chandok, Director General, Sri Surenndra Kumar, Director, Sri Naveen Joshi, Deputy Director and Sri Kaushish, Consultant. We extend our sincere thanks to Regional Directors of DFP, Sri A. K Lakara (DFP, Ranchi), Sri Dinesh Kumar (DFP, Guwahai), Ms Ritu Shukla (DFP, Jaipur), Sri Ajaya Upadhaya,(DFP, Bhopal) and in charge of field units of Gumla, Kunthi in Jharkhand, Nagaon, Jorhat in Assam, Barmer, Jodhpur in Rajasthan , Panna and Sehore in Madhya Pradesh for extending their cooperation and sharing their views with the research team. During the course of the field-work, women beneficiaries, officials from the health department of the district, local health functionaries, PRI representatives from all the states shared their experiences, views and opinion on NRHM and JSSY and their role in achieving the goal. It was an enriching experience and these conversations with common people, men and women and children in villages invested the field data with more substantive meaning and wisdom. We also thank the investigators at the field level who helped in the data collection and in providing a better understanding of the field situation. The timely support and guidance of Mr. Suneet Tandon, Director General IIMC, Mr. Jaideep Bhatnagar, Officer-on-Special-Duty, IIMC and his staff helped in the smooth conduction of the study. We owe our thanks to the entire staff of the Press, Administration and Library of IIMC for the support provided in undertaking this study. DECORE IIMC i Preface Health Communication is nowadays accepted as an essential component for the successful delivery of health services. The National Rural Health Mission (NRHM) aims to provide better quality health services, along with promoting more healthy life styles in rural areas. This aim can be more effectively achieved if the beneficiaries themselves are able to make informed choices while demanding health services. This interface between the people and the health system can best be achieved and sustained through innovative communication strategies designed to stimulate positive attitudes and behaviours. This would be in tune with the spirit of our times, in which peoples’ participation in the process of governance is integral to the process of democratization. Extending the reach of the development programmes among the vast majority is the main objective of organizations like Directorate of Field Publicity (DFP). The DFP provides yeoman service by giving such program visibility and credibility among sections of population with limited access to know-how and resources. The Directorate also has the ability to provide feedback about people’s concerns to development agencies as an invaluable input in shaping development programmes as well as mechanisms for their delivery. Communication technologies, as an ubiquitous part of our lives today, are also becoming a reality in rural India and contributing towards bridging urban-rural digital divide. In spite of flurry of wide-reaching technological developments in the way we access and process information, some things do not and will not change. These are ways in which people use interpersonal and ‘offline’ communication to seek information and deal with issues that require understanding, credibility and confidence. At the Indian Institute of Mass Communication, the Department of Communication Research (DECORE) has been involved in studies that provide roadmap, as well as an understanding about the complex world of media technologies, media content, the interplay between these and lives of people and how society and government can use these learnings gainfully and efficiently. Under the aegis of the Ministry of Health and Family Welfare, DFP implemented a communication campaign for promoting mother and child health in rural and semi-rural areas in nine states in 2011-12. As a signatory to Millennium Development Goals (MDG), India has pledged to reduce maternal mortality and ensure child survival. This can best be achieved if the communities, mothers and front-link workers, as well as the health system, work in unison and acquire adequate knowledge of health and life-skills. The broad objective of the study by IIMC was to determine the effectiveness of DFP’s communication campaigns for promoting healthy practices among disadvantaged communities. The study also explored critical campaign factors that determined an incremental change in knowledge, attitudes, practices and uptake of health services in different parts of the country. The study evaluated the campaign ii materials and the impact of the communicative processes among beneficiaries. It aimed to identify enablers as well as barriers – socio - cultural and systemic- which impact the relevant health schemes. We hope that this study will help the Ministry of Health & Family Welfare and the Directorate of Field Publicity in process of evaluation and evolution for their strategies of interpersonal communication. We also hope that it will be of interest and value to all who are interested and engaged in the study and practice of communication for development. Sunit Tandon Director General Indian Institute of Mass Communication Dated: June 2012 iii Glossary DFP M/o HF&W JSSK JSY S& D NRHM ANM ASHA AWW ANC PHC MGNREGA SSA BCC CMP BDO M.O. C.M.O. MPW RCH CHC SHG NGO CBO PRI FPAI ICDS LHMC CP UNICEF : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Directorate of Field publicity Ministry of Health and Family welfare Janani Shishu Suraksha Karyakram Janani Suraksha Yojanna Song and Drama Division National Rural Health Mission Auxiliary Nurse and Midwife Accredited Social Health Activist Anganwadi Worker Ante Natal Care Primary Health Centre Mahatma Gandhi National Rural Employment Guarantee Act Sarva Shiksha Abhiyan Behaviour Change Communication Common Minimum Program Block Development Officer Medical Officer Chief/Medical Officer Multi-Purpose Worker Reproductive & Child Health Community Health Centre Self Help Groups Non-Govt. Organization Community Based Organisation Panchayati Raj Institution Family Planning Association of India Integrated Child Development Services Local Health Management Committee Community Participation United Nations International Children’s Emergency Fund iv EXECUTIVE SUMMARY Executive Summary Introduction It is well accepted that since independence the pace of development in this country had been fast but not uniform. A large segment of rural population continues to be bereft of benefits of the schemes targeted and designed for them due to lack of awareness and motivation. The colossal task of overcoming social and psychological barriers in comprehension and mobilisation of people requires building trust and credibility for the programmes. This can be achieved by picking such communication channels that best suit the physical conditions and psychological conditioning of people. For many years, mass media has proclaimed to have reached the masses with the messages on health under various programmes but lacked a mechanism of assessing its acceptability and compliance. Unlike mass media, the role of both DFP and Song and Drama division is unique since these combine the best of mid-media and interpersonal channels to overcome the disadvantages of the mass media in disadvantaged settings. These outfits repeatedly undertake the elaborate process to understand, incorporate and deliver messages on varied themes and subjects. The task of generating awareness contains essential elements of initiating and encouraging an interpersonal dialogue/interaction with the audience and scope of instantly ensuring the receptivity and comprehension of the message. Such efforts that are ‘built on foundations of inter personal communication also provide hope that the knowledge transmitted through participatory communication will translate into desired change in attitude and health practices’. Understanding Awareness Generation For many years, efforts were restricted to finding the reach of the messages and lesser emphasis was laid on assessing the impact of messages disseminated in terms of change in attitude and practice. It was later in 1950s that the KAP survey tradition was first born in the field of family planning and population studies. KAP surveys were designed to measure the extent to which an obvious hostility to the idea and organisation of family planning existed among different populations, and to provide information on the knowledge, attitudes, and practices in family planning that could be used for programme purposes around the world (Cleland 1973, Ratcliffe 1976). The amount of studies on community perspectives and human behaviour grew rapidly in response to the needs of the primary health care approach adopted by international aid organisations. Hence KAP surveys today continue to be widely used to gain information on health-seeking practices (Hausmann-Muela et al. 2003, Manderson & Aaby 1992)1 in a participatory manner to elicit participation and credibility for such programmes. Understanding the levels of Knowledge Attitude and Practice will enable a more efficient 1 How much can a KAP survey tell us about people's knowledge, attitudes and practices? Some observations from medical anthropology research on malaria in pregnancy in Malawi by Annika Launiala (University of Tampere and University of Kuopio, Finland). http://www.anthropologymatters.com/index.php?journal=nth_matters &page=article&op=viewarticle&path%5b%5d=31&path%5b%5d=53 v process of awareness creation as it will allow the program to be tailored more appropriately to the needs of the community2. About the IIMC Study Innumerable campaigns have been launched to reach out to population with essential tailor made messages intended to cause some healthier change in one’s well being. Similarly studies have been undertaken in past to assess the outcome of campaigns but were restricted to finding the extent of knowledge gained. ‘Such studies often lacked the critical constituent to find out the likelihood of transformation of knowledge into action.’ The goal of health campaign devised by DFP was to generate awareness JSY, family planning and breast feeding which would provide: Stimulus and acceleration in the service utilization by the target groups with reference to JSY, family planning and breast feeding Encourage coordination among health front-line workers, block level health officials, important community organisations and members of PRIs Spread of NRHM programme to inaccessible areas Keeping this mandate in view, a campaign focussing on these salient issues, especially on JSY, was organised in nine states. The task of evaluating the campaign was guided by the objectives to determine effectiveness of communication campaign for promoting change in (a) knowledge (b) the attitude (c) practice and uptake of services in the area of JSY, family planning and breastfeeding. More specifically, IIMC study was conducted to evaluate: 1. 2. 3. 4. 5. 2 Campaign material and processes. Feasibility of the two-step participatory communication process Impact of such communicative process among beneficiaries. Mapping changes occurring at KAP level among beneficiaries in three core health areas (Institutional delivery, Family planning and Exclusive Breast Feeding). Evaluation of competencies, enablers and barriers – socio-cultural and systemic which impacted the health scheme. Guideline for Conducting a Knowledge, Attitude and Practice (KAP) Study by K. Kaliyaperumal, I.E.C. Expert, Diabetic Retinopathy Project. http://laico.org/v2020resource/files/guideline_kap_Jan_mar04.pdf vi Methodology The Study stretched across 3 stages of campaign, beginning from pre campaign period, field campaign and post campaign period. It was conducted in 3 steps, each step corresponding to each stage of campaign. Out of nine campaign states, the evaluation was done in 4 states of Assam, Jharkhand, Madhya Pradesh and Rajasthan. Multi-stage Evaluation of the DFP Campaign Stage I Pre Campaign period Step 1 Assessment of DFP workshop (based on workshop reports) Stage II Field Campaign period Step 2 Observation of the campaign activities and eliciting response of the target audience Stage III Post Campaign period Step 3 Baseline assessment of beneficiaries, health functionaries & DFP staff Changes in knowledge and uptake of services Content Analysis of Campaign material Sample of the Study The responses were elicited from women beneficiaries, micro-level health functionaries, DFP officials at regional and district level, visitors at campaign site and opinion leaders of the village where campaign was organised. This approach of collecting data from the field sites assisted in understanding changes in attitude and perceptions of the people exposed to the campaign. Apart from this, views and opinion on planning and organisation of the campaign was gathered to provide clues for improvement in future campaigns. Type of Sample Research tool Sample size Stage II: Field Campaign Period DFP and field functionaries IDI 1 IDI x 1 site x 8 Districts = 8 Opinion leaders at Village site FGD 1 FGD x 1 site x 8 Districts x 6 participants = 48 Beneficiaries at Village site FGD 1 FGD x 1 site x 8 Districts x 6 participants = 48 Entry-Exit Polls for Visitors/ beneficiaries Questionnaire 1 site x 8 Districts x 30 Respondents =240 Beneficiaries of the campaign activities FGD 1 FGD x 4 districts x 6 participants = 24 Micro-level health functionaries FGD 1 FGD x 4 districts x 6 participants = 24 Opinion Leaders at Village site FGD 1 FGD x 4 Districts x 6 participants = 24 Stage III: Post Campaign Period Total = 8+ 48 + 48 + 240 + 24 + 24 + 24 = 416 * IDI- In Depth Interview **FGD- Focus Group Discussion vii Major Findings A. IMPROVEMENTS IN KNOWLEDGE DUE TO CAMPAIGN Campaign has made a significant impact on awareness generation on breast feeding, institutional deliveries, and family planning. Figure 1: Differences in Knowledge due to Campaign 2.5 2.2667 1.9 2 1.5333 1.375 1.5 1.2167 0.9167 1 0.5 0 Breast Feeding Institutional Delivery Mean Entry B. Family Planning Mean Exit DIFFERENCES IN ATTITUDE DUE TO CAMPAIGN Major impact of the campaign is significant changes in the reported positive attitude towards institutional delivery, and breastfeeding. As compared to institutional deliveries, the attitude change for breastfeeding practices is greater. Figure 2: Differences in Attitude due to Campaign 10 9 8 7 6 5 4 3 2 1 0 8.54 5.98 9.23 6.36 3.58 Attitude for Institutional Delivery Attitude for Breast Feeding Mean-Entry 3.35 Negative Attitude for Family Planning Mean- Exit viii C. FINDINGS ON KAP AND ITS IMPLICATION FOR COMMUNICATION STRATEGY i. Campaign had had a significant impact on awareness generation as well as on promotion of positive attitude for breast feeding across the states. Observed relation of 26% variance between levels of knowledge and attitude for breast feeding explains that the prescribed route for attitude change can be tracked through awareness generation, which also indicated that major change agent is rooted in socio-cultural practices. Evidence suggests Jharkhand and Rajasthan require more intense and rigorous campaign to overcome the lag between awareness and attitude which in effect will get converted to practice. ii. Campaign succeeded in bringing awareness about JSY programme among women belonging to deprived sections of the society living in remote and backward areas. Higher awareness about JSY programme has been due to the incentive for pregnant women and ASHA. iii. Contribution of campaign was significant in promotion of positive attitude i.e. 'institutional delivery is safe delivery'. Since the observed relationship between knowledge and attitude was negligible for institutional deliveries, it provides a compulsive argument to organise more focussed campaigns on knowledge generation, attitude change, and socio-cultural barriers. Awareness generation is less likely to lead to action unless facilitated by positive attitude of individual and an enabling social and health system environment. Thus each area needs separate communication strategy. iv. The campaign had a limited impact on the uptake of family planning services. The challenge in this case was not about generating awareness alone but utilising higher awareness to reduce negative attitude towards family planning. D. SUGGESTIONS FOR IMPROVING KAP LEVELS OF BENEFICIARIES i. Uses of ‘harm reduction’ and ‘fear appeal’ are recommended for breast feeding programme. As ‘harm reduction strategy’, campaign could highlight for example that ‘first milk’ of mother is of utmost importance than ‘honey’ which can be given to the child at a later stage during the occasion of “Annaprashan”. As an element of ‘fear appeal’, the campaign should highlight ‘harmful consequences’ of not breast feeding on the child and the mother both psychologically and physiologically. ii. For promotion of institutional deliveries campaign should highlight that ‘celebration of parenthood’ is incomplete without institutional deliveries, which is the key to the safety of mother and child. iii. For family planning programme a clearly articulated promotional programme on ‘contraceptive choices’ and ‘size of the family’ should be implemented in conjunction ix with access to quality services. More discreet and veiled messaging need to be designed and promoted, which enhances the desirability of ‘small family’ as a viable and as an alternative to ‘large size family’. More rigorous message dissemination regarding contraceptive choices, which a couple/individual can choose from, should form a major plank of the interpersonal communication forums. E. METHODS OF INFORMATION DISSEMINATION and PROGRAMME i. There was heavy reliance on lectures/seminar as a mode of information delivery. The pattern of lecture/seminar was not uniform across the regions. Speaker's focus was more on health prevention activities than on promotion of available services and its utilization. Hence, selection of speakers and choice of topics should be in alignment with the kind of audience available. Careful and deliberate attention should be given to selection of guest speakers, by informing them much in advance about the campaign topics. ii. Health Camp: Campaign in conjunction with the health camp is a viable option as it provides an opportunity for monitoring as well as for image correction/building of the client ministry (MOHFW). Evidence suggests that this model can be implemented with certain riders. iii. Village Rallies: Rally, used as an energizer method but was unable to open the channel of communication and remained restricted to a passive communication exercise with live models in some districts. The rally as a method of instilling interest and curiosity of the community can at best work as a trigger. iv. Baby Show: The baby Show activity can be used as an important strategy to reach specific target population. For better management of the ‘baby show’ selection criteria of the baby and number of awards should be announced in advance. As there is an active involvement of the health department, this activity provides a chance to identify and reach the specific target population with minimal redundancy of efforts. v. Quiz: Quiz format was used at all sites. It was used less for information delivery and more for ensuring receptivity & comprehension of messages. As a programme activity, it proved effective in terms of initiating audience response and participation. F. FINDINGS & SUGGESTIONS FOR IMPROVING PROGRAMME PLANNING AND EFFECTIVENESS i. Coordination between health department and DFP: DFP should collaborate with local health officials periodically for finalizing their activities through email and mobile to reduce time lag and overcome the difficulty of meeting in person to sort out issues of programme planning and management. This will also help in addressing the local needs and customizing services to the benefit of beneficiaries. At the same time x health department as the client agency should promote the synchronization of their activity with DFP. ii. Training workshop on Message Framing and Issue of Knowledge-Transfer: Briefings at the regional/state workshops were heavily tilted in favour of select schemes (JSY), while emphasis on other important schemes and entitlements of the people was toned down to their detriment. In some of the regional workshops, speakers/trainers (health officials) were not well prepared to provide adequate briefing even on JSY. For example, the scheme of Janani Shishu Sureksha Yojana, as an add-on to the existing JSY, was presented as a new scheme (JSSK) which created an ambiguous impression about JSSK as a replacement to JSY. a. Preparing for workshop: DFP should give more attention to the organisation of the training-workshop by identifying appropriate trainers in advance and assigning such topics to speakers to avoid repetition or omission. To ensure availability of the guest speakers during the training sessions an advance confirmation should be taken, and an alternative list of speakers should be prepared to fill the gap in case of dropouts. iii. Emphasis on community Participation: The role of PRIs under NRHM was not elucidated, which resulted in failure to assign minor and major responsibilities to them before and after the event. The NRHM/health Officials at the DFP workshops should have highlighted the active role of village functionaries and opinion leaders as crucial to continuation of the programme. a. Strategy should align with efforts of client ministry's mandate under NRHM i.e. 'community processes'. This will not only support the activity of the client ministry in activating and revitalizing its institutional structures, such as VHSCs etc, but it would also help in multiplying the efforts of DFP. For this process to unveil, orientation of officers has to begin from the top and translate into clearly laid-out plans and specific tasks. iv. Meeting with Opinion leaders: Effort was partially fulfilled as DFP’s activities were limited to briefing the opinion leaders about various schemes, and did not extend beyond to developing and building consistent association. The preparation and orientation regarding planning and designing for the campaign at the central and regional level however failed to translate and transfer at the district levels, and subsequently at the campaign sites. a. A better and alternative approach could be to involve the panchayats in organizing meetings and provide a forum of information and feedback. Encouragement can also be given to participation of local NGO members, and development agencies and their functionaries in such meetings as well. xi v. Timings of the Programme: The timings of the designated programmes should synchronise with the availability and presence of the local population. It is recommended that before scheduling the programme, days of weekly market, festivals, and timing of agricultural activities should be ascertained to ensure availability and participation of community in the programme. vi. Inter Departmental Coordination: A mechanism for inter-departmental coordination needs to evolve, especially with S&D and DAVP, to garner support that will augment the effort of DFP. As a forward movement DFP’s programme can ensure better impact if people’s participation is not reduced to the level of a passive audience, but women and men and youth are motivated to become part of the communication programme planning, implementation and monitoring process for community’s ownership of the development programmes. A participatory approach where people feel empowered to think, rationalize, participate and express their understandings and concerns will help programmes to gain credibility and acceptance. This precept will help in changing the way communication programmes are conceived, designed by those who usurp the creative process of the communities to express their ideas and in a language which is as rich as their cultural moorings. xii REPORT Chapter I Participatory Communication Campaign Approaches in Improving Health Practices in India Introduction Social change for development requires a change in archaic beliefs and practices of individuals and communities. Empowering communities to question existing practices and seek viable solutions in an environment characterised by socio-economic deprivation is a challenging issue in the development process. Participatory approaches can help in raising awareness, mobilisation and building capacity for sustainable community action. Several global initiatives as part of the consensus building for development like the Earth Summit 1992, ICPD 1994, World Summit for Social Development 1995, World Food Summit 1996 have recognized the significance of communication in engendering development and social change (Balit 1999). Mass media has been regarded as the simplest and cheapest way to reach out to a large population in a short time. NFHS- II, III data revealed that women who were exposed to family planning messages on television or radio were more likely to approve of family planning than women without mass media exposure. They were also likely to discuss family planning with their husbands; and use contraceptive measures at some time or have an intention to do so in the future (Olenick, 2000). The use and outreach of electronic media however is limited due to various infrastructural and socio-economic factors. The peculiarities of cultural, linguistic, regional and even semiotic differences further complicate the problem. The successful implementation of a development plan hinges upon customizing messages to people’s needs and the local institutional structures (Bashirudin, 1978). In his review Costello (1977) has discussed four functions of communication in health care: diagnosis, cooperation, counsel, and education. On the broadest level, these four functions are still relevant in the health empowerment process, but health communication concerns have moved well beyond this. Now role of community and its actors has been changed, and they are no longer passive beneficiaries of health education, rather they are the co-partners of social change. Communication Campaign for Social and Behavior Change Well-being and health of the people forms the main plank of the development change which can be sustained through use of participatory communication strategies. Expectation is that this would culminate in achieving change in health behaviours at an individual and the community levels. Behaviour Change Communication (BCC) is a planned process that utilises interpersonal communication, community level activities, and/or mass media to attain individual and social change. Behaviour Change Communication was located in needs and desires of people to achieve individual and community goals through knowledge, motivation and skill up-gradation. