Media Action Insight Blog Feed

Seven lessons from scaling up mHealth in India

2023-03-24T09:00:00+00:00

Our challenge: How do we ensure families in India have timely information about childbirth, childcare and family planning, during pregnancy and in the first year of the child's life?

The innovation: High-quality health information and advice to Indian families - particularly in rural areas – through the growing use of basic mobile phones. Our human-centred design mobile health solution has been scaled to 17 states by the Government of India to empower families and frontline health workers to improve child mortality and maternal health.

Kilkari (a baby’s gurgle) is our mobile messaging service designed to reinforce frontline health workers’ counselling by delivering information to families to help healthier choices and lives. Combined with tools and training for frontline health workers – our Mobile Academy training course, and Mobile Kunji tool to support frontline workers in communicating with families - the service is strengthening this ‘last mile’ of the health system, to increase their knowledge, skills and confidence in communicating, and reinforcing their information. Aiding with all of this is the trusted voice of ‘Dr Anita', the fictional narrator across our suite of mHealth services – Mobile Academy, Mobile Kunji and Kilkari – providing health information, guidance and friendship to families across India.

Kilkari’s free, weekly, stage-based audio messages about pregnancy, childbirth, childcare and family planning are delivered directly to families’ phones as one pre-recorded call per week for 72 weeks, linked to the stage of pregnancy or child’s age and timed for the highest-risk periods, between the second trimester of pregnancy until the child is a year old. Available in five languages – Hindi, Bihari, Oriya, Assamese and Bengali – family mobile phones are automatically subscribed as soon as a pregnancy is registered in the government database.

Following two independent evaluations and analyses from Johns Hopkins University and Stanford University, now published in a special supplement of BMJ Global Health, here are the lessons we learned over a decade of digital development:

Dr. Anita is the fictional narrator of Kilkari, Mobile Academy and Mobile Kunji, providing health information, guidance and friendship to families across India.

1. Mobiles can provide access to health information at scale using appropriate technology

Kilkari is one of the world’s largest mobile maternal messaging services and has reached 24.6 million subscribers across 17 states. Mobile Academy is the largest mobile-based training programme for health workers in the world and has reached over 235,000 frontline health workers across 16 states in India. Amid low levels of smartphone access and ownership among women in low-income and low-literate settings, both services use IVR (Interactive Voice Response) technology to help overcome these challenges.

2. Timed and targeted information can improve modern contraceptive use and immunisation

When Dr Anita gave advice on condom use, people listened: Those who listened to Kilkari were associated with a 3.7% higher use of modern reversible contraceptives; the number rose to 7.3% among those who heard 50% or more of Kilkari content, compared to non-listeners – largely driven by increased condom use. Effects were even larger for families with a male child (9.9% increase), in the poorest socioeconomic strata (15.8% increase), and in disadvantaged castes (12.0% increase). The evaluation also found higher rates of immunisation among infants at 10 weeks (2.8%).

3. A relatively small amount of the relevant content, delivered at the right time, is a cost-effective way of saving lives

Seven Kilkari calls on reversible contraceptive methods, totalling just over 10 minutes and delivered direct to families’ mobile phones, had an effect on those families’ practices. Peer-reviewed analysis of our randomised controlled trial showed that Kilkari has saved nearly 14,000 lives (96% child lives and 4% maternal) and has been declared a highly cost-effective intervention, with the cost per life saved ranging from USD $392 to $953 depending on the intervention year.

4. Design mHealth solutions with an equity lens to reach the poorest communities with mobile phone access

It’s important to think about how communities are using mobile phones, and when. The poorest subscribers, educated to at least secondary level, appear to have had the biggest equity gains from exposure to Kilkari, thanks to design decisions like the ‘retry’ algorithm – which tried mobile phone numbers at different times of the day, to reach families when they had time to listen.

5. Subscription-based business models are challenging in low-resource settings

In the initial years, Kilkari subscribers were charged a nominal fee – but this user-fee model failed to cover marketing costs. Kilkari became a toll-free service in 2016 with call costs covered by the Government of India, enabling greater reach and impact.

6. Digital interventions must be informed by gender intentional design

The gender digital divide in India, and the offline and online norms that create this divide, necessitate a gender-intentional, research-driven approach to designing mHealth interventions. We needed to understand who is left behind by digital interventions - and how to reach and impact those groups through alternate communication channels and platforms.

7. Digital direct-to-beneficiary communications need to be complemented by a mix of other interventions to shift social norms and change deeply entrenched behaviours.

Despite advice that covered a full range of infant and childcare, Kilkari was not found to have had measurable impact on infant and young child feeding practices. Our evaluators found that practices under ‘normative influence’ – where families do not need to engage with the health system, like complementary feeding - saw more positive associations when communication tools like Mobile Kunji were used, providing opportunity for further discussion.

This article was first written in November 2022 and updated in March 2023.

Kilkari is one of only five mHealth services globally to reach over one million subscribers and won ‘Best mobile innovation for women in emerging markets' at GSMA Global Mobile Awards 2019. Learn more about Kilkari on our website, in the BMJ Global Health (third-party site) and at the International SBCC Summit from December 2022.

Calculations on lives saved and cost effectiveness appear in an article by LeFevre, A.E. et al, ‘Are stage-based, direct-to-beneficiary mobile communication programmes cost-effective in improving reproductive and child health outcomes in India? Results from an individually randomised controlled trial of a national programme.’

We are grateful to Stanford University for analysis of our evaluation, and to Johns Hopkins University for conducting the randomised controlled trial.

Sara Chamberlain is currently on sabbatical as India Digital Director; Radharani Mitra is India Creative Director and Global Creative Advisor; and Anna Godfrey is Head of Evidence at ��tv Media Action.

Learn more about Kilkari and its impact.

Designing for inclusion: From invisible to #Invaluables

2022-08-30T12:05:30+00:00

Cities tend to forget the very people who are their lifeline.

The 12.5 million denizens of Bengaluru, known as India’s Silicon Valley, generate 5,757 metric tonnes of solid waste per day.

But the city’s estimated 30,000 informal waste pickers, who form the backbone of Bengaluru’s waste management system, are invisible and ignored. They live in deplorable conditions with low and unstable incomes, face significant workplace hazards, and are treated with suspicion and contempt.

Funded by the H&M Foundation, Saamuhika Shakti (SaaS, the Collective Impact Initiative), aims to address this situation. ��tv Media Action, an initiative programme partner, turned to social media to create our Pathway to Respect, Identity, Dignity and Empowerment (PRIDE) project for informal waste pickers.

An informal waste picker who featured in our #Invaluables campaign

Lack of recognition

The PRIDE project’s formative research revealed that there is a lack of recognition of the humans behind the process of waste management. While people in the city see waste on the streets, and they are concerned about it, they failed to list waste pickers as important to their lives. On further probing, we found that while people appreciated the work of formal waste collectors, who are hired by the municipality for door-to-door garbage collection, informal waste pickers were still stigmatised. More than half of our study respondents said that informal waste pickers are dirty and shouldn’t be allowed inside residential building complexes.