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 1 During the period of reconstruction in many erstwhile colonies, Mendelsohn (1968) had suggested that use of mass media can be extremely powerful in involving audiences with the abstract matters of health in an exciting personalized ways. But the evidence suggests that many mediated health message fall short of attaining this goal. According to Levy and Windahl (1985) failures partly occur because of the ways people ‘process the information’. According to Elaboration Likelihood Model (ELM) given by Petty and Cacippo (1986) messages which were processed through central route are more persuasive. Thus, the messages, which are appealing and involve the audience for active cognitive effort, are more persuasive. From the message designing perspective, the information processing approach has certain promises. The model has an implication for the language and content of the campaign material. However, information processing model and it’s over reliance on ‘cognitive effort’ as key consideration relies heavily on an individualistic model, and there is inherent assumption of ‘rational individual’, and negation of social context. This model has also an inbuilt assumption of an existing optimal functional health system, which would actively respond to the generated need of the individual. A balance between ‘over socialised’ model and ‘over rationalised model’ of man would be more appropriate in a setting where disenfranchisement and limited access to health services can compromise an ability to attend to innovative and alternative healthy choices. Behaviour Change Communication (BCC) is a process that motivates people to adopt and sustain healthy behaviours and lifestyles. Sustaining these healthy behaviours usually requires a continuing investment in BCC as an integral part of an overall health program (Salem, Bernstein, Sullivan, 2008). Such behaviours which are embedded in the normative practices require social sanction for change, while those seen as ‘easy to manage and with little effort’ can ensure individual compliance without delay. To prevent relapse and to ensure new forms of practices do not lose their momentum, facilitation through communication channels and change agents/partners becomes integral part of the change (Bamezai, 2010). To put all the focus on an individual for initiating change in the community is limiting the scope of the changes itself. SBCC (Social and Behaviour Change Communication) process effectively requires communitybased communication to mobilize public opinion, social sanction and approval for individual behavior changes. To build such constituencies of support and participation interpersonal and group communication can provide avenues for people and individuals to gain confidence and credence for any new practices. Success of Pulse Polio’s programme demonstrated effective use of social mobilization in a campaign mode to energize the communities, instill emotive elements in the messaging and branding the programme in terms of easy access, friendly and timely service at the door-step. According to Salmon and Atkin (2003) there are four essential elements of campaign: (a) a campaign is intended to generate specific outcomes or effects (b) in a relatively large number of individuals, (c) usually within a specified period of time and (d) through an organized set of communication activities. Campaigning is not only limited to impart any new knowledge or A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 2 practice, rather it is also the reinforcement of the existing but low prioritised healthy behaviour patterns. Building an Enabling Environment The utmost requirement for health promotion is creating an enabling environment in which new behaviours can be embedded for easy adoption. In 1986, Marshall Becker wrote a paper entitled “The Tyranny of Health Promotion,” in which he critiqued the individual lifestyle approach to health promotion and cautioned against its tendency to equate “being ill” with “being guilty” and to substitute “personal health goals for more important, humane societal goals”. The lifestyle approach to health promotion was criticized for turning health into a commodity, something to be bought and sold in the marketplace, which now included not simply the physician’s office or the hospital but also the health food store, exercise club, or stress management program (Robertson and Minkler, 2010). An individual is likely to accept a new practice, or alter an old practice, if the policy and legal framework, economic and socio-cultural factors all provide a conducive (and acceptable) environment. An understanding has emerged that cultural and social context should provide a reference point for legitimacy and acceptance of new behaviours. Hence, BCC attempts to create an environment where positive behaviour change is acceptable, possible and promoted (Bamezai, 2010). The ideal communication strategies do not just implore people to change, but help them live healthier lives and in making appropriate health decisions throughout life by building and strengthening healthy, participatory communities and effective health care delivery systems, supported by enlightened health policy (Servaes, 2006). Changing Meaning and Focus There is recognition of the shortcomings of individually focused approach to health communication/promotion. It has led to acceptance of new approaches, where there is importance of social life and cultural rooting of individual; and actions of the individual that has an impact on his/her health, are seen as more than the result of an individual decision to act in a certain way. However, to understand groups of people as ‘organisms’ we needed to shift toward understandings of the person as inextricable from their social context: the individual as a part of, product of and producer of that context. One useful descriptive word for this approach is ‘community’. McLeroy et al. (2003) identified four types of community-based interventions: community as the setting; community as the target for change; community as the resource and community as agent. The stance of BCC components today have shifted from individuals and households to communities and the wider society; from involving beneficiaries of change to ‘partners’ in social development; from demand creation to participation and empowerment; from top- down channels to participatory, dialogue based learning models and from needs to rights. Sustaining the change requires optimization of local assets in the form of material, know-how and human resources to ensure that interventions (healthy behaviours) have fiscal viability and can easily A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 3 germinate in the local culture to gain acceptability and sustained practice. Mass media’s ‘multiplier effect’ was enjoined with participatory approach through engagement of local communities and ‘target groups’ in production, distribution, interaction and evaluation of the process of change. Primacy was given to bringing change through building consensus, conciliation and popular consent (Bamezai, 2010). National Rural Health Mission and Its Communication Strategies National Rural Health Mission was need of the hour, as during post nineties the systematic withdrawal of the state as a primary provider of health care and its dependence on market and later its failure, had generated an utmost requirement for organized and systematic effort from state. ‘There has been an unrepentant increase in maternal mortality among young women between the ages of 15 to 19 due to complications of pregnancy and childbirth in the developing countries. Evidence suggests that more number of such pregnancies is either unwanted or is a result of indirect pressure exerted through social expectations; and absence of timely availability of contraception and help of professional birth attendants. These deliveries result in risky abortions, leading to morbidity and mortality. Nearly all (98%) maternal deaths occur in developing countries where pregnant women lack access to basic health care services - before, during and after delivery’ (WHO, 2006). NRHM represents a major departure from the past, in that central government health financing is now directed to the development of state health systems rather than being confined to a select number of national health programmes. The NRHM framework shows a conscious decision to strengthen public health systems and the role of the state as health care provider but concomitantly recognises the need to make optimal use of the private sector to strengthen public health systems and increase access to medical care for the poor. The NRHM is thus also about health sector reform – or in its language – an “architectural correction” of the public health system so as to make it “equitable, affordable and effective”. Such architectural correction is organised around five pillars, each of which is made up of a number of overlapping core strategies (First Common Review Mission Report, 2008). Under NRHM communication is an integrated task which works at multiple levels from policy making, community ownership to community counseling. NRHM has been using innovative communication mechanisms such as branding the identity of NRHM, facilitating advocacy and social marketing (Bamezai, 2010). NRHM has been able to position its communication interventions at the primary health care level by creating a network of peer counsellor in the form of ASHAs, who provide easy access to critical information. The findings of the Common Review Report of the NRHM in Chattisgarh (First Common Review Mission Report, 2008) indicates that the ‘Mitanin Program’ has been successful in involving the community and the PRIs by facilitating dialogue and empowering the community to participate in health services through Mitanin worker. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 4 Need for Customised Communication Campaign The Ministry of Health and Family Welfare Evaluation Study of the JSY in 2007 in the states of UP, Rajasthan, MP, Orissa, Assam and West Bengal noted that there was a substantial increase in institutional deliveries, increased utilization in ANC services and front-line health facilitators like ANMs/ASHAs/AWWs were the main source of information of programme. The number of beneficiaries rose from 7.39 lakhs in 2005-06 to 73.3 lakhs in 2007-08. Institutional deliveries were 80% of the total deliveries under the JSY. However, the study showed that awareness about the programme was low in some states particularly among rural women and the BCC intervention was needed to emphasize the importance of institutional delivery effectively and comprehensively. Such an intervention required greater participation of PRIs, NGOs and SHGs in the process and full community involvement. Village bazaars, religious congregations provide an opportunity and conducive environment for spreading the message of JSY since such venues attract people in large numbers and are receptive to new information and can participate in decision-making simultaneously. The recent Programme Evaluation Report of JSY (NHSRC, 2011) states that, “About one third of those who had home deliveries were not able to access institutions on account of not being able to afford transport costs”. Poor service quality and high costs in institutions were also reported as deterrents of institutional delivery. About one third had cultural preference for home delivery and a lacked awareness about how quality care could reduce risks. At least half of these home deliveries would become institutional deliveries if transport and quality of care improved and another half would also require communication related to risks of pregnancy. Messages on JSY had not reached to about 40% of those who delivered at home, and those to whom the message has reached, the financial incentive are much better communicated than the health and safety aspects”. Closing the gap between knowledge and attitude regarding institutional deliveries would be one of the ways of reducing risks and stemming the trend of high mortality. Lack of informed choice about other health interventions can equally prove detrimental to women’s health and put at risk the health of the infants. The stimulus to coverage of services can best be endorsed not by mounting a series of communication activities in villages and drawing conclusions based on overt mass approval, sanction and acceptance. Assessing the role of communication from a perspective in which people become the arbitrator in seeking information, planning and organizing programmes is more feasible and sustainable. The participatory approaches in communication can serve aspirations and needs of the people living in remote and inaccessible areas who can be best mobilized by a participatory campaign-mode approach to seek better alternatives for healthier lives. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 5 Assessing Communication Campaign Approach in Health NRHM aims to impact various important maternal and child health indicators by implementing health schemes such as family planning, popularly recognized as inverted red triangle, breast feeding and institutional deliveries. As a signatory to Millennium Development Goals (MDG), India has made a pledge to reduce maternal mortality and ensure child survival which can best be achieved if the community, mothers and front-link workers and the health system work in unison. Communication strategies have multi-fold purpose and can be designed in collaboration with different partners, collaborators and the target audience to maximize the reach and impact of the village-level programmes. Under the aegis of the Ministry of Health and Family Welfare, the DFP planned, organized and implemented participatory communication programmes in rural and semi-rural areas in nine states during 2011 to 2012. These activities were focused on promotion of: (a) Institutional delivery, (b) Family planning, and (c) Exclusive Breast Feeding. Aims & Objectives Aim: The aim of this project by IIMC was to assess the communication campaign factors that determined an incremental change in the (a) knowledge (b) the attitude or (c) behavioral and uptake of services in the area of MCH. Broad Objective: The broad objective of the study was to determine the effectiveness of the communication campaign for promoting Mother and Child Health practices/behaviours among the disadvantaged communities. Specific Objectives: To assess communication of the selected health schemes1across two levels of the campaign included: 1 Evaluation of campaign materials and processes. Evaluation of the feasibility of the two-step participatory communication process Evaluation of the impact of such communicative process among beneficiaries. Mapping changes occurring at KAP level among beneficiaries in three core health areas. (Institutional delivery, Family planning and Exclusive Breast Feeding) Evaluation of competencies, enablers and barriers – socio-cultural and systemic which impacted the health schemes. These communication activities are focused on the schemes of (a) Institutional delivery, (b) Family planning, and (c) Exclusive breast feeding. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 6 Research Methodology The study was conducted at three levels and at three stages. The chain of communication of knowledge, and its correspondence with research is as follows: STAGE I: PRE-CAMPAIGN PERIOD During stage-I reports of DFP regional workshops in four states were reviewed to assess the type and nature of training given as a preparation for the field-based participatory communication activities and the proposed communication strategy for enlisting the support, partnership and collaboration of different agencies at the district and village levels. At this stage primary data was collected from health and DFP officials to understand their perspectives about health and participatory communication interventions. Figure 1.1 Step 1 Assessment of DFP Workshops (Based on DFP reports) Step 2 Base-line assessment of Beneficiaries, Health Functionaries & DFP Staff Stage I of research: PreCampaign Period Secondary Sources based on WS Reports IDIs and FGD with Women, HF’s and DFP Step 3 Observation of the Campaign activities and eliciting target audience’s responses Changes in Knowledge and uptake of services among Beneficiaries & Health Functionaries Stage II of research: Field Campaign Period Stage III of research: Post-Campaign Period Entry Exit Interviews: Conducted with beneficiaries during Stage-II, Observation and Content Analysis IDI and FGDs Conducted with beneficiaries and Health Functionaries. Health records analysis of services uptake STAGE II: FIELD CAMPAIGN PERIOD Entry exit interviews were conducted during stage-II i.e. Field Campaign Period to measure the changes in knowledge and attitude among the respondents. The focus was to understand the recall and relearning on salient issues of institutional delivery programmes and other allied programmes. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 7 The training materials used during the training and campaign were reviewed and assessed for content, quality and relevance. Content analysis was conducted on textual and audio/visual material used to convey knowledge and understanding about technical aspects and the information on services and entitlements to the beneficiaries. The standard of textual/ audiovisual/ audio material was determined by categorizing, evaluating and reviewing the material. STAGE III: POST-CAMPAIGN PERIOD Impact Assessment among Beneficiaries: The impact of the interventions in the form of campaign, health camps and consultations with the PRIs was assessed in terms of retention of information over time, comprehension and awareness about the schemes like JSY and incremental changes in the uptake of services. The information was collected from two categories of stakeholders: (a) Field-level functionaries responsible for implementing the schemes (ASHA, ANM and other PRI functionaries), (b) Beneficiaries who attended the activities at stage II. The purpose was to gauge the quality and quantity of knowledge remembered and accurately reported after a period of time and making an assessment of changes in inclination, motivation and behaviour. METHODOLOGY2 AND SAMPLING FOR STAGES I, II AND III Methodology and Sampling for Stage I The DFP selected 9 states to conduct the campaign in different regions of the country. Of these 9 states, IIMC conducted research activities in 4 states, which were selected purposively. Table 1.1 Reasons for Inclusion in sample S. No State 1 1. Assam 2. Jharkhand 3. Rajasthan 2 3 4 4. 2 M.P. Reasons for Inclusion in sample North-Eastern state, unique cultural context, historical issues with access to institutional care. Relatively new state infrastructure, presence of tribal population, quite serious issues of underdevelopment. Culturally different from much of North India, tribal population, quite serious issues of underdevelopment Needs inclusion in any sample evaluating communicative issues in North India. Historical issues with underdevelopment, including education, health etc. Largest north Indian state, covering varied cultural territory. This is minimum risk research. Verbal consent will be obtained from participants prior to research activities. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 8 Use of Multiple Research Methods a. Review of Workshop Reports of 4 Regional Centres b. IDI with 2 DFP officials from each region= 8 (2 IDI x 4 Regional Level briefing) Methodology and Sampling for Stage II The DFP provided information on the division of the state for logistical purposes, and the campaign activity sites. On the basis of district-level information, 2 districts with the best and low health indicators were selected (see figure 2) from each state along the following parameters: a. b. c. d. e. Infant Mortality Rate Maternal Mortality Rate Education Life Expectancy Income 1. From each District, one village site, based on the above stated parameters (low indices) was selected. Researchers from IIMC attended and observed the field campaign activity at one site in each selected districts of the four states, therefore, a total of (1 site x 2 districts x 4 states) 8 campaign activity sites were evaluated. Figure 1.2 A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 9 2. As per the Terms of reference following sessions were organized by the DFP in different sites consisting of: Session I Session II Session III 3. Meeting with Opinion Leaders Rally in the Village Interactive session with potential beneficiaries/ common people Information from the existing Records of MCH at the Block/PHC/Village level was collected for assessment of changes in the service coverage/uptake before and after the campaign. Following Tools were used for compiling the data: a) Observation Reports of all the three sessions (Meeting with Opinion leaders, meeting with beneficiaries and rally/social mobilization activity at the village level) = 8 (1x 8 campaign activity sites) b) IDIs were conducted with significant briefers from DFP and field functionaries at the District level = 2 IDIs x 8 Districts = 8 FGDs/16 IDIs c) FGD with opinion leaders = 8 (1 x 8 campaign activity sites) d) FGD was conducted with potential beneficiaries/ common people=8 (1 FGD x 8 campaign activity sites) = 8 FGDs e) Entry-exit polls was conducted to provide a rapid gauge of new learning=240 respondents (30 x 8 campaign activity sites). f) Health Records- MCH data was gathered from local health functionaries, including examination of Records/Registers of MCH status and services at CHC/PHC. g) FGDs with ANM/ASHA/AWW/VHC members=1 FGD x 8 campaign activity sites = 8 FGDs with outreach workers at each site. Methodology and Sampling for Post Campaign at Stage III Researchers conducted the following stage 3 research activities to determine the overall impact of the two-step communicative process in three selected areas of MCH. In the Post-Campaign period, the retention of information and attitude or behavior change was assessed. The impact of the two-step communication process over time was mapped by conducting interviews in consultation with: (a) Micro-level functionaries who were responsible for implementing the schemes- ASHA, ANM, any other PRI functionaries, (b) Beneficiaries who attended the activities in stage II. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 10 This post-campaign assessment was conducted two months after the campaign activities during stage II in the selected states. Local health functionaries provided contact of beneficiaries who attended the activities at stage II. At this stage, 4 districts in each state were selected for post campaign assessment for following survey and data collection: a. 1 FGD with beneficiaries at 4 sites: 4 (1 FGD x 4 campaign activity sites) = 4 FGDs b. 1 FGD with micro-level health functionaries: (1 FGD x 4 campaign activity sites) =4 FGDs Table 1.2 Total Sample at National, Regional and District Level Type of Sample Research Tools Total Sample Size Stage II: Field Campaign Period 1 Significant briefers among DFP and 1 field functionaries at district briefings IDI 1 IDI x 1 site x 8 Districts = 8 IDIs 2 3 2 Opinion leaders at Village site FGD 3 Beneficiaries at Village site FGD Entry-Exit Polls with common people/ 4 beneficiaries (participants of the 4 Rally/Social Mobilisation Efforts) Stage III: Post Campaign Period Beneficiaries 5 of the campaign 5 activities in stage II Micro-level 6 health functionaries 6 responsible for implementation 7 Opinion Leaders at Village site * IDI- In Depth Interview Questionnaire 1FGD x 1site x 8 Districts x 6 participants = 48 participants 1 FGD x 1 site x 8 Districts x 6 participants = 48 participants 1 site x 8 Districts x 30 Respondents = 240 Respondents FGD 1 FGD x 4 districts x 6 participants = 24 Participants FGD 1 FGD x 4 districts x 6 participants = 24 Participants FGD 1 FGD x 4 Districts x 6 participants = 24 Participants Total = 8+ 48 + 48 + 240 + 24 + 24 + 24 = 416 **FGD- Focus Group Discussion Primary Sources of Data Both Qualitative and Quantitative techniques were used to collect the data that formed the basis of research: i. Interview Schedules: For in-depth interviews with Health/DFP officials. ii. Content Analysis: To review the quality and relevance of material used for training across two-steps of the communication process, and also to assess the publicity material distributed at stage II. iii. Focus Group method: FGD with specialized groups comprising of DFP officials and field functionaries, common people/beneficiaries, and micro level health functionaries. iv. Entry-Exit Poll: For common people/ beneficiaries at district level briefings. v. Questionnaire: Baseline information will be gathered with a questionnaire. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 11 vi. Observation Reports: On-the-spot evaluation of organization, people’ response, conditions, and presentation of knowledge over the two steps of the process. Secondary Data Sources In addition to the survey and qualitative information, information based on the health records maintained at the CHC/District and by the front-line workers (ANM/ASHA, AWW and self-help groups) were collected during the campaign at the third stage of the campaign. Data Analysis Data analysis involved both qualitative and quantitative approaches. The collected information on profile of the respondents, knowledge and attitude towards health seeking behavior and practices were analyzed by using descriptive and inferential statistics3. Composite scores of studied dimension were computed, and all the analysis was done on means of computed scores. Inferential statistics like T-test4, Analysis of Variance (ANOVA) 5 and Correlation 6 were used to infer the changes and relations with in variables. For qualitative data content and thematic analysis was done. 3 Inferential statistics tries to infer from the sample data what the population might think. Or, inferential statistics is used to make judgments of the probability that an observed difference between groups is a dependable one or one that might have happened by chance in this study. Thus, we used inferential statistics to make inferences from our data to more general conditions. 4 T-test assesses whether means of two groups are statistically different or not. It also helps to identify to measure the variation of two different sample mean and the mean difference and also comparing the means of two samples (or treatments), even they have different number of replicates. It is appropriate to analysis of two groups when randomized experimental design is followed. 5 ANOVA intends to measure the variation (Sum of Square), the variance (Mean Square) are given for the within and the between groups; as well as F value and the significance of F (Sig.) describes the difference between two variables. The factorial experimental designs are usually analyzed with the Analysis of Variance (ANOVA) Model. 6 Correlation helps to identify the degree of relationship between two variables whether there is a perfect positive co-relation, perfect negative co-relation or no co-relation. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 12 Chapter II Impact of DFP Campaign This chapter provides an assessment of the impact of the campaign activities undertaken by DFP in rural areas. The communication campaign has been evaluated in terms of its effectiveness in creating awareness among the prospective beneficiaries about selected healthcare services, entitlements under each of the health schemes and how to access these facilities. These special communication campaigns at the grassroots level were organized in the selected villages from October, 2011 to February, 2012 by the unit in-charge of DFP across 9 states, out of which four states were monitored and assessed for this impact study i.e. Assam, Jharkhand, Rajasthan and M.P (refer table-2.1). Specific dates were fixed for conduction of these community-based campaign activities by DFP in the selected districts and villages. On the ground assessment of several activities were conducted before, during the campaign and after an intervening interval, based on a check-list, focus-group discussion and entry and exit interviews with the audience of these activities. Table-2.1 Schedule of DFP Campaign Name of State Jharkhand Assam Rajasthan M.P Name of District Gumla Khunti Nagaon Jorhat Jodhpur Barmer Panna Sehore Name of Village Palkot 4th Jan, 2012 Khunti 6th Jan, 2012 Jhumarmor 7th Jan, 2012 Namdeuli 10th Jan, 2012 Sathin 17th Jan, 2012 Kaprau 19th Jan, 2012 Udla 7th Feb, 2012 Dobra 15th Feb, 2012 Campaign organized (date) SECTION I: SOCIO-DEMOGRAPHIC PROFILE OF ENTRY-EXIT RESPONDENTS The people in the reproductive age (18-40 years) group were the target population of the DFP campaign. In some villages people from the late reproductive age group (40 years and above) were part of the audience group. Those belonging to late-reproductive group are also important stakeholders and make decisions in decisive matters relating to family size and in granting permission to women of the household to access and avail immunization, family planning and ANC services. Among the auedience who participated in these communication activities larger proportion (63%) were female, and less than half (36%) were male. As women are the beneficiaries of JSY scheme, and also the target population for breast feeding, their presence in high numbers and involvement in the campaign activities was evident.. Significantly, in all the states the largest group comprised of women as the audience, especially in Jharkhand, followed by Assam, MP and Rajasthan. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 13 Figure 2.1 Age and Gender Profile of Entry-Exit Respondents Majority of the women interviewed were not only housewives but were involved in some type of economic activity as well. While majority had some type of education, only 30 per cent did not have any formal education, whereas 30% had studied in school up to class eighth. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 14 Figure 2.2 Patterns of Media and Mobile Use (Multiple Responses) 90.0 Assam Jharkhand 80.0 Rajasthan M.P. 70.0 60.0 63.3 80.0 40.0 83.3 50.0 46.7 26.7 0.0 TV Radio 3.3 10.0 26.7 16.7 10.0 23.3 36.7 16.7 10.0 33.3 20.0 20.0 40.0 30.0 Newspaper Mobile Phones Significant patterns and changes were evident in the use of media across all the states with TV as the preferred choice as compared to other media. Of immense value was the availability and use of mobile phone in all states and its ubiquitous presence parallel to that of TV. In some states access to mobile phones was higher than TV and other media, especially in Jharkhand and Assam. Among all mass media, TV was a preferred medium, with an exception in Rajasthan (20%), wherein at least one third respondents owned and watched TV to fulfill their need for information and entertainment. As compared to other states, media consumption in Assam, especially use of TV and Radio was higher. Rajasthan had comparatively lower media penetration, even use of TV and Radio was much lower than other states. Readership for newspapers was at a nascent stage and low in use across all the states. More than 45% of respondents, with the highest (80%) in Assam, were using mobile phones for their day to day communication activities. Overall, the use of mass media in rural areas has not become of such significance even today. Hence, interpersonal and ground-level communication activities assume a primary role in building awareness and participation of communities in the development process, especially in promoting health. SECTION II: CHANGES IN BEHAVIOURS CONTINGENT UPON POSITIVE KNOWLEDGE AND ATTITUDE Evidence of cause and effect relationship between the exposure to campaign programmes and change in health practices thereafter is limited since it is also contingent on consistent exposure and concomitant changes in the availability and quality of services. There is however significant proof of direct correlation-ship between exposure to messages leading to higher awareness among the target audience. Socio-cultural barriers, semiotic complexities in meaning of A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 15 messages for individuals and communities can stall and prevent assimilation of favorable attitude and practice thereafter. As the study result (refer table 2.2) suggests that there is a symbiotic and complex relationship between knowledge and attitude as in the context of breast-feeding practices as well. Its knowledge is situated in the cultural practices which are entrenched in the attitude towards feeding of the child. Any displacement of the negative or neutral attitude would require a well-developed strategy altogether. Relationship between knowledge and attitude explains nearly 26% (R2 =.25907) of variance, particularly when any increase in the knowledge would lead to the attitude change. But in the case of other programmatic interventions, the relationship between knowledge and attitude is not so straight; since there are various moderator/mediator variables like social, cultural or institutional which affect the relationship. Especially in the case of institutional deliveries the relationship is negligible. Evidence suggests that it is desirable that separate strategies should be framed for information, awareness and cultivating positive attitudes towards institutional deliveries. It is to identify such contextual factors which can facilitate attitude change and help in developing communication strategies for creation of an enabling environment for behavior change. Table-2.2: Observed Relationship between Knowledge and Attitude for Three Studied Dimensions Thematic Area Correlation Knowledge-Breast Feeding Attitude- Breast Feeding Knowledge-Institutional Delivery Attitude-Institutional Delivery Knowledge-Family Planning Negative Attitude- Family Planning ** Significant at .01 level .509** .007 -.127 SECTION-III: DIFFERENCES IN KNOWLEDGE AND ATTITUDE DUE TO CAMPAIGN As the focus of the DFP activities was to promote core and critical services and facilities like institutional deliveries, breast feeding and family planning, the results are presented accordingly. As part of the communication programme, messages on these core areas were given in all the states which were verified by developing message content list for each study sites. As we have seen in the previous section that a complex relationship exists between knowledge and attitude. Hence, a systematic effort was undertaken to determine an overall impact on knowledge and attitude on the above-said dimension, as well as an analysis to ascertain regional variations. The 7 R2 is coefficient of determination A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 16 statistical results presented, provide evidence of the effect of DFP campaign on knowledge and attitude of the beneficiaries. 2.3.1 Improvements in Knowledge due to Campaign Campaign has made a significant impact on awareness generation on breast feeding, institutional deliveries, and family planning. Figure 2.3 Differences in Knowledge due to Campaign 2.5 Mean… Mean Exit 1.9 2.2667 2 1.5333 1.375 1.5 1.2167 0.9167 1 0.5 0 Breast Feeding Institutional Delivery Family Planning Recall test8 shows an improvement in means above .61 with the highest .89 which is also significant at .01 level (refer table 2.3). Significant changes have been achieved in the knowledge regarding advantages of breast feeding and family planning practices as a result of the campaign. It is important to recognize that there has been more systematic and sustained effort on these practices in the past as well. Thus, past exposures could have helped the audience in recalling and relearning. These changes could also be explained by the manner in which people’s action is not solely dependent on health services but can be practiced by their own volition. On breast feeding there is highest improvement, this activity, if based on complete information and can be carried out by the individual without any interface from the health department. Table 2.3 Differences in Knowledge due to Campaign Mean Entry Exit Mean Diff. Std. Deviation t-value Min. Max. Breast Feeding 1.3750 2.2667 .89167 1.32078 7.395** .00 3.00 Institutional Delivery .9167 1.5333 .61667 .96304 7.014** .00 2.00 Family Planning 1.2167 1.9000 .68333 1.16665 6.416** .00 3.00 Knowledge * Significant at 0.01 level 8 Exit test is the test of immediate recall. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 17 In section two we have seen that there is a significant correlation between information and attitude change on this dimension, stimulated by self-decision of the individual. What is important for facilitation of this activity is identification of socio-cultural practices, which can act as a barrier. If barriers are deeply rooted in cultural practices, as is the common practice of offering honey, it is desirable that we should follow the ‘harm reduction’ strategy. The campaign should highlight that ‘first milk’ of mother is of utmost importance than ‘honey’ which can be given to the child at a later stage such as “Annaprashan”. It is desirable that campaign should align its activity with socio-cultural factors and messages should be rooted in the local language and visual imagery. In sharp contrast, promotion of institutional deliveries (JSY) depends on the availability and quality of health facilities; wherein reliance on cooperation of health functionaries becomes crucial during the delivery and post-delivery period. From mothers’ and family’s perspective, the JSY programme replaces family and community interdependence with an impersonal and alien environment of the hospital and with no ‘apparent advantages’. The positive side of the campaign is that there is a significant improvement in awareness about institutional deliveries. FGDs with women at all studied sites also show that they were aware of institutional deliveries and had an inclination to choose institutional over home deliveries since provision of free medicine and post-natal treatment in the hospitals at the nearest CHC or district hospital was made available at no cost by the government. To suggest that decision to avail such services at the government health facilities was prompted by lure of incentives would be to discount the impact of educating women and their families and other stakeholders in villages about the longterm and additional health benefits which would accrue by choosing a hospital-based delivery. Women in these sites were of the opinion that risks of infection and post-delivery complication could be forestalled as a result of such a decision. Timely availability of transport and timetaken to reach the nearest health facilities are consequential factors for institutional deliveries especially in hard to reach areas. Prospects of the programme creating a momentum based on its performance are promising, since an individual’s access to the health facility, even for the first time, would be of a crucial consequence for building faith and credence for the health services. His/her continuance would depend upon his/her experience with the health department, cooperation of health functionaries, and sustenance of the communication activities. Matching of words with performance lends credence to the other services and builds confidence with the system and builds loyalists as well. Communication of complete and customized information, assurance of quality services by the health providers, and mitigation of concerns of people would help in reducing the gap between knowledge, attitude and behaviours. 2.3.2 Differences in Knowledge due to Campaign and Study State There is no significant interaction effect (campaign*state), which indicates that there is uniformity in improvement in terms of differences due to campaign; it has made somewhat similar impact on each study sites. But results presented here bring evidence for greater insight A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 18 and learning for undertaking communication programmes in future with adequate prior planning, formative research and good management and collaborative programme implementation. Figure 2.4 Level of Knowledge at Study Sites 4.5 Mean Exit 4 Mean Entry Breast Feeding 2.2 2.0333 1.2667 0.9 Rajasthan M.P 1.5667 0.8333 Assam Institutional Delivery Jharkhand 1.8667 1.3667 0.8333 0.5667 Rajasthan Assam M.P. Rajasthan Jharkhand Assam 0 M.P 0.8 Jharkhand 1.4667 1.6333 0.9 0.5 1.3 1 1.6667 1.5 1.5 1.3667 2.1 2 1.8 2.5 1.9 2.1667 2.4 3 2.4 3.5 Family Planning The baseline data results indicate regional variation in existing knowledge, while simultaneously showing regional variations in improvement in KAP which can act as a projection for future course of action and help in designing messages and programmes which address local conditions and concerns. It is evident that Rajasthan, MP, and Jharkhand require rigorous campaign for JSY to improve institutional deliveries, as their entry and exit means are comparatively lower. However, Assam has shown marked improvement, but it needs further stimulus for an overall achievement. Any improvement in institutional delivery as a result of the campaign will require sustenance and a readiness from health facility/department to make quality services available. User’s experience with health system will be the key for his/her continuance and the health system needs to cash on the very first opportunity in terms of demand generation through the campaign. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 19 Table 2.4 Differences in Knowledge due to Interaction of Campaign in Selected States F9 Mean Knowledge Breast Feeding Institutional Delivery Family Planning Selected States Assam Entry 1.6667 Exit 2.4000 Jharkhand 1.3000 2.4000 Rajasthan .9000 2.1000 M.P. 1.6333 2.1667 Total 1.3750 2.2667 Assam 1.4667 1.9000 Jharkhand .8000 1.3667 Rajasthan .5667 1.5000 M.P .8333 1.3667 Total Assam .9167 1.5333 1.8667 2.2000 Jharkhand .8333 1.5667 Rajasthan .9000 1.8000 M.P 1.2667 .2167 2.0333 1.9000 Total 1.703 1.568 1.32 Among the programmes campaigned, special attention to breast feeding programme is required in Rajasthan where such practices were not found to be consistent and frequent. The communication campaign strategy has to identify the social-cultural factors, which work as impediments in making healthy choices by the individual, family and communities. Evidence also suggests that other states, especially Jharkhand, need rigorous campaign not only for ‘benefits of breast feeding’, but also for ‘ill-effects of not breast feeding’. In this case it is suggested that ‘fear appeal’ can be used to highlight ‘harmful consequences of not breast feeding’ on the child and the mother. Among the selected states, Rajasthan and Jharkhand require rigorous campaign on promotion of family planning programme. There are systemic variables affecting the programme and its outcome, but the communication programme needs sustained efforts because of two reasons: First, each year a certain proportion of population enters the reproductive age, thus educating them about contraceptive choices should be the utmost priority. Secondly, consistent and continuous promotion of small family size is necessary to motivate those in early reproductive age group. In terms of adopting a strategic approach, a clearly articulated promotional programme should be implemented in conjunction with access to quality services, and in making decisions regarding contraceptive choices and size of the family. As there are some socio9 F value shown here is for interaction effect of within and between variables. In this case campaign is within variable and state is between variable. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 20 cultural barriers for what constitutes ‘size of the family’, it is desirable that covert message should be given to make small family as a viable and an alternative to ‘large size family’. More vigorous message dissemination regarding contraceptive choices which a couple/individual can choose from should form a major plank of the campaign through interpersonal communication forums. Delinking of these two activities -small family norm and contraception programme will help in reducing the barriers and apathy and in reaching the target population, which will serve the purpose of a viable ‘size of family’ in the long run. 2.3.3 Differences in Knowledge based on Stand-alone Campaign v/s Campaign with Health Camp This analysis has been undertaken with the purpose to determine what changes accrue if information and such services are delivered simultaneously; secondly what effect health camp can have on the knowledge and uptake of services if it is made as a standard activity. Health Camp in Assam Table 2.5 Differences in Knowledge due to interaction of Campaign with Health Camp Mean Knowledge Beast Feeding Institutional Delivery Family Planning Health Camps Health Camp No Health Camp Total Health Camp No Health Camp Total Health Camp No Health Camp Total Entry 1.4167 1.3333 1.3750 1.0500 .7833 .9167 1.3833 1.0500 1.2167 Exit 2.1000 2.4333 2.2667 1.5833 1.4833 1.5333 1.9167 1.8833 1.9000 F 2.000 .898 3.037* * Significant at 0.10 level The result (Table 2.5) suggests that in absolute term means of exit and entry interviews both are higher. Thus it is showing relatively a lower improvement as compared to the other phenomenon i.e. no health camp sites. Definitely health camp will distract the attention of the audience, but it has certain advantages: first it can act as a means for monitoring the campaign activity, and address the local concern of the health department; secondly, it can help in priming a readiness to receive the information; third it gives an opportunity to the audience to interact and avail certain services. Thus, it can act as a window of opportunity to the health department for changing and A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 21 correcting people’s perception about the apathy of the health system in reaching out to them. To make health camps function both as a single window for provision of health services and as a stimulus for mobilizing the people, it is desirable that more organized efforts is brought into preparation and allotting time for the health camp as part of the scheduled communication activities. The health camps should be organized in such a way that people attend the information session and then proceed for health camp to reduce the distraction effect of the health camp. To achieve this coordination between health department and DFP, collaboration with local officials of health department should become primary, before finalizing their activities. At the same time health department as client agency should promote the synchronization of their activity with DFP. Health Camp in Sehore, MP 2.3.4 Differences in Attitude due to Campaign What can be termed as a major impact of the campaign is significant changes in the reported positive attitude towards institutional delivery, and breastfeeding (refer table 2.6). As compared to institutional deliveries, the attitude change for breastfeeding is greater. Result supports the findings of section two, which clearly identifies the complex inter-relation between knowledge and attitude. Favorable attitude towards institutional deliveries connotes that campaign was able to provide further impetus to the incomplete or deficient information regarding JSY though, besides such services offered under JSY, monetary incentive had a role in shaping this attitude. Interviews with the women and PRIs provide evidence that all of them knew about the monetary incentive. In terms of learning, the campaign should highlight that ‘celebration of parenthood’ is incomplete without institutional deliveries, which is the key to the safety of mother and child. Table 2.6 Differences in Attitude due to Campaign Attitude Attitude for Institutional Delivery Attitude for Breast Feeding Negative Attitude for Family Planning * Significant at 0.05 level MeanEntry 5.98 MeanExit 36 Mean Difference .37 Std. Deviation 1.954 8.54 23 .69 3.58 35 -.23 t value Min. Max. 2.103* 3 9 2.80993 2.696** 4 12 1.477 1.75 2 6 ** Significant at 0.01 level A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 22 A significant finding is non-significant effect of campaign on negative attitude towards family planning. The challenge is of converting knowledge improvement on family planning dimension into more uptake of such services which however has been forestalled by limited reduction in the negative attitude. The result poses two important questions: is there problem in the overall strategy; and second, have the strategies failed to address the effects/concerns arising due to systemic/contextual variables, which have countered our efforts. In more explicit ways, is the health department reluctant to cater to other health needs of its beneficiary, or ANM/MPW/MOIC is too preoccupied to meet their family planning targets/RCH targets, or their concern is limited to permanent sterilization methods. An increasing realization has surfaced which underscores the fact that patients/people are not passive beneficiaries, and they cannot be treated or seen as new targets for different service. Secondly, FGDs with women showed that behavior of health functionaries and AWW was not found without bias and discrimination based on caste, class and gender. Many times denial of services was based on the caste of the beneficiary. In Sehore, Barmer and Jodhpur women expostulated about several instances of the treatment and neglect by even grassroots health functionaries like ASHA who rarely visited them in their village. Caste of the beneficiary is an important consideration at Aaganwadi as well. If the AWW is from a higher caste, her behavior is characterized by caste prejudices and she would serve food to children from the lower caste from a distance, expect them to bring their own plates and wash them after use. If women have raised their voices against AWW, ASHA and ANM, they usually stop providing services to this group of women. Thus, their disadvantageous position does not allow them to remonstrate about such conditional access to services or even for their misdemeanor. 