Street rag-pickers look scary, so we don't go near them!

- Female, 39, housewife, Bengaluru

The pandemic strengthened these negative perceptions. Waste pickers, in turn, confirmed having to regularly deal with discrimination.

’They (the public) scold us. They feel they will catch the disease (COVID-19) from us. They think we have the virus. So, I do not like to go to work.’’

- Female waste picker, under 18

Research was used to identify segments within social media users among the general population of Bengaluru, based on their attitudes towards informal waste pickers. Our research and analysis showed three broad segments of people:

Appreciators, who valued the role and contributions of informal waste pickers and understood their circumstances
Sympathisers, who displayed an overall sentimentality towards informal waste pickers accompanied by stereotyping of their work
Stigmatisers, who wanted to distance themselves from the waste picking community and displayed extremely negative attitudes

The project decided to focus on appreciators and sympathisers, who were more likely to become early adopters of any changes in attitude or behaviour.

Strategic reframing

In a country with a history of caste-based occupations and discrimination, bringing a change in mindsets is uphill work. The project turned to Professor Judith Butler to understand why some lives are valued and others not, and how marginalisation is contingent on rendering social groups virtually invisible.

Based on the reading of Butler and formative research, the project’s Theory of Change focused on the need to end the invisibility of informal waste pickers if their lives and work were to be properly valued. This involved a reframing of the work of waste pickers as involving special skills and productive labour essential for the city’s survival, as well as recognition of the fragility of social media users’ own lives in the face of environmental hazards. The recognition of this shared fragility is a pathway to creating a social bond that obliges us to care for each other. Establishing the interconnectedness between the lives of social media users and the work of waste pickers was integral to the former valuing the life and work of the latter.

Designing for PRIDE

The project used social media to connect the people of Bengaluru with informal waste pickers, by positioning the waste pickers as ’invaluable friends’, friends they did not know they had. The creative strategy was designed to lift the shroud of invisibility and open the eyes of Bengalureans to the value that informal waste pickers bring to their lives - as professionals, as humans, and as residents living side-by-side in the same city.

A social experiment film explored the concept of friendship and revealed how informal waste pickers share the values normally associated with true friendships. The social experiment was conducted by Radhika Narayan, a popular actor and social media influencer. The film ended with a call to action to join a moderated private community on Facebook called the #Invaluables Facebook group.

Participants in our #Invaluables social media experiment were asked who their dearest friends were - then shown how informal waste pickers fit the description. /��tv Media Action India

The content posted on this group brought Bengalureans closer to the waste picking community, by creating awareness and demonstrating the value of their work to save the city from being buried under a mountain of garbage, and therefore demonstrating their interconnectedness.

Crafting this journey of perception change required a steady stream of relevant content through the week, seizing every opportunity and fact in a strategic manner and converting it into engaging content that would bring this interconnectedness to life. We built the social media strategy carefully, weaving in the use of influencers wherever necessary and taking the conversations beyond social media to discussions on FM radio during regular shows, hosted by prominent city RJs.

The branding, Invaluables, was designed to strengthen the idea of ‘interconnectedness’. The brand identity uses image, colour and text to combine three graphic ideas – the joining of two hands, the use of two eco-friendly colours - blue and green - and the skyline symbolising the city of Bengaluru.

Analysis and impact

Social media statistics show that the first phase of the #Invaluables content reached at least 2.6 million unique people, 21% of the city’s population, with a total of 4.4 million video views and 509,429 engagements (e.g. likes, comments).

The first round of impact evaluation also shows that we have started to shift people’s understanding of waste pickers. There was an improvement in spontaneous awareness of different segments of informal waste pickers, from 10% at baseline to 16% among those exposed to the #Invaluables content. There was no such change within the control group. Analysis also shows greater discussion about informal waste pickers, their work and place in society among those exposed (60%) to the content, compared to those not exposed (49%).

We have demonstrated that an evidence-based, insight-driven, carefully crafted social media campaign can help shift negative perceptions attached to certain occupations and help reduce inequalities. With significant positive shifts in awareness and discussions about informal waste pickers after the first phase of the campaign, we are now confident in taking forward the idea of Invaluables to the next phase of building understanding and appreciation for the critical importance of their work.

Our next phase will demonstrate the connection between the people of Bengaluru and the city’s waste pickers - and why everyone should be aware of and celebrate a Happy Number.

Check out the Happy Number to learn more.

Varinder Kaur Gambhir is director of research, Soma Katiyar is executive creative director and Ragini Pasricha is director of content strategy at ��tv Media Action India.

Learn more about our Invaluables project here: /mediaaction/where-we-work/asia/india/invaluables/

Read our press release about the Happy Number here: /mediaaction/where-we-work/asia/india/happy-number-invaluables/

The Invaluables project is part of the Saamuhika Shakti (collective impact) initiative, funded by the H&M Foundation.

How poo became one of our biggest creative challenges yet

2022-06-20T15:33:12+00:00

How many of us ever think about what happens after we flush?

Yet it’s an issue that concerns governments, sanitation experts, urban planners and public health specialists around the world - particularly in India, where 60% of urban India is not connected to modern sewage systems and relies on on-site sanitation such as septic tanks and leaching pits. This makes faecal sludge management (FSM) a pressing but hidden public health issue.

That’s why five years ago, Madhu Krishna, then deputy director of WASH and communities at the Bill and Melinda Gates Foundation India, gave ��tv Media Action this challenge:

“Could you make faecal sludge management an issue that is as important to people in urban India as air pollution has become? Could you get people to care about what happens after they pull the flush?”

Few homes in India's urban areas are connected to municipal sewerage, making waste management a major health issue. Credit: ��tv Media Action

Since the launch of the ambitious Swachh Bharat Mission (Clean India Mission) in October 2014, India has made huge leaps forward in building toilets and eradicating open defecation. But faecal sludge management - or what happens to poo after you flush, how it is contained, when to empty the tank and where it ends up - was not getting as much thought as it deserves.

An invisible problem

Our research showed that the predominant attitude among our audiences was to flush and forget about faecal sludge, or avoid the problem for as long and by any means possible – including by building enormous septic tanks that do not need cleaning in their lifetimes. As one man from Trichy in the southern state of Tamil Nadu told us: ‘’I have built a big tank so that we don’t have to clean in frequent intervals. Why should I empty the tank if there is still so much space?”

According to a 2019 WaterAid report, adequate facilities and services for the collection, transportation, treatment and disposal of faecal sludge do not exist in most Indian cities. Private operators – often using illegal, manual methods – may even dump faecal sludge in drains, waterways, and on land. This untreated sewage contributes to high levels of diarrhoeal disease, which is responsible for more than one in 10 infant deaths in India. Faecal sludge is the largest polluter of ground water in urban India.