2.3.5 Differences in Attitude due to Campaign and State There is significant interaction effect (State*Campaign) on breast feeding and institutional delivery programme, which provides an evidence that differences in attitude due to campaign on is not uniform across the states. Interaction of context and intervention (campaign) shapes the effect of the campaign since local conditions also influence the receptivity and determine the practice. All states showed an incremental favorable attitude towards the institutional delivery programme except in MP. M.P. has shown a decline in positive attitude, which is contrary to the mandate of the campaign. Reasons for decline could be more than one and could be attributed to message framing, perceived meaning of the message and the projection of such information. However, what is promising, are the changes not only in the dimension of knowledge, but also in changes in attitude. In the light of the result of the section II, evidence suggests that current strategies are able to address and impinge on other mediating/moderating factors necessary for attitude change. The most significant result is visible on the dimension of breast feeding. What is promising is significant attitude change for breast feeding practices in Jharkhand and Rajasthan. For the sustenance of the attitude, these areas need periodic intervention through ground-level A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 23 promotional activities and channels, as their media-use suggests that there is low penetration of TV, Radio, and Newspaper. Table 2.7 Differences in Attitude due to Interaction of Campaign and State Selected State Within Variable Between variable Assam Jharkhand Attitude for Rajasthan Institutional Delivery M.P Attitude Feeding for Breast Mean Entry Exit 6.10 6.47 5.67 6.77 5.87 6.20 6.30 6.00 Total 5.98 6.36 Assam 8.47 7.80 Jharkhand 7.70 10.30 Rajasthan 8.53 9.33 M.P. 9.47 9.50 Total 8.54 9.23 Assam 3.26 3.20 Jharkhand 3.33 3.33 Negative Attitude for Rajasthan Family Planning M.P 3.93 3.47 3.80 3.40 3.58 3.35 Total * Significant at 0.05 level F10 2.685* 9.035** .774 ** Significant at 0.01 Level These results point towards a thorough review of communication strategy for family planning, but also review the ground level activities related with it. Campaign based on a revised communication strategy and image correction is a need of hour for these areas. SECTION IV: WOMEN EVIDENCE FROM IN-DEPTH INTERVIEWS (IDIs) WITH IDIs with women were conducted prior to campaign, and two months after the campaign. Women have shown favorable attitude for institutional deliveries, and this attitude was found consistent even after an interim period after the campaign. Awareness about monetary incentive 10 F value shown here is for interaction of within and between variables only. To ascertain source of variance please see the mean values A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 24 among women also lends support to the sustenance of preferential attitude towards changing traditional practices if better alternative services are offered and fears are allayed of negative consequences. IDI With Women in Rajasthan Figure 2.5 Women’s Opinion about Place of Delivery 90 83.3 80 70 60 76.7 50 40 Pre Campaign 30 Post Campaign 20 10 18.3 16.7 0 Home Delivery Institutional Delivery Opinion about Place of Delivery SECTION V: ASSESSMENT OF CAMPAIGN BY HEALTH FUNCTIONARIES AND EVIDENCE FROM SERVICE UTILIZATION DATA Views of health functionaries i.e. Medical Officers (MO), Multi-Purpose Workers (MPW), Auxiliary Nurse Midwife (ANM) were ascertained on the health conditions of the women and uptake of FP and MCH services in the selected districts and villages. In-depth interviews were also conducted with Anganawadi Workers (AWW) and Accredited Social Health Activists (ASHA), who assist and facilitate women in the early reproductive age to access government health facilities. Information was collected from these health functionaries to estimate existing perception, attitude and uptake of JSY, Breast feeding and Family Planning services since these services formed the fulcrum of the DFP’s communication campaign. IDI with Health functionary in Assam A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 25 Information was also collected to assess the ‘DFP campaign has motivated people. There is impact, which has impact of the campaign on resulted in change in their knowledge and attitude. Now there are their understanding about asking, clearing their doubts and accessing health facilities’. key health schemes and AWW, Gumla, Jharkhand during the post campaign period women’s awareness about recall of messages delivered and awareness level among the beneficiaries and local health officials awareness about the program under JSSY and JSSK, barriers and difficulties in accessing health facilities and media use by women and the innovative strategies adopted for the programmes. Perceived Changes in Health Seeking Behavior Health functionaries found changes in attitude of beneficiaries towards accessing health facilities under different schemes. After the campaign beneficiaries were keen to learn more about different schemes and were open about discussing their doubts on the different health related issues. According to AWW in Gumla, Jharkhand, ‘such programs motivate people. “Earlier I used to give my own example for family planning, now it is easier for me to convince them”. In Assam, it was found that people turned up to get clarifications of their doubts on sterilization process. In Rajasthan, it was observed that DFP campaign had helped people to think about their health and encouraged to seek help of health functionaries to clarify of their queries on different issues. According to Multi Purpose Worker (MPW) in Panna, M.P. ‘Earlier I was facing problem in motivating people regarding family planning methods but after the campaign, it made people more aware about family planning methods and helped them in clearing their doubts. What is significant is change in their perception regarding my role’. According to health officials, an increase in use of health services by pregnant women such as 3 ANC checks up, asking for IFA tablets and getting immunized has become more common. In contrast, according to MPW, CHC, Powai, MP, there was no significant change on uptake of family planning services and breast feeding due to several misconceptions and cultural/traditional beliefs. Perceptions of health functionaries were indicative of the fact that the communication campaign had effects on health behavior, particularly among rural people. Evidence suggests that more programmes should be organized to sustain these definite and observed changes. Awareness about Schemes among Grass Root Level Functionaries Awareness about JSY and JSSK “We are given training and get awareness on the relevant and entitlement provided under information for the local beneficiaries on family planning, these schemes among health immunization, institutional delivery etc. functionaries and worker is Smt. Mithlesh Raja,AWW, Udla, Panna, M.P. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 26 crucial since they are supposed to facilitate and extend health benefits to the beneficiaries at grass root level. It was found that ANM, AWW and ASHA were aware about the messages, but few of them were unable to discuss about entitlements under JSY and JSSK. Lack of knowledge about entitlements affects service delivery for the beneficiaries. There is a need for awareness generation of functionaries at grass root. Physical Barriers: An Important Mediator in Accessing Health Facilities Tough terrain, lack of available infrastructure and transport facilities have an important mediating role in accessing health facilities. It is widely accepted among health functionaries that these barriers demotivate both them and the beneficiaries in availing services. In most of the study sites, hospital is situated far from the villages and due to Kachha road or tough terrain ambulance fail to reach at the time of delivery. Service Utilization Data Data related with service utilization (3 ANC checkups, Institutional Deliveries, Home Deliveries, T.T-II, and IFA Tablets) was collected from the health records available with the health functionaries for the period of eight months i.e. four months before the campaign and four months after the campaign. To bring homogeneity and rule out the impact of seasonality, ratio has been calculated. For ANC services, number of women registered with health facilities was taken as a base for the calculation of compliance ratio on three programme dimensions (presented below). Available data has certain limitation, as in certain places women registered themselves at later stage and utilized certain services during that period, thereby shoring up the ratios. Similarly, for delivery total number of deliveries was taken as a base for calculation. Thus, cumulative ratio of first four months and after four months was compared and plotted below to show the trend. Table 2.8 Changes in Service Utilization for ANC services after the Campaign Indicators Observed Changes after the DFP Program Assam Jharkhand M.P Rajasthan Jorhat Nagaon Gumla Khunti Sehore Panna Barmer Jodhpur 3 ANC Check Ups T.T-II I.F.A Tablets Indicates decrease in the utilization of the service Indicates increase in the utilization of service A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 27 Table 2.9 Changes in Service Utilization for Delivery services after the Campaign Indicators Observed Changes after the DFP Program Assam Jharkhand M.P Rajasthan Jorhat Nagaon Gumla Khunti Sehore Panna Barmer Jodhpur Institutional Delivery Home Deliveries - It is visible that DFP Program has some impact on the service utilization as there is an increase in utilization of various services in five districts. In Jodhpur, Panna, Jorhat and Nagaon decrease in service utilization of ANC services was found in general. What is important here is to recognize that there is a decline in number of home deliveries in 5 districts, whereas in Sehore, Panna and Barmer an increase in the number of home deliveries has been found. In Panna, Sehore and Barmer simultaneously a decrease in institutional deliveries was evident. FGDs with Women Beneficiaries A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 28 IDI with Beneficiaries and Health Functionaries A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 29 Chapter III Assessment of DFP Campaign Activities This chapter, presented as a critical assessment of DFP’s campaign activities, is divided into two sections: the first section provides an assessment of pre-campaign activities, and the second section is an appraisal of campaign-day activities. SECTION I: PRE – CAMPAIGN ACTIVITIES The pre-campaign process, undertaken as a preparation for the communication activities, was the fulcrum of the campaign in the villages which required strategic planning and systematic enunciation of roles and responsibilities of each partner agency. These planned activities are congruent to efforts under NRHM (National Rural Health Mission) to reduce maternal and child mortality, promote family planning and enhance the role of PRIs in health services as part of the community process. At another level, association of PRIs and other village functionaries, with DFP’s ground-level programme, would strengthen the efforts of NRHM under community processes, which involve participation of community members at various level of planning and management of health services. In this regard the action plan of DFP was very well conceptualised and visualised. An assessment of pre-campaign programme is based on an evaluation of workshops organised by DFP at the state/regional level in different regions of the country. These workshops were organised by the Regional Directorates with various stakeholders (NRHM and state government officials, political and media representatives) to ensure a coordinated effort among all agencies working at the state and district level. This partnership was expected to boost the reach and effectiveness of the communication campaign in priority rural areas. As a measure to provide crucial advantage and facilitate implementation of programmes in remote and disadvantage settings, DFP garnered support and participation of administrative and political representatives, apart from NRHM and other health officials at the workshop. To ensure credibility and support for DFP’s initiative, extensive coverage of the DFP workshops in the regional, state and local media was a significant step in this direction. The workshops formed an integral part of the planning process across all regional and district headquarters in orienting district DFP officials with the priority programmes under NRHM and drawing up plans for implementation of the campaign. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 30 The workshops enabled formulation of the following strategic design: 1. Identification of the Target audience: The main focus of the programme was to promote awareness and motivate women in the reproductive age and their family since individual behaviour change is influenced by peer and community/caste imperatives. The talks and discussion held with the health officials during the workshops concentrated mostly on JSY and various components of the programme. However, the briefings at the workshops toned down the emphasis on other important schemes and entitlements of the people, and role of PRIs under NRHM. The NRHM/health Officials at the DFP workshops should have highlighted the active role of village functionaries, and opinion leaders since it would have further buttressed in devising appropriate communication strategy for the target population. 2. Designing Appropriate Message The salient messages identified for dissemination, as part of the campaign activities, focused primarily around Janani Suresksha Yojana (JSY) to the exclusion of other associated and priority entitlements. The speakers from the health department restricted their presentation to JSY to the exclusion of other schemes. In some of the regional workshops, speakers/trainers (health officials) were not well prepared to provide adequate briefing even on JSY. For example, the scheme of Shishu Sureksha Yojana, as an add-on to the existing JSY, was presented as a new scheme (JSSK) and created an ambiguous impression among the DFP officials that JSSK was a replacement to JSY. The information about JSSK as a complement JSY scheme, and the additional payment to the mother for her nutritional diet and for recuperation post-delivery was not emphasised. The training workshops should have highlighted not only conditional payment as an entitlement, but other key features of JSSK i.e. free medicines, foods, and facility for transport for the mother before, during and post deliverry as a continuum of support. These topics were however perfunctorily treated at the workshops. No substantive information was provided about imperatives of advocacy initiatives by opinion leaders as part of the field campaign activities and the crucial role PRIs were expected to play in sustaining the programme. This would have formed the basis for collating and designing the requisite information to devise the strategy for co-opting PRI leaders and in organising and framing the issues for the 'meetings with opinion leaders'. At second level, since this group was to play the role of a multiplier of DFP efforts and radiate the efforts of DFP in villages, this potential was not adequately tapped. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 31 Display of Messages In A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 32 3. Participatory Training For learning Another important issue was of the process of transfer of knowledge from top to the district-level functionaries with same potency and intent for effective translation of ideas into sustainable results at the grassroots level. As participants of the workshop, DFP’s field publicity officers, had the onerous task of transferring knowledge to their other associates, collaborators and partners with same intent and purpose. If certain issues are not made as the focal points, chances of dilution and loss of meaning will occur in any transaction process. Filling the wide gap, between the communication content at the regional workshop and truncated version at the local level, would have ensured matching 'vision of top with action at bottom level'. Field level functionaries opined that training at the DFP Regional Workshops helped them in better planning. Thus, it is desirable that they should not only impart information but should be oriented and trained in transfer of knowledge in a participatory manner to elicit ready cooperation and alignment of local leaders with larger goals of the programme. As part of the workshop preparation, DFP should have given more attention to the organisation of the trainingworkshop by identifying appropriate trainers in advance and assigning such topics to speakers to avoid repetition or omission. Secondly, to ensure availability of the guest speaker confirmation should be taken in advance, and alternative list of speakers should be prepared to fill the gap if any speaker drops out. Such detailed preparation for the workshop would train the DFP district teams adequately about the scope of the campaign. Restricting the scope of the programme to purely passing information or putting an assembly of activities would be compromising the comprehensive implications and prospects of the programme. To delimit the scope of the programme would attribute failure about an understanding of the NRHM programme and ill-prepare the district DFP team to organise a wellcoordinated and customised programme. In those states where well-organised and coordinated workshops were conducted, it resulted in successful campaign activities in the villages. 4. Preparation for the Planned Activities All the states followed a common design and frame-work for the field-level campaign which comprised of meeting with opinion leaders, rally and mass mobilisation through community meetings. The field level activities were dependent on pre-campaign activities and any lapses at this level could have had a ripple effect on the campaign. A common framework of activities followed by DFP in all the states had an advantage since it ensured uniformity in the delivery of the programme messages across the country and concomitantly in allocation of budget for such programmes. However, it is more feasible to allow state-level variations in customizing the programme design and content which can adapt to district specific requirements. These factors are geographical distances, social-cultural practices and programme imperatives which are significant determinants in organisation of village-level programmes. Neglect of these factors can impinge on the quality of the campaign programmes. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 33 Efforts to coordinate activity with health department have had dual advantages for the DFP: one of keeping the ‘client’ department in the loop of ongoing activities and secondly of providing them critical and meaningful feedback periodically. It also ensured support of the client department (MOHFW) at the top level for rolling out the campaign at different levels and provided credibility to the DFP’s initiative. In some state-level workshops the emphasis on developing linkages with the health system was handled in a lackadaisical manner which resulted in disjunction between promotion of health, demand generation and availability of services at the campaign sites. Better Inter-departmental coordination between Directorate of Field Publicity, Song and Drama Division and DAVP for strengthening the campaign efforts is a primary requisite. Each unit should supplement efforts of others, which would involve their active participation in planning, and supplementing DFP’s efforts through organisation of community-based edutainment programmes. SECTION II: FIELD CAMPAIGN ACTIVITIES This section provides brief assessment of campaign activities undertaken by DFP in the rural areas. The three sub-sections provide an overview of the three-tiered Communication Campaign based on the observation of ‘Session I- Meeting with Opinion Leaders’, ‘Session II-Organizing a Rally of People/Beneficiaries’, and ‘Session III- Edutainment programme with potential beneficiaries/community group: Session I: Meeting with Opinion Leaders The objective of the ‘Meeting with Opinion Leaders’ comprising of Panchayat, SHG members and leaders of the community was expected to create informed facilitators, who could lend legitimacy and multiply the efforts of DFP. The vision was to strengthen the advocacy initiative of opinion leaders. But this effort was partially fulfilled as DFP’s role and responsibilities was consigned to briefing the opinion leaders about various schemes but did not extend beyond to developing and building consistent association. The resultant inadequate turnout of beneficiaries and uneven presence of opinion leaders/PRI members /village health and sanitation committee (VHSC) members at the campaign sites points to lack of adequate preparedness about effective mobilization and in building a participatory mechanism for sustainable response. Except at one site in Assam where 6 PRI members were present prior to the programme, in other states limited participation of PRI representatives was in evidence. This was corroborated by the observation reports and interviews with DFP personnel who assigned limited role to PRI functionaries and perceived them as passive ‘organizers of the event or gatherer of crowd’. Limited appreciation of the larger and consistent mediation role of the panchayats and other opinion leaders with the health workers/officials was evident. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 34 Meeting with O”pinion Leaders – Banner seen in MP and Meething in Rajasthan This could be attributed to lack of clarity on how these change agents could work in conjunction with DFP even after the culmination of the DFP’s present campaign. Keeping in touch with the villagers on regular basis is often not possible due to organizational and logistical problems; hence local bodies can share the responsibility of monitoring change in knowledge, attitude and practices and keep DFP updated. Concerted efforts would be required to inform/discuss with village health and sanitation committee members and Gram Panchayat members (institutionalised bodies under NRHM) the prospects of facilitating and channelizing the feedback from community groups to the relevant departments and officials. DFP's efforts can activate these committees and provide a channel of communication for further dialogue and action. This mechanism between PRI representatives and DFP officials in some measure was visible in selected places, especially in Barmer District in Rajasthan. Following activities were carried out by DFP in each study sites. Table 3.1 Activities Conducted at Various Study Sites Districts Gumla Khunti Nagaon Jorhat Jodhpur Barmer Panna Sehore Rally √ √ √ √ √ √ √ √ Lecture/Quiz √ √ √ √ √ √ √ √ Film Show X X X X √ √ X √ Health Check-up X X √ √ X √ X √ Session II: Rally of People/Beneficiaries Session II activities were carried out at each and every campaign site though with varying degree of success. Rally was one of the major activities for two reasons (i) it provided ample A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 35 opportunity for participation of large number of people, (ii) rallies added visibility to the campaign due to movement and presence of mass of people. In all the districts, both students from the local schools assembled at the venue wearing the T shirts with NRHM logo, distributed by the DFP officials. Except in Jharkhand, in other three states, rally attracted few community members and did not generate much enthusiasm, except for the children who found it as novel and as an opportunity to do something different from their routine. In Jorhat, Nagaon and Barmer rally was taken to the lanes of the village, in other places it was showcased only on the road-side. Participants of the rally were primarily the schoolchildren while community members were conspicuous by their absence in the rally. Led by a DFP member, the rally moved on the designated routes through the village with children carrying some messages on the banners and placards. The leader also shouted slogans which were repeated by the students, but this feature did not remain constant throughout the rally. Duration of the event (rally) was not uniform across the states or even districts i.e. it varied from half an hour to an hour. It was noticed that rally did not gather crowd during its movement and community members did not show any interest or curiosity in the rally. Rally in Jodhpur, Rajasthan More efforts are required to garner social support through greater participation of Panchayat and NGOs for 'mobilising the mobilisers'. Since village rallies were primarily used to create a sense of heightened activity with students and children, better and alternative approaches should be mounted to involve the panchayats. Rally was used as an energizer method but was unable to open the channel of communication and remained restricted to a passive communication exercise with live models in some districts. The rallies as a method of instilling interest and curiosity of the community can at best work as a trigger. Generating an interest in the programme at the initial stages, the processions can at best be a rallying point for diverse groups in the villages, and give visibility to the issues. To ascribe a greater role by making rallies as the central point of activities would be a failure to assess that these have a limited role and the entire programme’s success should not be hinged upon it. Attendance at the rallies and at the community meetings was also affected by the prior engagement of the local people. The timings of the designated programmes should be such that these activities synchronise with the availability and presence of the local population. At one site (Khunti) DFP’s programme clashed with the local weekly haat (market), which resulted in poor attendance of women and youth during the campaign. Before scheduling the A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 36 programme, days of weekly market, festivals, and timing of agricultural activities should be ascertained to ensure availability and participation of community in the programme. Assam- Nagaon and Jorhat A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 37 Jharkhand – Gumla and Khunti MP – Panna and Sehore A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 38 Rajasthan – Jodhpur and Barmer A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 39 Session III: With Beneficiaries/Community groups 1. Lecture and Quiz To reduce all communication interventions to the level of item-wise activities by DFP would be trimming-down the larger perspective of mobilising people for social change and improving health status. Various programmes were clubbed together to reach the target audience. Heavy reliance on lecture delivery with quiz was used as a primary method to spread the message among diverse audience groups across the state. The main constituent of the lectures delivered were messages on JSY and JSSK, especially the focus was on cash incentives and institutional benefits. The pattern of lecture/seminar was not uniform; it depended upon the DFP and health experts’ own orientation to subjects at hand to make the messages sound resilient and meaningful for a diverse groups. The compilation of messages delivered in each district showed commonality in themes, but differences associated with socio-cultural barriers were evident in the way people responded to such schemes of cash incentives. Addressing the local issues was a prime concern at all places, and audience were encouraged to seek the help of ASHA, ANMS and village health committees, but no platform was provided for listening to concerns of the effected target population . Participants of the quiz were primarily school children and ASHAs, whereas women in the reproductive age (target population) were largely conspicuous by their absence. This reflects DFP’s preconceived notion that receptivity of messages would be faster among ASHAs and they would be better positioned to take home messages directly to the target audience. Assam A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 40 Jharkhand Lecture giving is an art, and selection of speakers and choice of topics should be in alignment with the kind of audience available. At some locations the Guest speakers had little time to prepare for the session which reflected in the delivery of the message and had less significant impression on the audience. Careful and deliberate attention should be given to preparation in selection of guest speakers, by giving them advance notice about the campaign topics. Thus at some places session was extended to 3-4 hours, and some places it was of a short duration. Speaker's focus was more on health prevention activities than on available services and promotion of its utilization. Places where quiz was part of ongoing lecture, audience enjoyed the session more as compared to the places, where quiz was organized as a standalone activity at the end. Encouragement should be given to participation of local NGO members, and PRI functionaries in such meetings as well. They should be co-opted and briefed in advance about focus of the campaign to provide a local connect, but should not be given a free run either to use it as a platform for self-serving agenda. At selected sites traditional and folk media were used with great success since interplay of drama and songs was able to entertain the audience and involve them in the story since it bore similarities to their life conditions in the village. For effective use of this medium, it would have been appropriate if the play had used a device (used in tele-serials by inviting suggestions from the audience about how the story should develop) of inviting suggestions of the community members/villagers regarding the way the drama should end. This method would have been effective for a number of reasons. 1) It is entertaining, 2), it encourages participation and 3) it clearly reflects participants’ attitude and perception. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 41 MP Rajasthan A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 42 Quiz - Prize Distribution 2. Healthy Baby Contest and Health Camps Healthy baby contest is a participatory method to create awareness among mothers about post natal care and award recognition to mothers for the child-care. Baby shows provided an opportunity to engage with specific target population i.e. mother/reproductive age group, but this activity was organized only atGumala. In Gumala, Sahiyas had informed mothers about baby A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 43 show in advance. Thus some women even traveled up to 17 kms to reach the campaign site and assembled at the venue before the start of the event. The baby Show activity can be used as an important strategy to reach specific target population. For better management of the ‘baby show’ selection criteria of the baby and number of awards should be announced in advance. Secondly, as there is an active involvement of the health department, this activity provides a chance to identify and reach the specific target population with minimal redundancy of efforts. Health Camps In the conduction of health camps, the turn-out of people is better and there is an immediate fulfilment of the need of direct access to the health department experts at the door-step. Out of 8 study sites health camp was organised at 4 sites. Some features of the health camp were (i) collection of blood samples for test of malaria, (ii) health check up, (iii) free distribution of medicine, and (iv) Immunization. Places, wherever health camp was organised along with the DFP activity, it managed to attract more people. The joint activity with the health department had a better impact as compared to the places, where DFP activity was standalone. It was not limited to attracting just more number of people; but at these places people had better recall of the message. This collaborative activity (between DFP and the Health department) also helped in priming and in absorbing more information and served the dual purpose: of monitoring by the client organisation and in bringing services to the target population. As part of the campaign, the A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 44 health camps helped in building trust among the target population for the service provider and an associated link and alignment with the messages disseminated through the rallies. SECTION III: ADDITIONAL FACTORS PERTAINING TO CAMPAIGN ACTIVITIES 1. Audience Composition and Density The audience largely comprised of either too young audience (students) or married men and women in their late reproductive age than those who were just married or were in their early reproductive age. Presence of pregnant and lactating women was found more in districts where baby show and health camps were organized. In Jorhat and Sehore more number of women gathered since local NGOs working for women were involved in garnering support and for enlisting their participation. A skeletal crowd gathered in village Kunthi, as community members were out to fetch groceries from the local ‘haat’, which clashed with the schedule of the campaign activities. A floating audience was also found at all places since rallies and health camp had resulted in constant movement at the venue of those who were from the neighboring places. In Nagaon, the seating arrangement was done inside a hall which was largely occupied by the health and NGO workers, thus limited seats were left for the villagers, who either hesitated to sit with them or were more interested in free health check up. In Jodhpur, hall of Gram Sabha Bhawan was used, which had a seating capacity of 80-90 persons. As men preferred sitting near the door, thus their seating arrangement restricted the entry of women in the hall. Dispersal of audience was seen at Jodhpur and Nagaon, where many women with infants left the hall before the programme ended. The proportion of women in both districts was one-third of men. 2. Audience Response Audience response is a key indicator of degree of participation and comprehension of any programme’s success. During the community sessions, audience expressed their reaction by way of clapping, laughing, showing non verbal signs of awareness in abundant measure, or by asking of questions or simply leaving the venue. The audience responded and applauded in ample measure during the quiz and the song and drama show. The interaction was highest during discussions between the audience and the moderator who usually happened to be the DFP or health expert. 3. Display of Messages Apart from the key message delivered during the programme, display of posters, charts, wall writings, banners on relevant themes and messages were put up at vantage positions to draw attention of the community. There were two categories of materials on display: materials A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 45 developed specifically and used for the campaign, and another category materials which already existed at the programme venue. The display of both categories of campaign materials was not uniform among all the districts and these varied in terms of number as well as messages. In Sehore, MP, an appropriate banner on JSY messages was designed and put up by MP regional DFP unit, while other places did not customize the message and visuals as per the needs of the local audience. According to the planned budget, first category of material consisted of T shirts and Caps with NRHM logo and prizes/awards (T-shirts, clocks, thermometers, umbrellas and dictionaries). In Assam T-shirts and caps were worn by students, NGO workers and health workers at the time of rally, seminar and quizzes, which added color to the programme. It was observed that the attraction of the material distributed, prizes /awards and refreshment diverted the attention and focus from the main programme messages disseminated through various activities. The placards with NRHM messages and slogans held by the rally participants were readable only at a distance of 15 ft and less since the typeface of such messages were not large and distinct. Slogans were repeated throughout the rally which added excitement to the event. In MP, instead of placards, banners were held by participants, which were bigger in size, colorful, readable and displayed the messages on immunization, iron tablets, breast feeding etc. 4. Display Sites The selected venues such as CHC, School, Anganwadi centres had some charts and posters on immunization, breast feeding, family planning. At Gumla, a small A4 size notice about the ‘Mamta Vaahan’ with mobile phone number was put up on the day of the programme which showed inadequate preparation for the campaign. Banners on ‘hum do hamare do’, ‘Health of mother’, ‘get nutritious food’ were put up in Sehore. The posters were put up largely inside the pandal where the programmes were to be conducted. By delimiting the outdoor media (posters and banners) within the confines of the venue of the proramme limited the exposure to the messages. Appropriately if these were displayed and put up at strategic places where the target population converges it would have served some tangible purpose. Wall writings and posters were used more commonly than banners or hoardings. Text size on wall writings was larger and readable than those on posters. Wall writings were more attractive and are more durable which gives them an edge in being used more commonly than non-durable material like posters, banners and print material. Some posters were loaded with too many messages of JSSY, which distracted attention and consequently restricted comprehension. Display of single message as wall writings and posters would have facilitated better understanding of the message among visitors to these venues. A mix of numerous messages, information and slogans visibly looked attractive but shifted the focus of the campaign. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 46 SECTION IV: CONTENT ANALYSIS OF CAMPAIGN MATERIAL Message dissemination is a vital component of the campaign in providing the content, visual appeal and emotive feel to the formation as well as delivery of important programmes. On the campaign day various publicity materials such as posters and banners were displayed which conveyed messages on various aspects of NRHM. Since the purpose of the campaign was to promote utilisation of Institutional services for child birth and family planning methods, the content of these print and outdoor materials was analysed to assess their suitability in consonance with the objectives and focus of the campaign. Print and Outdoor Material Content analysis of the distributed printed material (Brochures, Leaflets and Booklets) provided an estimation of the appeal of the content i.e. the strength of the message and its nature. These materials were assessed on the parameters and standards of design as well their contextual appeal based on the current socio-cultural factors. These parameters were studied primarily from the point of view of the audiences’ capacity for identifying with the information given, comprehension of language and its meaning and therefore the content analyses were undertaken with following objectives: 1. Suitability and appropriateness in terms of information and target audience. 2. Assess appeal of the material in terms of text and visual effects for easy comprehension and relevance Methodology A total of 31 printed materials were selected as sample for assessing their quality and relevance in making the campaign achieve its objective. These materials were analysed on the following parameters: 1. 2. 3. 4. 5. 6. Content, Appeal factor (based on fear, reward, future promise and choices) Relevance of the subject matter/topic to the campaign Good Presentation in terms of balanced mix of visuals and text Suitability for the target population Utility as a training, informative, educative or display material Findings Distribution of Material: Distribution of material was not even among states. Jharkhand lagged far behind others. DFP’s efforts to produce material in Assamese language were evident. MP is the only state where leaflet on JSY was prepared customized to the local needs. Fewer materials on JSY were distributed to the audience at the campaign sites, which may raise doubts on efforts A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 47 put in to develop material on topics that was the major thrust of the campaign. The reasons ascertained was that DFP laid larger stress on oral/verbal dissemination of messages during the campaign. Much effort was seen in utilizing lecture, seminar, quiz, group discussion formats to communicate information on JSY, JSSY to audiences. It cannot be ignored that explanation of details of programme, repetition of vital messages was possible only through face to face interaction; hence lesser publicity of JSY through print material did not dampen the effect of the campaign. Secondly, as per mandate by Ministry of Health, fund was allocated for publishing material on health issues/problems other than JSSY as well. Print material on other core areas of Family Planning, Immunization, breast feeding and Communicable diseases were distributed to people as well. Considering the magnitude of the goal for the client ministry and DFP, the material distributed on major health messages was far too less. Overall only 20 Brochures, 8 pamphlets and 3 booklets on the various health issues were distributed across all states, Maximum of 12 print materials were distributed in Madhya Pradesh followed by 11 in Rajasthan , 6 in Assam and further low of only 2 in Jharkhand. Issuing Agency: Print material on various health issues were produced and distributed in sampled states by agencies: DFP, MoH&FW and Unicef. Though the specialization lies with the client ministry, more material developed by DFP was distributed. In all the states, 19 materials by the DFP, 10 by NRHM and 2 by UNICEF were distributed. Since population is a challenging issue in India, materials on Family Planning are being distributed. For this campaign, 9 out of 20 contained messages on family planning methods followed by Dengu, Chikanguniya, Iodized Salt, Female Feticide, H1N1, Iron Tablets and ICDS. Immunization (7) stood third in position among the subject catered to followed by NRHM & Bharat Nirman Abhiyan and JSY at fourth and fifth position respectively. Language: In Rajasthan and Madhya Pradesh all print material were distributed in Hindi language whereas, in Assam use of both English and Assamese language was common. Target Audience: The content largely targeted people in general. Within general masses, mothers, children, married women and men and health providers were targeted for specific information. The content in brochures on breast feeding targeted mothers and brochures on NSV was meant for both married men and health providers. Similarly information on IUCD was designed keeping in mind the requirement of both married women and health providers. There was clear difference between content for men or women and those for health providers. Leaflets on ICDS have specifically targeted women and child both. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 48 Visual Appeal of the material: Visual appeal was assessed in terms of layout and design which included size of material, number of folds, font size, number of colours used, text and visual ratio and photographs. Brochures, leaflets and booklets are printed on both sides using combination of different font sizes for visual appeal. Photos Added to Appeal: Photographs in good number occupied substantial space in brochures. Those on family planning depicted procedures of using IUCD, NSV and methods, small and happy family, health functionaries counseling women, precautions and after care etc supported the text and facilitated understanding of information therein. Similarly in other Brochures and leaflets on communicable diseases, immunization, iodated salt, NRHM etc, photographs have been selected with care and appropriateness and reflect similar meaning as the text. However, there are lesser number of Visuals is used in leaflets compared to brochures. Value Addition with Slogans: A slogan is a memorable motto or phrase used in to ensure recall and triggering as a reminder of more information and as a repetitive expression of an idea or purpose. Crystal defined slogans as “"A forceful, catchy, mind-grabbing utterance which will rally people to buy something or behave in a certain way." (Crystal). A variety of printed materials were used but the emphasis on core programmes was missing and it added to overload of too many messages for dissemination. Among the materials brochure was widely used and with good effect in terms of its visual appeal. It emerged as the best material as it comprehensively provided information on several issues. However, such material is of greater value where recipients are front-line workers, associated partners. For the community where literacy is still an issue, especially among women, such brochures will have limited validity. Such material should be used to train and as a repository of information among the development agencies since information helps in preparing and in discussing salient points during meetings with target audience in villages. They were distributed in large number in all the states. On the other hand Leaflets are good for focused and specific issues customised as per the local context and these were used in Rajasthan and Madhya Pradesh in good measure. All the materials used were in colours with an ideal combination of font as both colour and font play an important role in attracting attention. Overall it was found that a significant material was distributed by DFP, followed by NRHM and UNICEF. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 49 Chapter IV Charting New Frontiers an Way Forward This chapter provides an overview of the impact of the DFP’s Campaign in different parts of the country. Major findings have been summarized by elucidating the success and challenges in the form of recommendations. At the outset the assessment of the campaign programme must be made with a proviso that expectation of success based on “one stand-alone activity” would be turning the empirical evidence upside down since no single activity through any method or device can change the stranglehold of age-old practices and deficiencies in the system of delivery at the grassroots level. The results should be viewed as a result of one single day’s effort to garner support, mobilise disparate groups under the banner of health to conduct activities in remote and against heavy odds, comprising of apathy, alienation and infrastructural constraints. Secondly, in the light of limitations imposed, as a result of deficient human resources within DFP, the task of campaigning becomes more challenging. A third related factor which provides a strong reason for supporting the DFP activity and efforts, is of lay in media use in such disadvantageous regions which are bereft of any other source of information. Except in Assam, other states have relatively low use of mass media, especially TV, radio and newspaper. Hence, such stark conditions provide a strong case for use of DFP machinery for health promotional activities in regions which have limited exposure to mass media and experience constraints in using media services because of infrastructural lag. As efforts of DFP are not supplemented by other media, there is need of periodic campaigning in innovative ways to keep attention of the people riveted on the health issues as a life-style and healthy option. For periodic campaigning 'edutainment' and ‘covert messaging’ can work as a good model for diverting attention from the product to possibilities of changes and a new experience through practice of new and improved behaviours. Here lessons from campaigning of successful commercial products and services can be borrowed to understand how people can be motivated with support by addressing their concerns (as part of the participatory process) and by showing alternative lifestyles as a result of changes in practice. Communication of complete and customized information, assurance of quality services by the health providers, and mitigation of concerns of people would help in reducing the gap between knowledge, attitude and behaviours. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 50 TEXT BOXES BELOW PROVIDE OVERVIEW OF LESSONS LEARNT AND CHALLENGES UNDER EACH THEME Breast Feeding Campaign has had a significant impact on awareness generation as well as on promotion of positive attitude for breast feeding across the states. Beside this, observed relation between levels of knowledge and attitude shows that prescribed route for attitude change can be tracked through awareness generation. As observed relation is only explaining 26% of variance, thus major change agent is rooted in socio-cultural practices. Evidence suggests Jharkhand and Rajasthan require more intense and rigorous campaign to overcome the lag between awareness and attitude which in effect will get converted into practice. In terms of communication strategies, uses of ‘harm reduction’ and ‘fear appeal’ in messaging are recommended. As ‘harm reduction strategy’, the campaign could highlight, for example, that ‘first milk’ of mother is of utmost importance than ‘honey’ which can be given to the child at a later stage during the occasion of “Annaprashan” i.e. first feed comprising of cereals. As an element of ‘fear appeal’, the campaign should highlight ‘harmful consequences’ of not breast feeding for the child and the mother, psychologically and physiologically. Institutional Deliveries DFP’s Communication Campaign has succeeded in bringing awareness about JSY programme among women of marginal communities and those living in remote and backward areas. Higher awareness about JSY programme has been due to the incentive for pregnant women and ASHA worker, but simultaneously the campaign has made significant contribution in conveying messages among the target population that 'institutional delivery is safe delivery'. This element of assurance and assuaging the fears and uncertainties in messaging is more relevant in acceptance and in reducing misconceptions circulating around such incentive-based programmes. Equally significant has been greater understanding about the programme. If there is a rollback of the incentive, sustenance of this pro-social attitude will help in improving the reach and efficacy of primary health services. But this sustenance needs continued and improved effort by DFP and support by the client ministry. Rajasthan, MP, and Jharkhand require rigorous campaign for JSY to improve institutional deliveries. However, Assam has shown marked improvement, but it needs further stimulus for an overall achievement. In case of institutional deliveries the observed relationship between knowledge and attitude is negligible. It makes for a compulsive argument to organise separate campaigns focussed on knowledge generation, attitude change, and socio-cultural barriers. Awareness generation will not lead to action unless facilitated by building a positive attitude of individual and an enabling social and health system environment. Thus each area needs separate communication strategy. It is recommended that the campaign should highlight that ‘celebration of parenthood’ is incomplete without institutional deliveries, and is key to the safety of mother and child. Second, it also requires adequate services and a readiness from health facility/department to make quality services available. User’s experience with health system will be the key for his/her continuance and compliance. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 51 Family Planning The campaign had a limited impact on uptake of family planning services. The results are not unexpected since in these regions the family planning services are at a nascent stage and are difficult to access. The challenge here is not about awareness generation but converting higher awareness into reduction of negative attitude for family planning. These results point towards a need for thorough review not only of communication strategy for family planning, but also for related ground level activities. In terms of communication strategies, a clearly articulated promotional programme on ‘contraceptive choices’ and ‘size of the family’ should be implemented in conjunction with access to quality services. . Existing socio-cultural barriers about what constitutes ‘size of the family ‘makes it imperative to plan for more discreet and veiled messaging to be designed and promoted which enhances the desirability of ‘small family’ as a viable and as an alternative to ‘large size family’. More vigorous message dissemination regarding contraceptive choices, which a couple/individual can choose from, should form a major plank of the interpersonal communication forums. Delinking of these two activities ‘small family norm’ and ‘contraception programme’ will help in reducing the barriers and apathy and in reach and access the target population, which will serve the purpose of a viable ‘size of family’ in the long run. Health Camp Campaign in conjunction with the health camp is a viable option as it provides an opportunity for monitoring as well as for image correction/building of the client ministry (MOHFW). Evidence suggests that this model can be implemented with certain riders. The health camps should be organized in such a way that people first attend the activity session where information about the scheme and the entitlements are shared. Thereafter, they should be directed to the health camp to reduce the ‘distraction effect’ induced by easy access to services at the health camp. To establish this coordination between health department and DFP on such issues, DFP should collaborate with local health officials periodically for finalizing their activities through email and mobile to reduce time lag and overcome time-lag and distance to sort out issues of programme planning and management. This will also help in addressing the local needs and customizing services to the benefit of beneficiaries. At the same time health department, as the client agency, should promote the synchronization of their activity with DFP. This sets the agenda for greater coordination, partnership and ownership of the activities planned in the selected sites. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 52 Pre-Campaign DFP Activities (i) Conceptualization and Planning Programme Activities Planned health promotion activities are congruent to efforts of ‘community processes under NRHM (National Rural Health Mission). Association of PRIs and other village functionaries, with DFP’s ground-level programme, will strengthen the efforts of NRHM under community processes, which require participation of community members at various level of planning and management of health services. The action plan of DFP was very well conceptualised and visualised since it identified various stakeholders (Media, NGOs, PRI, health functionaries, and political party representatives) who would provide efficient and viable support and partnership at the grassroots level. (ii) Training, Message Framing, and Issue of Knowledge-Transfer During Workshop Briefings at the regional/state workshops were heavily tilted in favour of select schemes (JSY), while emphasis on other important schemes and entitlements of the people was toned down to their detriment. The role of PRIs under NRHM was not elucidated which resulted in failure to assign minor and major responsibilities to them during pre and post event period. The NRHM/health Officials at the DFP workshops should have highlighted the active role of village functionaries and opinion leaders as crucial to continuation of the programme. Strategy should be aligned with efforts of client ministry's mandate under NRHM i.e. 'community processes'. This will not only support the activity of the client ministry in activating and revitalizing its institutional structures, such as VHSCs etc, but it would also help in multiplying the efforts of DFP. For this process to unveil, orientation of officers has to begin from the top and translate into clearly laid-out plans and specific tasks. In some of the regional workshops, speakers/trainers (health officials) were not well prepared to provide adequate briefing even on JSY. For example, the scheme of Janani Shishu Sureksha Yojana, as an add-on to the existing JSY, was presented as a new scheme (JSSK) which created an ambiguous impression about JSSK as a replacement to JSY. As part of the workshop preparation, DFP should have given more attention to the organisation of the training-workshop by identifying appropriate trainers in advance and assigning such topics to speakers to avoid repetition or omission. Secondly, to ensure availability of the guest speakers during the training sessions, an advance confirmation should be taken, and an alternative list of speakers should be prepared to fill the gap in case of drop-outs. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 53 Campaign Activities (i) With opinion leaders Effort was partially fulfilled as DFP’s activities were limited to briefing the opinion leaders about various schemes, and did not extend beyond to developing and building consistent association. This resulted in inadequate preparation during pre-campaign activities. The preparation and orientation regarding planning and designing for the campaign at the central and regional level however failed to translate at the district levels, and subsequently at the campaign sites. Reorientation of the training schedule should follow a cascading structure and this system requires an innovation and reorientation. (ii) Rallies Village rallies were used to create a sense of heightened activity with students and children. Rally as an energizer method however was unable to open the channel of communication and remained restricted to a passive communication exercise with live models in some districts. The rally as a method of instilling interest and curiosity of the community can at best work as a trigger. A better and alternative approach could be to involve the panchayats in organizing meetings and provide a forum of information and feedback. Encouragement can also be given to participation of local NGO members, and development agencies and their functionaries in such meetings as well. They should be co-opted and briefed in advance about focus of the campaign to provide a local connect, but should not be given a free run either to use it as a platform for self-serving agenda. (iii) Timings of the Programme The timings of the designated programmes should be synchronised with the availability and presence of the local population. It is recommended that before scheduling the programme, days of weekly market, festivals, and timing of agricultural activities should be ascertained to ensure availability and participation of community in the programme. (iv) Method of Information Dissemination There is a heavy reliance on lectures as a mode of information delivery. The pattern of lecture/seminar was not uniform across the regions and; it was heavily depended upon DFP and health experts’ own orientation to subjects at hand to make the messages sound resilient and meaningful for diverse groups. Speaker's focus was more on health prevention activities than on promotion of available services and its utilization. This was quite obvious at village level where speakers provided information which was not customized as per the needs of the audience and was delivered in a lecture mode. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 54 Lecture giving is an art, and selection of speakers and choice of topics should be in alignment with the kind of audience available. Careful and deliberate attention should be given to preparation in selection of guest speakers, by giving them advance notice about the campaign topics. (v) Baby Show The Baby Show activity can be used as an important strategy to reach specific target population. For better management of the ‘baby show’ selection criteria of the baby and number of awards should be announced in advance. Secondly, as there is an active involvement of the health department, this activity provides a chance to identify and reach the specific target population with minimal redundancy of efforts. (vi) Inter Departmental Coordination DFP has to evolve mechanism for inter-departmental coordination especially with Song and Drama and DAVP. There support will augment the efforts of DFP. In final assessment, DFP’s programmes were a well coordinated and planned series of programmes in regions where access to government programmes and services is limited and poses innumerable challenges. Taking information to such settings and enlisting the support of the local agencies like PRIs, NGOs, front-line workers like ANM, AWW and ASHA, augurs well since this is one step towards a participatory and inclusive approach. As a forward movement DFP’s programme can ensure better impact if people’s participation is not reduced to the level of being, passive audience but women and men and youth are motivated to become part of the communication programme planning, implementation and monitoring process for community’s ownership of the development programmes. Final Note Although formative research is an accepted practice, it is not always carried out since campaign planners believe they know their audience well, have material already produced, or feel pressed for time or when media producers feel it is their right to maintain ‘control over messages’ (Bela Mody, 2003). A participatory approach where people feel empowered to think, rationalize, participate and express their understandings and concerns will help outreach programme to gain credibility and attain acceptance. This precept will help in changing the way communication programmes are conceived, designed by those who usurp the creative process of the communities to express their ideas and in a language which is as rich as their cultural moorings. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 55 Bibliography Bibliography 1. Bashiruddin, S. (1978). Prospects for Communication Planning in – an Overview in Peter Habermann and Guy de Fontgalland (eds). Development Communication–Rhetoric and Reality. Singapore: AMIC. 2. Bamezai, Gita (2010). Behavior Change Communication Framework. Paper Prepared for Population Council of India. 3. Becker, M. H., Haefner, D. P., and Maiman, L. A. (1977). 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(2003). International Development Communication: A 21st Century Perspective. New Delhi: Sage Publication 10. Ministry of Health and Family Welfare. (2005). Framework for Implementation. New Delhi, Government of India 11. MOHFW, (2005). Framework for Implementation. New Delhi: Government of India. 12. MOHFW, (2005). NRHM Mission Document. New Delhi: Government of India. 13. MOHFW, (2007). First Common Review Mission. New Delhi: Government of India. 14. National Health Systems Resource Centre. (2011). Programme Evaluation of Janani Suraksha Yojana. Government of India. 15. Olenick I. (2000). Women’s Exposure to Mass Media Is Linked to Attitudes toward Contraception in Pakistan, India and Bangladesh. International Family Planning Perspectives, 26, 48–50. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 56 16. Petty, R. E., & Cacioppo, J. T. (1986). Communication and Persuasion: Central and Peripheral Routes to Attitude Change. New York: Springer-Verlag. 17. Robertson, A. and Minkler, M. (1994). New health promotion movement: a critical examination. Health Education and Behavior, 21, 295– 312. 18. Rogers E. M., Singhal A., (2001). India's Communication Revolution: From Bullock Carts to Cyber Marts. New Delhi: Sage Publications. 19. Salem R.M., Bernstein J., Sullivan T.M., Lande R., (2008). Communication for Better Health. Population Reports. Series J: Family Planning Programs, Jan ;(56),1-27. 20. Salmon, Charles T. & Atkin, Charles (2004). Using Media Campaigns for Health Promotion. In Thompson, Teresa L., Dorsey, Alicia M., Miller, Katherine I. & Parrott, Roxanne (Eds). Handbook of Health Communication. London: Lawrence Erlbaum Associates, Publishers 21. Servaes J., Malikhao, P. (2004). Communication and Sustainable Development. Rome: FAO. 22. Servaes, J., ed. (2008). Communication for Development and Social Change. New Delhi: Sage Publications. A report by IIMC for Directorate of Field Publicity, Ministry of Information & Broadcasting, GOI 57 Annexure A. Research Instruments - Interview Schedule for DFP Officials Entry & Exit Questionnaires IDI with Health Implementers IDI for Opinion leaders IDI for Women FGD for Women B. Table: Content Analysis of Print Campaign Material Research Instrument No. 1 Interview Schedule for DFP Officials Participatory Communication Campaign Approaches in Improving Health Practices in India A Project for conducting an Impact Assessment of DFP’s programme for improving Mother and Child Health Village District State Date of interview: Interview Schedule No. Interview Schedule for DFP Officials (Please seek concurrence of the official before beginning the interview and assure the concerned respondent that the identity will not be revealed and information given will be used only for drawing overall inferences about the program and will have no reflection on him/her in their personal capacity.) Section 1 Personal Information 1.1 Name: (Optional) _____________________________________________________________ 1.2 Designation_________________________________________________________________ 1.3 Place of Current posting: HQ 1.4 Job responsibility: Program 1.5 Number of years associated with DFP: 1. Less than 5 years Regional Office Coordination 2. 6-10 years 3. 10-15 years 1.6 Educational Qualification: 1.7 Training received on communication media in last 2 years Training Level (National/State) State Office Administration 4. 15-20 years District Level Technical 5. More than 20 years Topics/themes covered 1 2 3 4 Section II 2.1 Program Information Are you aware of the Janani Shishu Suraksha Yojana? 1. Yes 2.1.1 1 2 3 4 5 6 7 2. No If yes please indicate the main message delivered by DFP in the above mentioned program JSY relates to institutional deliveries Delivery by trained team of health worker and doctor Compensation to mother during delivery It motivates mother for breastfeeding It informs them about family planning About neo-natal deaths Any other I 2.2 What according to you will be the most effective media to communicate this program? (Fill the appropriate number in the bracket) 1. Very Effective 2. Effective 3. Less Effective 4. Not Effective Radio 2.3 Films Face to Face None of these Any other: What media strategies you suggest so that this program can reach out to maximum beneficiaries? (Number of pregnant and expectant mothers in village) ______________________________________________________________________________________ ______________________________________________________________________________________ Section III 3.1 TV Program Strategy Methods used Which is the most effective media to communicate the program? Write: 1 Very Effective 2. Effective 3. Less Effective 4. Not Effective Effectiveness Activities Film Shows Drama Celebrity Endorsement Music Concert Ballet Folk Dance Seminar Group Discussions Radio Talk Any Other (Specify) 3.2 What new innovations are being used by DFP to actively encourage and mobilize people especially pregnant woman to take part in the JSY Scheme. _____________________________________________________________________________________ 3.3 Can observed changes (in attitudes, capacities, institutions etc) be linked to the campaign’s interventions? 1. Yes 2. No 3.4 In how far is the campaign making a significant contribution to broader and longer-term development impact? Is the campaign strategy and management steering towards impact? _____________________________________________________________________________________ 3.5 Has the campaign successfully built or strengthened an enabling environment ( policies, people’s attitudes etc)? _____________________________________________________________________________________ 3.6 Are the campaign results, achievements and benefits likely to be sustainable? Yes No _____________________________________________________________________________________ 3.7 Can the campaign approach or results be replicated or scaled up by national partners or other actors? Is this likely to happen? What would support their replication and scaling up? _____________________________________________________________________________________ II 3.8 Can any unintended or unexpected positive or negative effects be observed as a consequence of the DFP’s interventions? 1. Yes 2. No 3.8.1 If so, how has the campaign strategy been adjusted? _____________________________________________________________________________________ 3.8.2 Have positive effects been integrated into the campaign strategy? _____________________________________________________________________________________ 3.8.3 Has the strategy been adjusted to minimize negative effects? _____________________________________________________________________________________ 3.9 Should there be a second phase of the campaign to consolidate achievements? 1. Yes 2. No People’s participation and Feedback Section IV 4.1 In your opinion what approaches/methods are most effective in reaching and seeking participation of the community? (Can select more than one option) S. No. 1 2 3 4 5 6 4.2 Personal visits Holding meetings in villages Meeting the leaders only Use of Public meetings Movie show Any other (Specicy) How effective is interpersonal communication/oral/face to face interaction towards increasing people’s participation in programs? 1. Very Effective 4.3 2. Somewhat Effective 3. Negligible 4. Not at all Is taking feedback from people about their reaction towards these programs, is a routine and essential part of the program implementation? 1. Yes 2. No 3. Sometimes 4.3.1 If yes, what is the nature of feedback? (i) People ask for more information on programs through personal contact (ii) Received complaints from community from time to time (iii) Receive requests from community for more efforts from our side (iv) Receive letters from community on which we take action (v) DFP refers complainant to the concerned department. 4.4 Do you or your staff regularly follow-up to assess the impact of your efforts? 1. Yes 2. No 4.4.1 If yes, then how? Describe three methods. _____________________________________________________________________________________ III 4.5 What challenges do you face while ensuring participation of the people in all these programs? Please state at least three major such barriers/roadblocks at: I) Department Level_________________________________________________________________ II) Community Level_________________________________________________________________ III) Personal Level___________________________________________________________________ 4.6 What are the benefits of reaching out to people through traditional methods/mass media such methods in the face of increasing use of information technology like internet and mobile? 1.___________________________________________________ 2.___________________________________________________ 3._____________________________________________________ 4.7 Does internet and mobile have a role to play in overcoming difficulties of reaching out to people in villages and remote areas? 1. Yes 2. No 4.8 What are the measures adopted by you to identify communication needs, objectives and activities in the area? _____________________________________________________________________________________ 4.9 How can we improve the quality of DFP’s communication campaigns planning and management? _____________________________________________________________________________________ ********************** IV Research Instrument No. 2 Entry & Exit Interviews Participatory Communication Campaign Approaches in Improving Health Practices in India A Project for conducting an Impact Assessment of DFP’s programme for improving Mother and Child Health Directorate of Field Publicity (DFP), a media unit of Ministry of Information and Broadcasting, New Delhi is organising campaign of events to propagate messages on NRHM & JSSY (National Rural Health Mission, Janani Shishu Suraksha Yojana) in all states of the country. Indian Institute of Mass Communication, M/o I&B, New Delhi is conducting research to assess the reach of messages on Maternal and child health, family planning, etc and change in knowledge, attitude and practices of target population towards improving the status of health. I am ................. (Name) and as a part of this study, I want your consent in asking you few questions about the government health programmes and the campaign. This will take maximum 10-15 minutes. Your responses are important to us. Can you spare few minutes for this. Your views will be kept confidential and will be utilised only for study purposes. Date of interview: Interview Schedule No. Village District State ENTRY INTERVIEW Section I Profile 1 Name 2 Age (In Years) 3 Gender 1. Male 2. Female 4 Marital Status 1. Married 2. Unmarried 5 Education: 6 Occupation 7 Personal Income, if any (In Rs.) 8 Age when got married 9 Children (If yes, No. of Children) 1 Yes 9.1 Age of Eldest and Youngest child Eldest 10 Belong to this village 1 Yes 10.1 If No, Name of the Village 11 Youngest 2. No Media Use 1. TV 12 No. of Children: 2. No 2. Radio Health Seeking Behavior 1. Visits Govt. hospitals 4. Uses Home remedies Section II 3. Newspaper 4. Mobile phones 2.Visits Private hospitals 5. Consults ISM practitioner 5. Movies 3. Both Govt. and Private Recall/Earlier exposure to such programme: 2.1. Have you attended any event organised by DFP earlier? 1. Yes 2. No 2.2. If yes, what kind of program (Exhibition/Film show/Talks/Rallies) was it? ____________________________________________________________________________________________________________ V 2.3. What was the theme of the program? S. No Theme Health and Hygiene 1 Development related (Employment related, infrastructure, agriculture 2 etc) Flagship programmes (like MGNREGA, SSA, CMP etc) 3 National Integration & Communal harmony 4 Iodized Salt 5 Family Planning 6 Farming, 7 Vaccination 8 Training for rural youth 9 Janani Suraksha Yojana (JSY) 10 Education 11 Any other (Please specify) 12 Write 1 for Yes 2 for No Section III. Source of Information/Publicity about the present Campaign/ program: 3.1. How did you come to know about this even/tprogram? 1. Through Panchayat and village functionaries 2. Through friend/ family 3. Announcement on loudspeaker 4. I was passing by this place & stopped to see 5. DFP 6. Health functionaries (ANM/ASHA/AWW) 7. Any other (Please specify) ______________________________________________________________ 3.2. What are you expecting from the programme? 1. Entertainment 2. Information 3. Both 4. Any other _______________________ Section IV: Knowledge and Practice 4.1 Are you aware of Janani Suraksha Yojana? 1. Yes 2. No 4.2 If Yes, what do you know about it? S. Themes No. 1 Child Marriage What is the Legal Age for marriage of boys and girls in India 2 Maternal Health Pregnancy at early age can affect woman’ health adversely 3 Immunization Immunization helps in fighting childhood diseases It is necessary to follow the immunization chart 4 Breast feeding An infant must be breastfed within half an hour of his/her birth Breast milk is the healthiest food for infants The first produce of breast is most nutritious 4 Female Foeticide Boys and girls should be treated equal Sex determination test is unethical and punishable There are laws to punish guilty of this crime 5 Institutional Institutional deliveries are safe for mother and child Deliveries Govt. gives incentives for institutional deliveries 6 Family Planning Reducing gap between children increases risk of infant death Male sterilization does not affect manhood or virility among males Smaller family means good quality of life 1 For Aware 2 for Not Aware VI 7 Communicable Disease Stagnant water allows breeding of mosquitoes 4.3 Give your opinion about following statements: S. No. Statements 1 For Agree 2 For Disagree 3 For partially Agree 1 Mother and child not allowed to go out for 40 days after delivery 2 It is important to keep baby warm after birth 3 Deliveries at home is not risky for mother and child 4 Anemia in women is common and does not cause complication during delivery 5 Mothers giving birth to baby girls are given no attention 6 Mothers are responsible for giving birth to baby girls 7 Breast milk immediately after birth should be avoided for 3 days 8 Infant should be given honey and water after birth 9 Child fed on breast milk is healthier and more intelligent 10 Breast feeding helps mother in regaining health faster after delivery 11 Breast feeding increases milk output among women 12 Male child is necessary for a complete family 13 Males sterilization affects manhood or virility 14 Bigger family means more hands to earn 15 Sons take care of parents more than daughters 16 Bringing a girl child is a burden 17 Boys take forward the name of the family 18 Having girls means fear of safely and dignity 19 Child marriage is necessary to avoid dowry system 20 Infant and maternal mortality are ill effects of Child marriage Note: Ensure the exit interview with the same respondent. EXIT INTERVIEW Section V Recall and Comprehension 5.1 What did you see/attend today? ______________________________________________________________________________________ 5.2 S. No 1 2 3 4 5 6 7 8 9 10 11 12 What was the theme of the program? Theme 5.3 Write 1 for Yes 2 for No Health and Hygiene Development related (Employment related, infrastructure, agriculture etc) Flagship programmes (like MGNREGA, SSA, CMP etc) National Integration & Communal harmony Iodized Salt Family Planning Farming, Vaccination Training for rural youth Janani Suraksha Yojana (JSY) Education Any other (Please specify) Did you understand the message delivered? 1. Fully 2. Somewhat 3. Not at all VII 5.4 If the answer is ‘somewhat’ or ‘not at all’, what are the reasons? 1. Subject was not clear 2. No prior introduction to subject 3. Subject not relevant to us 4. Information was given through songs so it was not clear. 5. Did not understand the language/dialect 6. The sound system was not good, could not hear the songs/dialogues 7. Crowd was too much, could not see 8. Performance was not entertaining 9. Was late for the show/ did not see the whole show 10. Any other _______________________________________________________ 5.5. Recall of the themes and messages S. No. 1 2 3 Themes Child Marriage Maternal Health Immunization 4 Breast feeding 4 Female Foeticide 5 Institutional Deliveries 6 Family Planning 7 Communicable Disease 1 For Aware 2 for Not Aware What is the Legal Age for marriage of boys and girls in India Pregnancy at early age can affect woman’ health adversely Immunization helps in fighting childhood diseases It is necessary to follow the immunization chart An infant must be breastfed within half an hour of his/her birth Breast milk is the healthiest food for infants The first produce of breast is most nutritious Boys and girls should be treated equal Sex determination test is unethical and punishable There are laws to punish guilty of this crime Institutional deliveries are safe for mother and child Govt. gives incentives for institutional deliveries Reducing gap between children increases risk of infant death Male sterilization does not affect manhood or virility among males Smaller family means good quality of life Stagnant water allows breeding of mosquitoes 5.6 Were these messages being conveyed earlier to people in this village? 1. Yes 2.No 5.6.1 If yes, what was the medium/source?______________________________________________________ 5.7 Give your opinion on following: Statements 1 2 3 4 5 6 7 8 9 10 11 1 = Agree 2 = Disagree 3 = Partially Agree Mother and child not allowed to go out for 40 days after delivery It is important to keep baby warm after birth Deliveries at home is not risky for mother and child Anemia in women is common and does not cause complication during delivery Mothers giving birth to baby girls are given no attention Mothers are responsible for giving birth to baby girls Breast milk immediately after birth should be avoided for 3 days Infant should be given honey and water after birth Child fed on breast milk is healthier and more intelligent Breast feeding helps mother in regaining health faster after delivery Breast feeding increases milk output among women VIII 12 13 14 15 16 17 18 19 20 Male child is necessary for a complete family Males sterilization affects manhood or virility Bigger family means more hands to earn Sons take care of parents more than daughters Bringing a girl child is a burden Boys take forward the name of the family Having girls means fear of safely and dignity Child marriage is necessary to avoid dowry system Infant and maternal mortality are ill effects of Child marriage Section VI 6.1 S. No. 1 2 3 4 5 6 7 6.2 Liking for the Programme: How did you find the arrangement for the programme? (put the rating against each response) (Give ratings: 1.Good, 2. Ok 3. Bad) Rating Reasons for not liking Venue Timing of the program Space Sitting Arrangement Lights Sound/Music Any Other Did you like the program you attended just now? 1. To large extent 2. To some extent 3. Not at all 6.3 Did any official approach you during the program? 1. Yes 2.No 6.4 Did you seek any clarification regarding Govt. programmes, during the program? 1. Yes 2.No If yes, A). What was the doubt/question? _____________________________________________________________________________________________________________________ B). Who responded your query? ____________________________________________________________________________________________________________________ Section VII Suggestions on Theme and programme 7.1 Do you think such themes / messages are good for improving the health of people in the village? 1. Yes 2.No 3. Can’t say 7.2 What would be most effective way of generating your village? 1. Film shows 2. Song and drama 5. Exhibition 6. Printed material 9. Interpersonal Communication 11 Panchayat meetings 13 Training by Anganwadi Centers 7.3 awareness/involving people and bringing change in 3. TV 4. Radio 7. Hoardings/ posters 8. Traditional folk media 10. Regular health camps in schools and PHC 12. Door to door visit by the health workers 14 Other _____________________ Please give suggestions to improve or make such programmes more effective. ________________________________________________________________________________________________________________________________________________ ********************** IX Research Instrument No.4 IDI with Health Implementers Participatory Communication Campaign Approaches in Improving Health Practices in India A Project for conducting an Impact Assessment of DFP’s programme for improving Mother and Child Health Name of the village:_______________ District:_____________ State: _______________________ A. Profile: 1. Name __________________________ 2. 3. Do you belong to this village: 3.1 If yes, (Please give name of the village) _______________________________________________ 3.2 Since how long you have been in this village_____________________________________ 1. Yes Age _________ 2. No We want to thank you for taking the time to meet us today. We would like to talk to you about your experiences as ANM/ASHA/AWW/VHC/SHG. Specifically, as one of the components of our overall program evaluation we are assessing program effectiveness in order to collect data that can be used in future interventions. The interview should take less than an hour. We will be recording the session because we don’t want to miss any of your comments. All responses will be kept confidential. This means that your interview responses will only be shared with research team members and we will ensure that any information we include in our report does not identify you as the respondent. Remember, you don’t have to talk about anything you don’t want to and you may end the interview at any time. 1) Are there any questions about what has just been explained to you? 2) Are you willing to participate in this interview? Interviewee Section I 1.1 Witness Date General Information How frequently you visit this village? ___________________________________________________________________________________________________________________________ 1.2 How many villages you look after/visit: ___________________________________________________________________________________________________________________________ 1.3 How many ANM/ASHA work in your team________________________________________________ 1.4 Did you attend any training/ orientation in near past? 1.5 Did you attend any training/ orientation in near past? 1. Yes 2. No 1.5.1 If yes. Give details__________________________________________________________________ 1.6 What is the role of following under JSY scheme? ANM _________________________________________________________________________ ASHA_________________________________________________________________________ AWW_________________________________________________________________________ VHC__________________________________________________________________________ SHG __________________________________________________________________________ X 1.7 Has your role changed after JSY came into being? ___________________________________________________________________________________________________________________________ 1.8 What changes do you find/see after JSY was introduced in this village, Increased use of services by pregnant women Increased knowledge of villagers Decrease in no. of women dying during pregnancy Less neo-natal deaths Increase in no. of children for immunization 1.4 Your job is quite challenging, how do you think you are helping in bringing changes in the practices such as institutional delivery, breast feeding and family planning? Please explain. _____________________________________________________________________________________ 1.5 Had there been any increase in the number of pregnant women taken to the health center for delivery? 1. Yes 2. No If yes. Approx how much________________________________________________________________ 1.6 In your opinion is JSY able to influence the family health behaviors/practices have? 1. Yes 1.6.1 2. No 3. Don’t Know If yes, what changes do you see 1) Age of marriage________________ 2) Small family norm______________ 3) Spacing _______________________ Section II Barriers 2.1 What do you think is the key element of JSY-institutional deliveries, breastfeeding or immunization? ______________________________________________________________________________________ 2.2 Why do you think so? ______________________________________________________________________________________ 2.3 What do you think are the main reasons why people don’t prefer institutional delivery? 1) Home is convenient 2) Not required since pregnancy was normal 3) Cost of institutional delivery 4) Delivery institution is far off 5) Nobody to take them to hospital for delivery 6) Untimely delivery 7) Family objects to institutional delivery 8) Any other (Specify)___________________________________________ 2.4 What is the structure of families in this village? 1) Joint family 2) Nuclear family 2.5 Who in the family takes decision regarding important issues such as childbirth or number of children in family? ______________________________________________________________________________________ XI 2.6 Do the people of this village practice family planning? 1. Yes 2. No 2.6.1 If No, Why do they prefer to have large family? ______________________________________________________________________________________ 2.7 What kind of health facility they prefer for / trust for childbirth & why? 1) Institutional/Government facility_________________________________________________________ 2) Accredited Private facilities _____________________________________________________________ 3) Private facilities ______________________________________________________________________ 2.8 Incase of emergency how do you take pregnant mothers to nearest health facility ______________________________________________________________________________________ 2.9 Percentage of children under 3 year’s breastfed within one hour of birth ______________________________________________________________________________________ 2.10 Do you receive queries regarding breastfeeding? 1. Yes 2. No 2.11 What are the major issues because of which women don’t breast feed? 1) Mothers are not healthy/weak 2) Family/ mother don’t consider breast milk good for infants 3) They consider formula food like Cerelac and Farex to be better 4) Difficulties- Breast Abscess 5) Mother don’t produce enough milk 6) Women are figure conscious 7) Any other (specify)____________________________________________________________________ 2.11 Do you take infants / newborn babies for routine immunization? 1. Yes 2. No 2.11.1 If No, then who does?___________________________________________________________________ 2.11.2 If Yes, a) Do mothers bring their child for immunization on their own?___________________________________ b) What information you share with beneficiaries?______________________________________________ c) In what way do you convince and mobilize mothers for immunization?___________________________ 3 3.11 How do you check dropouts of immunization? ______________________________________________________________________________________ ______________________________________________________________________________________ 4 4.11 What percentage of children 12-23 months fully immunized (BCG, measles, and 3 doses each of polio/DPT) ______________________________________________________________________________________ ______________________________________________________________________________________ Section III Communication 3 3.1 What are the factors responsible for the pregnant women not to avail medical facility? ______________________________________________________________________________________ XII 3.2 What rumors and misconceptions are prevalent related to various programs (Immunization, JSY or ANC and institutional delivery, contraception especially vasectomy) ______________________________________________________________________________________ 3.3 Who are the detractors who do not allow women to access health care during pregnancy? a) Family b) Cultural setup c) Money d) Lack of awareness e) Psychological reasons : ________________________________________________________ : ________________________________________________________ : ________________________________________________________ : ________________________________________________________ : ________________________________________________________ 3.4 Who can best motivate people/women and their families to come forward and avail health services and practice dos and don’ts for child and maternal health? ______________________________________________________________________________________ 3.5 What are the other possible methods to motivate pregnant women for institutional delivery and breast feeding? ______________________________________________________________________________________ Section IV 4.1 Government’s policy What are the methods are adopted for popularizing the scheme among pregnant women and their families? 1) Is there? 2) What is it? 3) Have you helped? 4) How does it motivate? 5) Does JSY incentive offered to pregnant women motivate them for institutional delivery? ______________________________________________________________________________________ Section V 5.1 Indicators of quality Do people in this village are interested for information on sterilization? 1. Yes 2. No 5.1.1 If yes, then who (M/F)________________________ 5.1.2 Who among the family go for sterilization process? (Husband/wife) Section VI Strategies to improvise 6.1 What strategies, interventions, tools should be discontinued? Why? _________________________________________________________________________________ 6.2 Do you find awareness generating activities to be adequate? 1. Yes 6.3 2. No 3. Cant say What is your suggestion to generate awareness about these schemes? _________________________________________________________________________________ _________________________________________________________________________________ ********************** XIII Research Instrument No. 5 IDI for Opinion leaders Participatory Communication Campaign Approaches in Improving Health Practices in India A Project for conducting an Impact Assessment of DFP’s programme for improving Mother and Child Health Name of the village:_______________ District:_____________ State: _______________ A. Profile: 1. Name __________________________ 3. Do you belong to this village: 3.1 3.2 1. Yes 2. Age _________ 2. No If No, (Please give name of the village) ____________________________________________ Since how long you have been in this village________________________________________ We want to thank you for taking the time to meet us today. We would like to talk to you about your experiences as ANM/ASHA/AWW/VHC/SHG. Specifically, as one of the components of our overall program evaluation we are assessing program effectiveness in order to collect data that can be used in future interventions. The interview should take less than an hour. We will be recording the session because we don’t want to miss any of your comments. All responses will be kept confidential. This means that your interview responses will only be shared with research team members and we will ensure that any information we include in our report does not identify you as the respondent. Remember, you don’t have to talk about anything you don’t want to and you may end the interview at any time. 1) Are there any questions about what has just been explained to you? 2) Are you willing to participate in this interview? Interviewee Witness Section I 1.1.1 Date General Information How frequently you visit this village? ____________________________________________________________________________________________________________ 1.2 How many villages you look after/visit: ____________________________________________________________________________________________________________ 1.3 What changes do you find/see after JSY was introduced in this village, 1.4 Increased use of services by pregnant women Increased knowledge of villagers Decrease in no. of women dying during pregnancy Less neo-natal deaths Increase in no. of children for immunization Your job is quite challenging, how do you think you are helping in bringing changes in the practices such as institutional delivery, breast feeding and family planning? Please explain. ___________________________________________________________________________________________________________ 1.5 Had there been any increase in the number of pregnant women taken to the health center for delivery? 1. Yes 2. No If yes. approx how much_________________________________________________________________ XIV 1.6 In your opinion is JSY able to influence the family health behaviors/practices have? 1. Yes 1.6.1 2. No 3. Don’t Know If yes, what changes do you see 1) Age of marriage_______________________________________________________________________ 2) Small family norm_____________________________________________________________________ 3) Spacing _____________________________________________________________________________ Section II Barriers 2.1 What do you think is the key element of JSY-institutional deliveries, breastfeeding or immunization? ____________________________________________________________________________________ 2.3 Why do you think so? ______________________________________________________________________________________ 2.3 What do you think are the main reasons why people don’t prefer institutional delivery? 1) Home is convenient 2) Not required since pregnancy was normal 3) Cost of institutional delivery 4) Delivery institution is far off 5) Nobody to take them to hospital for delivery 6) Untimely delivery 7) Family objects to institutional delivery 8) Any other (Specify)___________________________________________ 2.4 What is the structure of families in this village? 1) Joint family 2) Nuclear family 2.5 Who in the family takes decision regarding important issues such as childbirth or number of children in family? ______________________________________________________________________________________ 2.6 Do the people of this village practice family planning? 