Our mandate was clear: how do we first make faecal sludge a problem you cannot ignore? How do we make the invisible, visible?

Our campaign #FlushKeBaad illustrated the sanitation value chain so that people could understand what happens after flushing. Credit: ��tv Media Action

Combining the art of drama with behavioural science

We examined our audience’s attitudes towards desludging, and the type of containment system they own, to help us identify three audience segments: proactive desludgers (22%), reactive desludgers (the majority – 66%), and connected to drains (11%).

We knew people weren’t making ‘optimal’ decisions when it came to sanitation and septic tanks. In fact, they departed from what traditional economic theory would classify as ‘perfect’ rationality in specific and predictable ways. For example, many focused on the short-term gains (e.g. not paying for regular desludging), and ignored both the long-term benefits (e.g. protecting water resources and ensuring the well-being of families and communities) and uncertain future costs (e.g. repairs or system failure).

Behavioural economists call this ‘present bias’. We needed to reach these ‘procrastinators’ as well as those who hadn’t thought about what happens after they flush. We also set out to frame the link between faecal sludge disposal and health as a positive gain, because we know people's choices are heavily influenced by inertia and avoiding losses.

We wanted to increase awareness about correct FSM practices – regular desludging, building the right kind of septic tank and asking where your poo is being dumped - and to heighten the sense of risk.

The drama focused on two triggers or framing effects – risk perception and social disapproval - which would make urban populations take either individual or collective action to bring about change.

Why drama?

Everyone likes a good story – particularly in India with its rich oral history and huge film and television industry. Working with national broadcasters gives drama unparalleled reach and scale. And we know drama works - it can be an incredibly powerful force for positive social impact.

But we don’t mean ANY drama. We mean locally produced, culturally relevant dramas that are developed using behavioural insights and informed by communication theory. These dramas are tested with audiences before they go to air, to ensure they deliver on engagement, entertainment and communication objectives.

Evidence demonstrates these carefully crafted narratives - sometimes called edutainment or drama for development - not only inform, educate and entertain. They can also prompt discussion, influence and challenge social norms, inspire intent to act and change behaviour.

Drama can be particularly effective because it engages people on an emotional level, unpacking complex issues and making them easier to understand, so they stick in people’s minds. Role-modelling positive behaviours over time can change mindsets – even around deep-seated behaviours and norms.

“Academics have demonstrated the link between what we see and how we behave. Narratives have the power to shape our mind and action. Navrangi Re! through powerful storytelling demonstrated that narratives can aid in unpacking a complex subject like faecal sludge management, and increase cognitive understanding of related actions. Narratives can introduce role models, new ways of working, frames of reference, and novel ways of decision making, which when emulated by people establish new norms in a subtle and acceptable manner.”

- Archna Vyas, Deputy Director, Communications, India Country Office, Bill & Melinda Gates Foundation

Pulling off two ‘firsts’

Taking these behavioural insights, we did two things no one had tried before in India.

First, we developed a public-private partnership around a drama on a social issue. While India has a long history of using using drama for social and behaviour change, it had always been in association with the public broadcaster, Doordarshan - not the private sector.

And then, we did what some might deem crazy: We created India’s first – and possibly the world’s first – drama on faecal sludge management.

The main characters in our hit comedy-drama, Navrangi Re! Credit: ��tv Media Action

The art and craft: our neighbourhood and our characters

Navrangi Re! (Nine to a Shade) is the story of an urban neighbourhood – a mohalla - where lots of different people live cheek by jowl. Through the trials and tribulations of life in an urban jungle, they find ways to overcome this constant crisis mode. The mohalla is a creative device to accommodate an entire socio-economic microcosm, with different families occupying different points on the sanitation value chain.

The lead protagonist, Vishwas, is a struggling TV journalist whose name means trust. His love interest – Chitralekha – is an aspiring bureaucrat, preparing to take her entrance exams. They represent two contrasting approaches to working with communities – she is authoritarian, he is a negotiator. It is the marriage of the two approaches that leads to a community transforming. Chitralekha and her father, retired army man Gajraj – do everything right: they have a toilet with a proper septic tank that they desludge regularly. Gajraj represents the ‘proactive deludger’ segment from our research.

Their neighbour, Motichoor, named after a favourite Indian sweetmeat, is the stingy, slippery neighbourhood confectioner. He has a toilet but no septic tank, letting poo out into open drains – a source of high-decibel neighbourhood conflict. He represents the segment of those connected to open drains.

Rajrani – the name means empress – is the local ‘don’. She and her son Kabaadi Seth, or scrap mogul, represent the ‘reactive desludgers’ segment. They have a palatial home with a toilet and a septic tank, but they have never desludged their tank.

There are others like Naseer the tailor, his wife and son, who use Seelan Deewar – the damp and decrepit community toilet, which is owned and tightly controlled by Rajrani. And there is Lota, the mohalla errand boy – whose name means the ubiquitous water container that people use to clean up when they defecate.

The mohalla and the characters are based on insights from our formative research, reflecting real desires, values, self-image, sense of pride and dignity and aspirations for a better life. Navrangi Re! has all the elements you would expect from a prime-time drama – romance, humour, conflict, pathos, villainy and even a talking wall!

Did the risk pay off?

Yes! At the end of 13 weeks, Navrangi Re! had reached 59.6 million unique viewers through three Viacom18 channels and its OTT platform. It was viewed equally by men and women across all age bands. It was also ranked among the Top 20 shows on General Entertainment Channels at 9 pm, as per data from the Broadcast Audience Research Council of India (BARC). We were delighted – and a little relieved – that we had taken faecal sludge management mainstream!

A novel evaluation approach

An independent evaluation provided some really powerful results.

Evaluating media - particularly popular, wide-reaching programmes - can be very difficult. The Navrangi Re! evaluation estimated impact in a real-world setting. It identified households who watched Rishtey – the TV channel airing Navrangi Re! – at any time of the day. Not all households who watched the channel would end up watching the show – but there was a high degree of similarity between households who watched and those that didn’t.

This approach identified households to be interviewed before and after the show aired – and they were retrospectively allocated to treatment and control groups, based on whether they watched Navrangi Re!. In this way, it was possible to compare outcomes among those exposed to the TV show with those unexposed in the panel of 2,959 respondents.

Researchers found that 37% of those who watched at least one episode showed intent to do something about their faecal sludge, rising to 78% of those who had watched at least seven episodes. There were significant improvements on audience’s attitudes towards regular desludging, willingness to save to pay for this, and a desire to improve the quality of existing septic tanks.

Researchers also found that viewers engaged emotionally, with 78% of viewers saying that they felt happy after watching Navrangi Re!, and more than two-thirds said that they would like to watch more episodes in the future. The show was particularly successful at stimulating conversations between viewers and their family and friends on faecal sludge management.

The impact evaluation showed that storytelling can help bring about social and behavioural change on a hard-to-address topic like FSM. Our follow-up, seven-episode web drama called Life Navrangi has just released on YouTube. It continues Vishwas’s story and the conversation on urban sanitation in India.

“FSM is not only an infrastructural issue but also a socio-cultural issue. It is critical to acknowledge the need for FSM because it has a considerable impact on public health, climate, and environmental pollution. Navrangi Re! opened our eyes to the role of media and storytelling in combatting this public health crisis and we welcome this second series with new and exciting storylines.”

- Professor V S Chary, Director, Urban Governance and Environment, Administrative Staff College of India, CEO, Wash Innovation Hub

Three lessons learned

We hope Navrangi Re! can inspire others to use innovative partnerships to leverage the creative power of narratives. Only by making invisible social problems such as urban sanitation visible will we really see greater public engagement.

When we combine the science, art and craft in this way using our Narrative Engagement Model, three key principles are vital:

We must root storytelling in behavioural insights and theory;
We must commit to immersing the creative approach in ‘people’s lived experiences’ of the issue, and
Most importantly, we must have an unwavering focus on ‘entertainment first’

Because after all, everyone loves a good story - even one about poo!

The cast of Life Navrangi - our follow-up to Navrangi Re! Credit: ��tv Media Action

Varinder Kaur Gambhir is India Director of Research; Radharani Mitra is Global Creative Advisor and Anna Godfrey is Head of Evidence.

Our followup series to Navrangi Re! - Life Navrangi - is now live on YouTube! Subscribe to Channel Navrangi and don't miss an episode (in Hindi with English subtitles).

Learn more about the Navrangi project, and its independent evaluation (third party site).

Learn more about our work in India.

How can digital technology empower women without worsening inequality?

2022-02-25T15:26:28+00:00

As use of mobile technologies surges in low and middle income (LMICs) countries, a pressing question has emerged: can the digital revolution be harnessed to empower women – socially, economically and politically - without creating deeper social and gender divides?

This is a particularly critical question in India, where the rates of digital adoption are high – but where the gender gap in digital is among the largest in the world. According to the GSMA, 75% of men but only 55% of women owned a mobile phone in 2020; when it comes to smartphones, the gap is even greater, with only 25% of women owning smartphones compared to 41% of men.

In 2019, ��tv Media Action began working on the Digital Women’s Economic Empowerment Project: A Research and Learning Agenda. Our focus has been on women’s collectives, which have shown significant promise as a platform for empowerment. Our objective has been to identify if and how digital technology could enhance pathways to women’s empowerment in collectives, without making existing inequalities and gender-based conflict worse.

The promise of collectives

Systematic reviews of evidence from countries around the world, including from self help groups in India, have shown promising outcomes for women’s economic and political empowerment, mobility, and control over family planning. In India, the scale of the opportunity is substantial: Some 47 million member-households have been mobilised into four million self-help groups since 2011, and the National Bank for Agriculture and Rural Development’s Self-Help Group Bank Linkage Programme now covers 138 million families through 11 million groups.

Evidence reviews have also identified three important pathways to empowerment in self-help groups: the accumulation of social capital, human capital, and financial capital.

A key driver is the expansion of women’s social networks , as they join small groups of 10-12 women and begin benefiting from ‘bonding social capital’ – the social support and trust that cohesive, homogenous groups can provide. Once women start interacting with the wider collective, they begin building “bridging social capital’ – that is, interacting with women from different backgrounds who act as role models and provide access to new ideas and opportunities.

Women in a self-help group show their mobile phones. Even though India is the world's largest market for social media platforms, users are overwhelmingly male. Photo credit: Sara Chamberlain, ��tv Media Action.

Limits on progress

However, there are constraints on the transformative potential of women’s collectives in India:

Geographically isolated groups have few opportunities to engage beyond their immediate circle with the wider collective;
Women have limited channels to request and receive targeted information, resources, and services from the wider collective;
Grassroots members have limited opportunities to make their voices heard in the wider collective;
The lack of access to high quality, standardised, flexible learning opportunities;
Members tend to be older and less educated, and younger women are under-represented;
There are limited opportunities for consultative decision-making, and leadership may not be transparent.

Digital technology could be a game changer

Chat applications and social media platforms, as social networking tools, could help women’s collectives overcome many of the constraints they face – for example, by:

Reducing geographical isolation, enabling women to interact more regularly with their wider collectives.
Improving internal information dissemination and consultative decision making by collective leadership.
Improving the bottom-up flow of information from grassroots members to collective leadership to transnational partners, amplifying marginalised voices.
Diversifying group membership by attracting younger women.
Helping collectives trying to scale to overcome challenges of transparency and leadership ossification by offering new growth pathways to young and emergent leaders.

Collectives could also use digital technologies to accelerate the accumulation of human capital by providing flexible, personalised digital learning to members, and the accumulation of financial capital by providing greater access to government entitlements and markets for their products and services.

Self-help groups in India pose a major opportunity for digital technologies that can empower women. Photo credit: Sara Chamberlain, ��tv Media Action

Low tech digital solutions have delivered results

There are already examples of low-tech digital solutions achieving some of these goals for disadvantaged women in India, including for women in collectives. For example:

Mobile Vaani, an Interactive Voice Response (IVR) social media platform for rural communities in India, enables women in self help groups to call a number to record an audio message about their community, or to listen to messages left by others. Over 100,000 unique users have been calling Mobile Vaani every month in the states of Bihar and Jharkhand, discussing a wide range of issues and sharing information, including health information during the COVID-19 pandemic.
Haqdarshak equips women in self help groups who already own smartphones with an application to support claims for government entitlements, helping 600,000 people claim entitlements in 22 Indian states.
��tv Media Action has used IVR to deliver impactful, cost-effective audio learning to rural, low-income women at scale in India for almost a decade – for example, delivering free health information to over 10 million families, and successfully training 200,000 frontline health workers in 13 Indian states in collaboration with the Indian government, as outlined in The BMJ.
During the pandemic, ��tv Media Action began collaborating with capacity building organisations - for instance, PRADAN to provide IVR-based learning in agricultural best practices to marginalised women farmers in self help groups in the state of Bihar, and with Chaitanya WISE to support digital adoption and digital literacy in self help groups in Madhya Pradesh.

The gender digital divide

However, the transformative potential of digital to support women’s empowerment in India is constrained by the gender digital divide, including on social media. In 2018, LIRNEasia estimated that only 9% of women aged 15–65 were using social media in India, compared with 22% of men. In addition, although India is now globally the largest market for platforms such as Facebook, Instagram, and YouTube, these are still heavily skewed towards male users. For example, according to estimates from publicly available advertising data, only 8% of Twitter users and 24% of Facebook users in India were women, as of January 2021. Even though more women began using the mobile internet during the pandemic, with usage increasing from 21% in 2019 to 30% in 2021, social media use did not reflect this: Facebook usage among women increased by just 1% during the pandemic, and Twitter usage among women fell by 6%.