1. Yes 2. No 2.6.1 If No, Why do they prefer to have large family? ______________________________________________________________________________________ 2.7 What kind of health facility they prefer for / trust for childbirth & why? 1) Institutional/Government facility_________________________________________________________ 2) Accredited Private facilities _____________________________________________________________ 3) Private facilities ______________________________________________________________________ 2.8 Incase of emergency how do you take pregnant mothers to nearest health facility ______________________________________________________________________________________ 2.9 Percentage of children under 3 year’s breastfed within one hour of birth ______________________________________________________________________________________ 2.10 What are the major issues because of which women don’t breast feed? 1) Mothers are not healthy/weak 2) Family/ mother don’t consider breast milk good for infants XV 3) They consider formula food like Cerelac and Farex to be better 4) Difficulties- Breast Abscess 5) Mother don’t produce enough milk 6) Women are figure conscious 7) Any other (specify)____________________________________________________________________ 2.11 Do you take infants / newborn babies for routine immunization? 1. Yes 2. No 2.11.1 If No, then who does?___________________________________________________________________ 2.11.2 If Yes, a) Do mothers bring their child for immunization on their own? ______________________________________________________________________________________ b) What information you share with beneficiaries? ______________________________________________________________________________________ c) In what way do you convince and mobilize mothers for immunization? ______________________________________________________________________________________ 2.12 How do you check dropouts of immunization? ______________________________________________________________________________________ 2.13 What percentage of children 12-23 months fully immunized (BCG, measles, and 3 doses each of polio/DPT) ______________________________________________________________________________________ Section III Communication 3.1 What are the factors responsible for the pregnant women not to avail medical facility? ______________________________________________________________________________________ 3.2 What rumors and misconceptions are prevalent related to various programs (Immunization, JSY or ANC and institutional delivery, contraception especially vasectomy) ______________________________________________________________________________________ 3.3 Who are the detractors who do not allow women to access health care during pregnancy? a) Family b) Cultural setup c) Money d) Lack of awareness e) Psychological reasons : ________________________________________________________ : ________________________________________________________ : ________________________________________________________ : ________________________________________________________ : ________________________________________________________ 3.4 Who can best motivate people/women and their families to come forward and avail health services and practice dos and don’ts for child and maternal health? ______________________________________________________________________________________ 3.5 What are the other possible methods to motivate pregnant women for institutional delivery and breast feeding? ______________________________________________________________________________________ XVI Section IV 4.1 Government’s policy What are the methods are adopted for popularizing the scheme among pregnant women and their families? 1) Is there? 2) What is it? 3) Have you helped? 4) How does it motivate? 5) Does JSY incentive offered to pregnant women motivate them for institutional delivery? ______________________________________________________________________________________ Section V Indicators of quality 5.1 Do people in this village are interested for information on sterilization? 1. Yes 2. No 5.1.1 If yes, then who (M/F)________________ 5.1.2 Who among the family go for sterilization process? (Husband/wife) Section VI Strategies to improvise 6.1 What strategies, interventions, tools should be discontinued? Why? ______________________________________________________________________________________ 6.2 Do you find awareness generating activities to be adequate? 1. Yes 2. No 3. Cant say 6.3 What is your suggestion to generate awareness about these schemes? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ *********************** XVII Research Instrument No. 6 IDI for Women Participatory Communication Campaign Approaches in Improving Health Practices in India A Project for conducting an Impact Assessment of DFP’s programme for improving Mother and Child Health Village District State Note for the researcher 1. Profile of beneficiaries (women in reproductive years, 18-40) will be be asked before Interview begins 2. Make the interviewee comfortable. Inform them that their views and opinions will be used only for the study and all personal details will be kept confidential 3. Listen for inconsistent comments and probe for understanding. 4. Listen for vague or cryptic comments and seek clarification. Section I A Profile 1 Name 2 Age (In Years) 3 Education: (Please tick mark the appropriate answer) 4 Occupation 5. 6 7 7.1 8 8.1 8.2 8.2.1 8.3 8.4 9. 9.1 9.2 9.2.1 10. 10.1 Personal Income, if any Age when got married Children (If yes, No. of Children) Age of Eldest and Youngest child Pregnant If yes, month of Pregnancy Taking iron Supplements Name of the Supplements ANC visits Assisted by any ANM/ASHA Whether Lactating If yes, Age of child (In months) If No, Have you breast fed earlier If yes, when did you stop breast feeding your (Record age of the child) Placechild of Delivery ofthe birth If at hospital, Who took you there? 1. Cant Read or Write 3. Formal Education 2. Cant Read and Write 4. No formal Education 1. Housewife 2. Employed 3. Self Employed 4. Any other (Specify)_________________________ 1 Yes Eldest 1 Yes 2 No 1 Yes 2 No 1 Yes 1 Yes 1 Yes 2 No 2 No 2 No 1 Yes 2 No 1. At home No. of Children: Youngest 2 No 2. At hospital Section I B 1. Media Use 1. TV 2. 2. Radio Health Seeking Behavior 1. Visits Govt. hospitals 4. Uses Home remedies 3. Newspaper 4. Mobile phones 2.Visits Private hospitals 5. Consults ISM practitioner 5. Movies 3. Both Govt. and Private XVIII Section II A Family health behaviors/practices 2.1 Who in family looks/looked after you or gives/gave suggestions during pregnancy? ______________________________________________________________________________________ 2.2 Do you agree that health of a mother is necessary to bear healthy child? 1. Yes 2.3 2. No 3. Can’t Say Do you agree that having frequent pregnancies can make women unhealthy? 1. Yes 2. No 3. Can’t Say 2.4 According to you how much difference (in years) is ideal between two children? ____________________________________________________________________________________ 2.5 Did you ever discuss with your husband/family members about keeping space between 2 children? 1. Yes 2.5.1 2. No If yes, are you aware of family planning methods? 1. Yes 1) 2) 3) Section II B 2.6 2. No What is legal age for marriage in India?___________________________________________ Do you agree that getting pregnant at early age is not good for health of women? 1. Yes 2. No In your opinion what is better: 1. Deliveries at home …… 2. Deliveries at hospitals…… Awareness about Family Planning Program Have you agree with ‘ small family is happy family’slogan? 1. Yes 2. No 2.7 How do you identify ‘hum do hamare do’ slogan with? __________________________________________________________________________________ 2.8 Are you aware of Governments family planning program? 1. Yes 2.9 2. No 3. Can’t Say How did you come to know about this Family welfare program? 1. TV 2. Radio 3. Newspaper 4. Posters 6. ANMs/ASHA 7. Neighbours 8. Friends 2.10 Are you aware of any family planning method? 1. Yes 2.11 2. No 3. Can’t Say Have you heard of vasectomy? (Explain vasectomy) 1. Yes 2.12 5. Programs (Films, Group Discussions) 2. No Which of the following family planning methods you have heard of? 1) Mala D 2) I pill 3) IUD: Copper T4) Vasectomy 5) Condoms XIX 2.13 If yes to Vasectomy, are you aware that vasectomy is done free of cost at govt. hospitals? 1. Yes 2.14 2. No Are you aware that Vasectomy couples are rewarded by the government? 1. Yes 2.15 2. No Do you know anyone in the village being rewarded? 1. Yes Section IIC 2.16 2. No Knowledge & Practices: Breast Feeding Do you agree that mother’s milk is the healthiest form of food for babies? 3. Can’t Say (For any answer, ask for reasons) 2) OK 3) Alternative food for infant 5) Insufficient 6) Any Other (Specify)________________ 1. Yes 2. No 1) Best milk for infants 4) Not good for infants 2.17 How long should mothers breast feed their infants 1) Up to 3 months 2.18 2) Anything else (specify)………………… 2. No If yes, what are the reasons? 1. Greater immune health 2. It is nutritious 4. So that infant gets warmth of her mother 5. All are true 2.20 3. It saves infant from getting infections 6. All are false Do you believe that breast feeding acts as a family planning method to avoid pregnancies? 1. Yes 2.21 4) Till mother is able to feed Do you know that an infant must be breastfed within half an hour of his/her birth 1. Yes 2.19.1 3) Till infant gets teeth When a child is born, what is the first thing that is fed to him/her? 1) Breast milk 2.19 2) Up to 6 months 2. No Have you seen any advt. on breast feeding anywhere? 1. Yes 2. No 2.21.1 If yes, ask for details. ______________________________________________________________________________________ 2.22 Has anyone advised you/ anyone in the family to breast feed your child? 1. Yes 2. No 2.22.1 If yes, who____________________________________________________________________________ 2.23 Have you/anyone in the family ever discontinued breast feeding? 1. Yes 2.23.1 2. No If yes, what are the reasons? ______________________________________________________________________________________ XX Section III 3.1 days? Awareness about Health facilities and services: Do you know that Government is providing medical facilities to newborn and his mother for 30 1. Yes 2. No. a. Are these medical facilities free? b. Required to pay for the medicines c. Required to pay both for the facilities and medicines 3.2 2. No IF YES, for how much time: 1) Full day 24 Hrs. 3.3 2. No 2. No If yes, what was the name of vaccination________________________________________________ 1. Yes 3.9 2. No Did you get your child vaccinated? 1. Yes 3.8 2. No Did you get yourself vaccinated during pregnancy? 1. Yes 3.7 2. No Do you know that MTP (GIVE FULL FORM) facility is available in Primary Health centers and Regional health center? 1. Yes 3.6 3) From Morning 9 AM to 9 PM Do you know that pregnant women are given travel allowance to reach hospitals? 1. Yes 3.5 2) From Morning 9 AM to 5 PM Has anyone in the village availed this facility? 1. Yes 3.4 2. No Has your child given Polio drops? 1. Yes 2. No 3.10 If yes, did you go to health centre? 1. Yes 2. No 3.11 If yes, did anyone come to your village/house to give polio drops? 1. Yes 3.12 2. No 2. No 2. No Do you have these facilities in your village? 1. Yes 3.2.1 1. Yes 1. Yes 1. Yes 2. No In your opinion Has JSY ( Janani Suraksha yojana) brought about any change in the health practices: At your family level____________________________________________________________________ ___________________________________________________________________________________________________________________ At village level_______________________________________________________________________ ___________________________________________________________________________________________________________________ ************************* XXI Research Instrument No. 7 FGD for Women Participatory Communication Campaign Approaches in Improving Health Practices in India A Project for conducting an Impact Assessment of DFP’s programme for improving Mother and Child Health Place________________________ Date__________________ No. f participants_____________ Note for the researcher Before the FGD 5. Make sure you have all required materials-FGD themes, pens, extra sheets of paper, gifts for the participants. 6. Profile of participants (women in reproductive years, 18-40) will be be asked before FGD begins, participants usually disperse soon after the FGD gets over. Use tick mark in all boxes) 7. Make the participants comfortable. Inform them that their views and opinions will be used only for the study and all personal details will be kept confidential During FGD 1. Encourage participants to speak one at a time, and it may be preferable for participants to identify themselves before they speak. 2. Make sure that you only facilitate the discussion. Allow free conversation. 3. As participants arrive, greet guests make small talks but avoid the topic of the focus group. This is to assess the communication styles of the participants. 4. Listen for inconsistent comments and probe for understanding. 5. Listen for vague or cryptic comments and seek clarification. 6. Consider asking each participant a final preference question. 7. Offer a summary of key questions and seek confirmation. Section 1A Discuss the common social beliefs/ myths and customs of people on health of a woman in general. Start by asking, who according to you is a healthy women/mother? Section 1B - Discuss how pregnancies, early or late can affect the health of a woman Why monitoring of women’s health during pregnancy is important People’s myths and views about deliveries at home and institutionalized deliveries. Discuss social beliefs of people towards early age marriage Section 1C - Discuss about importance of keeping space between 2 children How it effects health of a mother How spacing can be achieved What are the common family planning methods they know about and practice Reasons for not using Family planning methods Availability of methods at sub-centre, in the village, any other place Section 1D - Discuss importance of breast feeding Changing attitude towards breast feeding (Myths about breast feeding) Diet of lactating women (food that boost) XXII Section 2A Section 2B Section 3A Section 3B - Discuss the role of health functionaries/implementers in generating awareness among people about new programmes /schemes What kind of services do ASHA, AWW, ANM provide to beneficiaries Who among them is the most valued and why Are their services regular and unbiased Their interpersonal & communication skills Discuss the factors acting as barriers to change in the attitude of people in the village in context to Social system, prejudices, myths etc Family structure Decision making powers within the family Status of women Lack of education- lack of educational facilities Lack of initiative of local governance in making govt. programme reach villages Limited sources of information How to minimize barriers Discuss the campaign which they have attended recently on health What was the theme What were the messages conveyed during the campaign What they liked/disliked about it Effectiveness of the campaign (Appeal, language, comprehension, format of campaign) What action have they taken Do they need such events in future too? Why What to do to make such events more attractive and attentive Discuss the suggestions to improve access to information Which media method will be more effective What to do to come out from the family level barriers **************************** (Thank the participants) Comments: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ XXIII Research Instrument No. 8 Observation Sheet Participatory Communication Campaign Approaches in Improving Health Practices in India A Project for conducting an Impact Assessment of DFP’s programme for improving Mother and Child Health Directorate of Field Publicity (DFP), a media unit of Ministry of Information and Broadcasting, New Delhi is oraganising campaign to propagate messages on NRHM & JSSY ( National Rural Health Mission, Janani Shishu Suraksha Yojana) in all states of the country. Indian Institute of Mass Communication, M/o I&B , New Delhi is conducting research to assess the reach of messages on Maternal and child health, family planning , etc and change in knowledge , attitude and practices of target population towards improving the status of health. Date :…………………………… State :…………………………… District :…………………………… Gram Panchayat :…………….……... 1) 2) Type of Event: Gram Sabha / Meeting/ Rally / Film show a) Time of starting………………… b) Time of end of event.....……………… c) Time of starting observation…… d) Time of finishing observation………… Section A A1 Block: …………………..………….. Village /Site of Event……………….. Field Publicity/ campaign material Observe and write the topic/subject/ message of the material seen/ distributed at the event site Material Poster Banner Handout Film Slogan Hoarding/sign board fliers kisoks brochure Other (specify) Section B B1 Audience/Participants: Composition- Kindly record approximate number of: Married males Unmarried women College going students B2 Subject: Unmarried males Children Old and aged persons What is the Density of the crowd? 1. Very less 2. Average At the start of event 3. Heavy Middle of the event Married women School going students 4. Scattered End of the event XXIV B3 S. No. 1 2 3 4 Did the crowd disperse during the event? Did the crowd move around to see the whole site ofthey eventcarrying any publicity material with Were them at time of leaving Did theythe stop to ask questions at helpdesk/information desk Did they at any point of time applauded/clapped?.....what was it What was the crowd doing 5 Audience response to event: ….. …. … What was attracting the crowd most? what per cent of the village population turned up for the event ( ask any villager) How were people reaching the site Was any pregnant women present at the event What was done to attract the crowd 6 7 8 9 10 11 Section C D1 Constantly moving around Involved Attentive Describe Describe Yes Describe NA NA NA NA Constantly sitting Bored Constantly standing Distracted No NA Activities at the Site of Event: Observe and list all activities organized by the DFP unit/ others? (describe) Who were the main audience/participants of the activity Did the activity involve/ allow interaction with the audience? Were people passing by stop to see the activity? Observe and list the stalls put up Which stall had the maximum crowd Which stall had most women Were any two activities happening simultaneously? Any Group discussion happened Any desk to answer people’s questions Any film show Section D Response ( tick mark or describe ) Yes No Yes No Yes No Yes No List here Write here Yes Yes List here Describe stall Describe stall Yes Yes Yes Yes No NA No NA No No No No NA NA NA NA Information Dissemination: Observe and record the information on the three health schemes: 1. Institutional delivery Type of material displayed on this topic Where was the material displayed What was /were the message/s Was the message readable Any slogan /song heard on loudspeakers Any slogan /song seen written anywhere Any material distributed Any film shown on this topic Write here At lamp posts Yes Yes If yes, what was it? Yes If yes, take picture of it Yes If yes, collect samples Yes Duration? Message? No No No No No Any celebrity? XXV Any advertisement/spot shown 2. Family Planning Type of material displayed on this topic Where was the material displayed What was /were the message/s Was the message readable Any slogan /song heard on loudspeakers Any slogan /song seen written anywhere Any material distributed Any film shown on this topic Any advertisement/spot shown 3. Breast feeding Type of material displayed on this topic Where was the material displayed What was /were the message/s Was the message readable Any slogan /song heard on loudspeakers Any slogan /song seen written anywhere Any material distributed Any film shown on this topic Any advertisement/spot shown Section E Yes Message? Any celebrity? No Duration? Write here At lamp posts Yes Yes If yes, what was it? Yes If yes, what was it? Yes If yes, collect samples Yes Duration? Yes Message? Any celebrity? No No No No No Any celebrity? No Duration? Write here At lamp posts Yes Yes If yes, what was it? Yes If yes, what was it? Yes If yes, collect samples Yes Duration? Yes Message? Any celebrity? No No Number Yes Yes Yes Yes Number Yes Yes Yes Yes Number Yes Yes Yes Yes Name No No No No Name No No No No Name No No No No No No No Any celebrity? No Duration? Presence of Officials 1. DFP officials present Were present till the end of event? Interacted with people Did they have fixed place to sit Were they moving around 2. Health officials present Were present till the end of event? Interacted with people Did they have fixed place to sit Were they moving around 3. Gram panchayat members present Were present till the end of event? Interacted with people Did they have fixed place to sit Were they moving around XXVI Section F F1 Physical/Logistical arrangements Observe and record the quality of items listed in the table Sound system Audible Stage/elevated area Yes Lighting arrangement Yes Help desk/ Information Desk Yes Projection screen Yes Section G Themes and messages delivered during the program S. No. 1 2 3 Child Marriage Maternal Health Immunization 4 Breast feeding 4 Female Foeticide 5 Institutional Deliveries Family Planning 6 7 Not audible No No No No Themes Communicable Disease What is the Legal Age for marriage of boys and girls in India Pregnancy at early age can affect woman’ health adversely Immunization helps in fighting childhood diseases It is necessary to follow the immunization chart An infant must be breastfed within half an hour of his/her birth Breast milk is the healthiest food for infants The first produce of breast is most nutritious Boys and girls should be treated equal Sex determination test is unethical and punishable There are laws to punish guilty of this crime Institutional deliveries are safe for mother and child Govt. gives incentives for institutional deliveries Reducing gap between children increases risk of infant death Male sterilization does not affect manhood or virility among males Smaller family means good quality of life Stagnant water allows breeding of mosquitoes Observer’s comment and overall assessment _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Observer’s sign_____________________ Date ____________________________ **************************** XXVII B. Table Content analysis of Print Material on Health Issues Material Immunization Leaflet Brochures State No Specific topic Issuing agency Target Pregnant Women Pregnant Rajasthan 1 - DFP MP 1 - DFP Jharkhand Assam - Hepatitis B NRHM & IEC dept. Rajasthan 2 Complete Immunization chart NRHM MP 1 Complete Immunization chart NRHM jharkhand 1 Complete Immunization chart NRHM Assam 1 Complete Immunization chart and time table NRHM 3 IUCD-380A DFP IUCD-380A DFP NSV IUCD-380A NRHM DFP IUCD-380A DFP women General Mother & child Mother & child Mother & child Mother & child Language Hindi local Hindi - Hindi Hindi Hindi English Family Planning Rajasthan 3 Brochures MP NSV Jharkhand 3 NRHM - Assam - Beneficiaries Health providers Hindi Beneficiaries Health providers General General Hindi Hindi Hindi Hindi Assamese English NSV1 NSV 2 NRHM IUCD-380A DFP Health providers English DFP General Hindi DFP General Hindi DFP General Hindi Overall NRHM Rajasthan 1 MP 2 Brochures Jharkhand Assam Booklet - Rajasthan 1 MP 1 Jharkhand Assam 1 Right age of marriage, Birth & Care of newly of infants, Identify the Foeticide of child, Safe maternity, Safe Delivery, Care of adult child Control over birth of children Institutional Delivery, JSY, Iron Tablets, Immunization, Family Planning, and Permanent ways of Family Planning Bharat Nirman Schemes (Water, Road, Indira Awas, National Social Help Prog., MGNREGA, SSA, JSY, Midday, ICDS and Samagra Sawachta Abhiyan Health and Family welfare (Slogan) Gagar me Sagar Health and Family welfare (Slogan) Gagar me Sagar Health and Family welfare (Slogan) Gagar me Sagar - - - (DFP) General Hindi (DFP) General Hindi (DFP) General Hindi XXVIII Other health problem/diseases 3 Rajasthan Leaflet Brochures Jharkhand Assam Rajasthan MP Jharkhand 1 1 Iodine Salt H1N1 DFP Unicef General General General General Women & child General General Assam 1 Iron Tablets and Nutritious Food NRHM General 1 - Payment on Delivery under JSY - 2 MP Rajasthan MP Leaflet Jharkhand Assam Breast Feeding Brochures Chikanguniya and Dengue Iodised Salt Female Foeticide H1N1 DFP DFP DFP Unicef ICDS Unicef - - - DFP - Rajasthan - - DFP MP - - DFP Jharkhand - - Assam 1 - National Breast Feeding Week - General Pregnant Women Pregnant women Mother of child Hindi Hindi Hindi Hindi Hindi Hindi Hindi Assamese English Hindi Assamese JSY Rajasthan Leaflet MP Jharkhand Assam Total 1 31 Payment on Delivery under JSY - DFP - Pregnant women - Hindi - XXIX Department of Communication Research Indian Institute of Mass Communication Aruna Asaf Ali Marg, JNU Campus, New Delhi – 110067 Web site: www.iimc.nic.in; Email ID: [email protected]