Social media users in India tend to be younger, better educated, wealthier and urban

Wealth and education are the strongest determinants of access to and use of mobile phones in India, but age and geography also matter. In 2018, a study by LIRNEasia found that only 5% of social media users in India had only a primary school education or had never been to school, and only 11% lived in rural areas. The same study found that only 10% of 36–45-year-olds had used social media in 2018. Although social media use among adolescents in India has increased since then, the gender gap is the most extreme in this age group. For example, a survey by the Population Council in Bihar and Uttar Pradesh in 2018–2019 found that 33% of 15–19-year-old girls who had completed fifth grade or higher had used social media, compared with 70% of boys in the same age group.

Women and men also behave differently on social media in India. Men tend to be more active participants in digital groups than women, with the most active users being men with other forms of social privilege. Most women (92%) use social media to stay in touch with existing friends and family, rather than to make new friends (38%), which could limit their access to new ideas, opportunities and ways of doing things – the accumulation of bridging social capital.

Women's access to mobile phones is often controlled by men, so face to face communication is also essential. Photo credit: Sara Chamberlain, ��tv Media Action

The role of gender norms

Gender norms - offline and online – are another constraint. Women’s use of mobile phones and the internet are often supervised and monitored by men, which limits the agency and freedom that digital technology could provide women. Technology-facilitated gender-based violence is rife in India, and nearly always against women. Research suggests that over 58% of women internet users have faced online sexual harassment of some form, most commonly on social media. While India has legislation on cyberbullying, cyber-stalking and online sexual harassment, victims of online gender-based violence do not usually seek legal recourse. Social media platforms have been grappling with the issue of online violence since their inception. However, despite best efforts, online violence and harassment remain pervasive issues.

Implications for designing social media interventions for women

The gender digital divide on social media platforms in India, and the offline and online norms that create the divide, necessitate a gender-intentional, research driven approach to designing social media interventions for women’s empowerment.

We need to begin with a gender analysis of who has access to digital technology and why, and who is excluded and why.
We also need to understand women’s level of digital skill among the population we aim to serve, as well as their usage habits and the factors shaping their use, including the implications of shared and supervised mobile phone use for privacy and data protection.
We need to design differentiated digital strategies, using appropriate digital channels and tools, to meet a diversity of needs.
We need to use women-centred design methodologies to co-create solutions with women who represent different segments of the target population, to improve accessibility, usability and relevance.
We must remember that face-to-face communication remains key to women in the target population who don’t own, or have meaningful access to, mobile phones – or the skills or permission to use one.
We require processes to respond to online harassment and violence that may be triggered by your intervention.
And we need to be patient. Test and re-test because there is the potential to do as much harm as good.

The third paper in our learning series offers more insights: ‘Why aren’t women part of the conversation? A study of the gender gap in social media use in India, its causes and the implications for women’s empowerment’

Learn more about our Digital Women's Economic Empowerment learning and research agenda here. The project is funded by the Bill and Melinda Gates Foundation and includes partners at Chaitanya WISE, PRADAN, the University of Southern California at Los Angeles, and the University of Denver, Colorado.

5 steps to enable health workers to better meet the needs of hard-to-reach communities

2019-04-05T14:05:00+00:00

As World Health Day approaches, and as we look towards the first-ever UN High-Level Meeting on Universal Health Coverage later this year, we’re sharing insights from ��tv Media Action’s work to help health workers and communities work better together to build a healthier world.

In low-income countries in Africa and Asia, many health systems are staffed by community health workers. In Nepal they are known as Female Community Health Volunteers, in Ethiopia, Health Extension Workers, while in India and Bangladesh they are generally known as Frontline Health Workers.

Whilst the names may differ, most are women, most work in remote areas, and many are volunteers. They play a vital role connecting people to, and sometimes providing, basic primary care; referring patients to clinical services and motivating families to adopt heathier practices.

All are tasked with communicating about health, but often they lack sufficient training or engaging communication tools that would help them do this more effectively.

This is where ��tv Media Action comes in. Over the last 10 years we’ve been supporting community health workers to better meet the needs of their communities. These are five important things we have learned in the process:

First, understand the world health workers live and work in

In Nepal, access to communities can be extremely challenging for Female Community Health Volunteers (FCHVs) due to large distances and difficult terrain between communities and health centres in rural areas. What’s more, FCHVs are often balancing their responsibilities with looking after family and, as many of them are volunteers, trying to earn an income.

Whilst access to mobile networks and internet is increasing, literacy rates remain low in rural areas and our research shows that some communities feel FCHVs should know more than they currently do. It became evident that updated training and tools that fit with the practicalities of FCHVs’ day-to-day lives and the changing community needs would help.

Most FCHVs have access to a basic mobile phone and mobile network, so we’re now working with our partners to explore how training and tools for basic mobile phones will help them to carry out their duties in remote areas. We’re also developing creative printed materials to support their interaction with people of all literacy levels in their communities.

In a similar project in Bangladesh, we discovered that health workers were using heavy, cumbersome flip charts to visit their clients in urban slums, so we developed a mobile app to help them undertake their roles more effectively.

“Now I’m getting all the topics by using one app which is not possible with other tools (flash cards, flip charts, leaflets). I can deliver all relevant information by the app which was difficult for me before” said one community health worker who frequently used the app.

Second, use human centred design and build partnerships

In rural India, the catalyst for the development of our highly successful Mobile Kunji and Mobile Academy projects was women’s lack of access to traditional mass media platforms. At the start of this work, our formative research showed that only a few women watched television or listened to the radio, however 82% had access to some form of basic mobile phone. So, rather than setting up a parallel system, ��tv Media Action leveraged the one available.

Using human centred design, our India team created content that worked on basic mobile phones and suited how health workers used them – to make and receive calls only. We created Mobile Academy, a training course for health workers, which is delivered through mobile audio messages, whilst Mobile Kunji is a set of visual cards and accompanying mobile audio messages that health workers can use during visits with families. Using these services and tools, our research has shown that health workers are able to better reach, engage, and influence families to improve their health.

These projects have not only worked, but they’ve shown sustainability. By working in partnership with the state governments in Bihar, Odisha and Uttar Pradesh, we’ve trained 263,000 health workers so far on Mobile Kunji and about 260,000 people have completed the Mobile Academy course.

Mobile Academy is now active in 13 states and we recently transitioned responsibility for the service to the Indian Government to continue its vital work long into the future.

Third, create relatable and accurate content to help to build trust

In Bangladesh we learnt that community health workers were struggling to communicate effectively about sexual health to young women and men, which limited the impact of their advice.

So we developed a smartphone app. It shows Dr Natasha, a real doctor, talking about some of the key sexual, reproductive, and maternal and child health issues their clients were facing. By using appropriate language tailored to their audiences, we made sure the content was relatable, accessible, and engaging – which mattered especially in areas with low literacy levels.

Our research showed us that health workers felt more trusted by their clients and were more successful in persuading them to adopt healthier practices, such as attending antenatal care visits. As one of the health workers described, “Most of my clients were not interested in listening to my suggestions before using the job aid. But now they are convinced as they see there is symmetry between Dr Natasha’s information and my own”.

We found the app also helped to give them credibility to dispel myths around issues such as contraception and family planning.

Fourth, go beyond training on health topics and train on how to communicate

Community health workers cover a wide variety of health issues on their visits. Our research often reveals the benefits of refreshing or deepening their knowledge, but also of them gaining new skills on how to communicate within a family setting. We found in remote parts of Ethiopia, communicating with the men in the family is often overlooked because family health is still seen as a woman’s responsibility.

So we ran training for Health Extension Workers which focused on how to create safer feeding and playing spaces for children under three, during which participants learned how to communicate effectively with, and actively involve, both women and men in the families.

We found role play really helped during training because it encouraged Health Extension Workers to practise how to have compelling two-way conversations.

And finally, break down the barriers between communities and health workers

Mistrust and suspicion between communities and health workers is common in many of the places we work. Through our research, we often hear about these difficulties and then aim to create safe spaces for communities and health workers to come together, get to know each other, and discuss often sensitive issues.

In Nigeria we facilitate discussions around polio vaccinations and routine immunisation as part of our community drama radio recordings which are performed in front of a live audience. And, working with different partners, we accompany women during antenatal care check-ups to record what happens. By sharing real-life experiences in our radio programmes, it helps to build understanding and trust in health services amongst the public.

In Tanzania, we trained and worked with radio partners to facilitate lively community events that were recorded and broadcast in weekly radio shows to audiences across the country. The events were designed to build understanding about maternal and newborn health issues and encourage interaction with health workers. By facilitating conversations, we found people gained understanding and confidence to access health services. We also saw increased male engagement in maternal and newborn health care.

Looking forward

In summary, we’ve learnt to not only help build the skills and confidence of community health workers, but also to help improve engagement between them and members of their communities. Through creative communication and human centred design, it is possible to create more effective tools fit for the difficult environments health workers operate in. And in doing so, we’re able to help health workers and communities work better together.

Informed by our experience, ��tv Media Action plans to continue this important work towards the UHC2030 global movement, to build stronger health systems for people around the world.

Emebet Wuhib-Mutungi and Genevieve Hutchinson
Senior Health Advisors for ��tv Media Action
On Twitter: @ewuhib / @genevieveh77

The projects featured in this blog were carried out in conjunction with: national government ministries and departments of health, DFID, UNICEF, The Gates Foundation, UNFPA, Options, Abt Associates, Viamo, Care International, the Grameen Foundation and our media partners.

Using human-centred design to achieve your goals

2017-11-07T13:26:06+00:00

This blog was originally posted on India Development Review (IDR’s) Practice blog

One can’t talk about design without quoting Steve Jobs.

“Design is a funny word," he said, "Some people think design is how it looks. But of course, if you dig deeper, it’s really how it works.” He hit the bullseye as always. Look at the success of design-driven companies like AirBnB and Pinterest, or even digital giants like Google, eBay and LinkedIn, who have invested in the design of more engaging and differentiated user experiences.

During the last couple of years, human-centred design has acquired a somewhat elusive and awe-inspiring reputation among donors and implementers. Everyone wants it, yet struggles to see how it can fit in with achieving development goals.

At ��tv Media Action, we use the power of media and communication to create social and behaviour change. For a lot of our work, like the mhealth services Mobile Kunji, Mobile Academy and Kilkari, we have been using human-centred design, long before it became a term de jour! “Admittedly I flip between being overjoyed that many in the development community have suddenly bought into design thinking, and being frustrated that this is seen as something new,” says my colleague Yvonne MacPherson, ��tv Media Action’s US director.

Now that human-centred design is trendy, we need to make sure it is not treated as a separate, add-on activity or process. It is integral to “doing development”. Donors are now putting out separate calls for proposals just for human-centred design, presumably to support other implementation efforts.

This then begs the question, why are all implementers not using human-centred design principles in their work? And if they are not, what could be the reasons—lack of resources, time or access to technology? Which brings me to the biggest myth around human-centred design—that it can only be used to create digital or tech solutions. Which is why, I will use a no-tech (not even low-tech!) innovation to talk you through the process. This is a tool we have created for pregnant women in Bihar, where 60% of women aged between 15 and 59 years suffer from anaemia, the silent killer.

Five tenets of human-centred design

1. Empathise/immerse – to create meaningful innovations, know your users and care about their lives

The problem with most pregnant women in Bihar is that even though they know what to do, compliance with whatever has been prescribed or is necessary is a challenge. Pregnant women not completing the full course of iron folic acid (IFA) tablets is a major issue. They start and then stop because of side effects. They also have no idea why this supplement is so critical because they have no understanding of the connection between their blood count and the baby growing inside them.

2. Define/mine the insight – frame the right problem and dig out the right insight to create the right solution

So what would help women stay the course? Creating risk perception. A mother’s body is like a factory that must produce blood for a healthy baby. Can she afford not to do this ‘most significant’ bit for her unborn child? Could we therefore ‘re-engineer a blood factory’?

3. Ideate – there’s no ‘right’ idea, generate many

How to show a rural woman (without access to ultrasonography) the baby growing inside her? How to explain visually the blood factory– the link between mother and baby through blood? How to use emotion to ensure compliance? How to use language moored in popular culture to convey a simple doable action? How to nudge the woman to take the same action every day over 180 days?

4. Prototype – build to think and test to learn

We created a paper-based prototype in three parts called Khoon ka Rishta (bloodline). The frontline health worker (FLW) would use one part to explain to women in a group how IFA tablets help create the bloodline between mother and child, and how missing even one tablet could actually break that line.

The second part of the paper, to be kept by the mother, carried an illustration: the outline of a baby’s body, with teardrop-shaped gaps inside. This paper prototype also included the entire course of IFA tablets and strips of teardrop-shaped adhesive bindis, to fit the gaps.

See below.

As the mother would take a tablet, she would use the red bindi to cover up those gaps in the baby’s body. And as she would complete her course of 180 tablets, she would watch this baby becoming whole.

The third part was a card with a congratulatory message using the same teardrop graphic.

5. Test – learn about your solution and your user

What did we learn? Both types of user - frontline workers and pregnant women, understood and liked the tool. But it needed to be simplified. So, we eliminated some details, redesigned a few and made instructions crisper and clearer.

Women engaged with the tool at an emotional level—it provided a visual and vivid reminder of a deep connection: “I’m taking a tablet and that’s helping my baby form and be whole and healthy.”

A quick, second round of testing helped ensure we had incorporated all the feedback.

Is Khoon ka Rishta working?

The tool has been in use across eight districts in Bihar for over a year. A state-wide scale up has been planned by the government on the basis of an impact evaluation study we commissioned. It shows that:

Women exposed to the tool are more than twice as likely to report correct knowledge about IFA compliance.
They are twice as likely as those unexposed, to report correct practice.
Data suggests exposure to the tool leads to an increased demand for IFA tablets at the Village Health Sanitation and Nutrition Day meets.

Anecdotally, chemists are saying they have noticed an increase in sales of IFA tablets, because, even when women cannot get them free from the system, they are buying the tablets because they realise how fundamental they are to the health of their babies. We have used human-centred design to create tools for other products and services that are available at village health sanitation and nutrition days, such as contraceptives, oral rehydration salts for diarrhoea management and complete immunisation. These tools are non-digital yet innovative.

This proves something else as well: keeping the user front and centre, resetting the paradigm, checking ideas and assumptions and learning from failure are not very different from how communication gets done in the first instance. But if you want to walk the tightrope between disruption and delivering outcomes, this approach definitely helps you to be surefooted in creating innovative solutions to problems of every kind, whether you are in Silicon Valley, or Bihar.

Tell me a story: narratives, behaviour change and neuroscience

2017-06-19T09:35:32+00:00

“Tell me the facts and I’ll learn. Tell me the truth and I’ll believe. But tell me a story and it will live in my heart forever.” – Native American proverb

I recently spent the day in a San Diego hotel room with 49 people who are obsessed with telling stories. Focused on overcoming public health and social justice challenges, we were gathered to discuss how to design, develop, monitor and evaluate communication responses based around storytelling.

The day we spent together was a story in itself: interesting characters…full of discovery…with not a single dull moment! I hoped it would never end, so, to re-live the thrill of it all, I thought I would share some of my highlights from the fabulous talks I heard:

How narratives influence ideas and behaviour

Stories are powerful, a quality captured by social psychologist Melanie Green in her presentation with the concept of ‘narrative transportation': the experience of becoming so caught up in a narrative that the real world fades away. Being in this state of immersion makes us more open to having our beliefs and attitudes changed, as our tendency to argue is reduced.

Reading up on Green’s ideas post-conference, I was reminded that when faced with an attempt at persuasion, we typically put our guard up and have our counter-arguments at the ready. Stories circumvent these instincts, proving effective at challenging entrenched views without us even realising what’s happening.

The theory is intuitive, but do we see these ideas play out in practice? Addressing this question, Jeff Niederdeppe said yes, we do. The Cornell academic talked about how stories can enhance support for health policies, like restricting the sale of soft drinks in schools and putting graphic warning labels on cigarette packets.

Delving into Niederdeppe’s work later, I learned about a study of his which involved asking people to read a story about ‘Cynthia’ and her daughter – who tries smoking in one scenario and grapples with weight issues due to drinking soda in another. Reading these narratives made the study’s participants more resistant to the kinds of messages industries put out to oppose healthy policies.

In addition to ideas, fiction can also influence behaviour. One study I found – led by academics in both medicine and communication – showed that watching just a 12-minute video could convince women to go get themselves screened for cervical cancer. It could also close the screening gap between different ethnicities. Mexican American women who watched the Tamale Lesson went from having the lowest rate of screening initially (32%) to the highest (82%) when surveyed six months later.

Comedy is the new serious

Suitably equipped with a broad overview of what storytelling can inspire people to do, let’s drill down into what different genres can achieve. As an organisation, Media Action has talked a fair amount about how drama can be used to broach difficult topics, such as gender-based violence. But comedy shouldn’t be overlooked, argued Caty Borum Chattoo, Director of the American University’s School of Communication, as it can bring its light touch to bear on serious issues.

Looking up some such gags-for-good, I came across toilet humour and condom-blowing competitions used to help people get over their self-consciousness and engage with topics like HIV and sanitation, which they might otherwise be reluctant to address. That’s not to mention all the satire putting transgressing politicians under the spotlight of public ridicule.

Here in Media Action’s India office, we’ve seen how comedy can reach and preach beyond the choir through our TV ads and PSAs on tuberculosis, sexually transmitted infections and condoms – the last of which features a puppy christened by a parrot.

Neuroscience is becoming communication’s new best friend

Many within the development sector would nod their heads approvingly at the examples above. They just want more hard evidence. Communication and media interventions certainly haven't had as much of a scientific basis as biomedical ones. But things are changing.

In San Diego, two new matadors in the narrative arena, René Weber and Ralf Schmaelzle talked to us about how they use functional magnetic resonance imaging (fMRI) to see what stories do to our minds. fMRI measures brain activity by detecting changes in cerebral blood flow.

At the conference, I discovered that fMRI can tell us a lot but it wasn’t until perusing one of Schmaelzle’s studies afterwards that I came to appreciate quite how much. For example, the brain signals of someone consuming a piece of health communication can help determine: the strength of an argument, its novelty, how visually engaging it is and whether it's tailored to their race or sexuality. And that’s just looking at some of what just one part of the brain – the 'medial prefrontal cortex and the precuneus' – is telling us.

fMRI can also be used to determine what target audiences ‘tune in’ to. In the study, Schmaelzle and his co-authors assessed the effectiveness of different public service announcements (PSAs) in convincing young adults about the risks of alcohol. They suggest that the messages which resounded the most engaged more of people’s brains.

The news tells us that even Facebook is getting in on the action. The social media company is due to open a neuroscience research lab, which will examine how users spend their time on the site by recording their eye movements, skin responses, heart rate and facial expressions.

These were just a smattering of topics covered at the event. One more worth a quick mention here was how to best leverage transmedia storytelling (sharing narratives across multiple platforms). As the day progressed, it became increasingly obvious that narratives have transcended the borders of ‘entertainment-education’ on television and radio; they are now embracing new platforms and trends like gamification, social media and graphic novels.

Clearly, storytelling as a tool for social change is still an unfolding saga. If neuroscientists are now getting involved, who knows who else will join us in our quest!

Communication Professor (and MC extraordinaire) Arvind Singhal summed it up aptly, "In my 31 year long involvement at ICA [the International Communication Association], never before I was witness to so many who cared about the social use of narrative power, to come together, to parley, to transport, and to enrich one another in mindful intellectual and heartfelt communion. We inspired each other with our narratives - shared and contested!"

This blog was based on presentations delivered at the Innovations in Narrative-based Interventions pre-conference at the 2017 International Communication Association conference. Presented by ��tv Media Action, Asian Institute of Technology (Bangkok), University at Buffalo and USC Annenberg School for Communication and Journalism, the pre-conference was organised by Angeline Sangalang, Helen Hua Wang, Joyee S Chatterjee and Michael J Cody.

Radharani Mitra is National Creative Director and Executive Producer of ��tv Media Action’s India office. She tweets as @radharani_m.

Blog: Using storytelling to make statistics accessible

Blog: Human stories inspire positive change

The case for adaptive programming

2017-06-08T09:08:54+00:00

I don’t like results frameworks. Most demand that you specify exactly what you will do, where, when, and how many times, in order to achieve specified objectives that contribute to overarching development goals.

Of course, that is a perfectly fair thing to ask of an implementing organisation. Development funds are scarce; every rupee spent needs to be accounted for and must contribute towards creating lasting and transformational change.

But traditional results frameworks force you to either continue doing what you have always done or predict exactly what will happen upon implementation. Neither allows you to learn from mistakes, improve or innovate. What does allow learning, improvement and innovation is adaptive programming – programming that is focused on outcomes rather than outputs, and is flexible.

At ��tv Media Action, the organisation I work for, we use the power of media and communication to help reduce poverty and support people in understanding their rights. We have been working in India since 1999 as an independent, international nonprofit arm of the ��tv.

And we have been fortunate enough to find funders that are wholly committed to our approach of adaptive programming. This concept can mean many things to many people but, at its heart, it is about a commitment to specific goals, with flexibility on how you achieve them.

Let me illustrate why I’m a firm believer in this approach. Majboor Kisko Bola! (Who are you calling helpless?) or MKB, was a Google Foundation-funded project to prevent bonded labour among the most vulnerable and marginalised communities in Madhya Pradesh, Chhattisgarh and Jharkhand. MKB was designed to be a radio programme targeting listeners in ‘media-dark’ communities across 110 villages.

The adaptation journey

Our first adaptation in this project was a result of a challenge we faced in reaching larger numbers of people in communities with little or no access to TV, radio or mobile phones. Rather than broadcast, we created a platform called ‘Listeners' Villages’.

Partnering with community-based organisations in those villages, we trained local facilitators and equipped them with a basic radio set that could play content off a flash drive. Each week, these facilitators would convene listening groups, play the MKB radio programme and then lead a facilitated discussion. The idea was to reach at least 50 percent of the households in the village with MKB, every week.

The second adaptation was in our feedback mechanism. We included a ‘missed call’ number in each episode, encouraging listeners to share their views about the show. Though we got the kind of response we had anticipated – people loved specific stories or characters and they wanted to share their own stories or jokes – we also received unexpected feedback.

People began voicing their questions and grievances about a range of issues: they had not received their entitlements, they wanted to know whom to approach to request water supply to their village, they wanted help rescuing friends and family they thought were bonded.

While we were ill-equipped to handle these questions, we saw the situation as a fantastic opportunity to enhance the impact of our project. If we could connect listeners to people who could actually resolve their grievances, we could maximise impact.

Thus, we introduced our third adaptation: Shrota Samvaad (listeners’ dialogue) events. These were large-scale events where MKB listeners came face-to-face with the district administration, including the district magistrate, local police, the labour commissioner and the press. Over 5,000 official grievances were registered with district authorities at these events.

Results of the MKB project were heartening:

37 percent of MKB listeners had a clear understanding of the legal definition of bonded labour versus 7 percent of non-listeners.
62 percent of listeners recognised at least three labour rights violations compared to 32 percent of non-listeners.
61 percent of listeners said they would encourage people to fight for their rights versus 47 percent of those unexposed to MKB.

So, what did we learn about adaptive programming?

1. Focus on the questions, not the answers: At the project planning stage, focus more on the outcomes and the ambition than on the specific solutions that will get you there. Think of your project design as questions you seek to answer. This allows for innovation, experimentation and out-of-the-box thinking.

2. Plan for financial flexibility: Don’t confuse this with loose financial control or a lack of financial processes and accountability. If anything, adaptive programming requires greater financial rigour. But if you can design your budgets to have flexibility in your project design and outputs, you have a much better chance at trying new things.

3. Adapting takes time and money: This is not the same approach as producing a single set of outputs and letting them ride all the way till the end of the project. Every change in approach, new strategy, or fresh output requires time, money and manpower.

4. Recruit for skills and attitude: Rather than focusing on specific experience, enable your team to build skills such as lateral thinking, problem solving and nimble implementation. Without these, adaptability is impossible.

5. Monitor constantly: Check whether your programme is on track to achieve your outcomes. Being adaptable means being able to identify when you need to adapt as well.

6. Be aware of both opportunities and threats: They are key drivers of adaptive programming. There may be opportunities you had not seen before starting the project, or those that arise along the way. Equally, keep your eyes peeled for threats that could derail your programme.

7. Trust your team’s instincts: Your team is immersed in the project and understands your stakeholders and the local context. That said, make informed decisions.

Adaptive programming can often seem like nothing is going to plan – indeed, there is no plan. Which is why it is essential to review consistently against your overall goals and ambition. Keep your eye on the horizon and make sure you use the instruments you have: your team, your monitoring research, and your relationship with donors and partners.

This article originally appeared on the India Development Review website on 1st June, 2017. The original can be found here.

Design thinking and health communication: learning from failure

2017-04-20T13:06:29+00:00

What do you do when your audience is difficult to reach, tough to keep engaged and doesn’t understand concepts you take for granted? Priyanka Dutt offers some words of advice from her team’s experience of running a health communication ‘laboratory’ in Bihar, northern India.

Anyone working in international development will attest that human-centred design (HCD) has been a ‘trending topic’ in recent years. Design thinking has been applied to a range of challenges, from supporting democratic transition in Libya to building an all-terrain wheelchair for under $200. Melinda Gates even hailed HCD as the innovation changing the most lives in the developing world.

But what exactly is design thinking? It involves bringing together multi-disciplinary teams – think creative writers working alongside ICT specialists – to address challenges through rapid prototyping and repeated testing. At the core of HCD is building empathy with the people you’re designing for with the overarching aim of producing something genuinely valuable to them.

Marrying these principles with our own core value of putting audiences at the heart of everything we do, we decided to set up a ‘laboratory’ in Bihar, in northern India, which aimed to improve child and maternal health through communication. We saw Bihar as a great site for HCD-style innovation because it offered us the scope to test and fine tune new ways of using communication to promote healthy behaviours for women and children alike.

Bihar is home to 29 million women of reproductive age, who give birth 3 million times every year. And although Bihar’s maternal mortality rate has declined in recent years to 93 per 100,000 live births, it is still well above the Sustainable Development Goals target of 70. As for the communication challenges, less than a fifth of these women watch TV and only 12% listen to the radio.

Yet the lab’s early creations achieved a great deal. Over 50,000 people have graduated from our Mobile Academy training course, which is delivered through mobile phone audio messages. The course teaches health workers how to communicate more effectively to persuade families to lead healthier lives.

We also produced a set of cards and audio messages delivered via mobile phone – called Mobile Kunji – for health workers to use during their visits with families. The evidence shows that families subsequently asked health workers more questions and were more likely to follow advice on preparing for birth, family planning and how to feed babies.

Rethinking strategy: learning from failure

High on our early successes, we set about developing Kilkari (a baby’s gurgle in Hindi). This programme sends weekly audio messages about pregnancy, child birth, and child care, directly to families’ mobile phones, from the second trimester of pregnancy until the child is one year old. The aim was that Kilkari would be listened to across Bihar, by the most vulnerable families, with the greatest need and least access to information and services.

Drawing on lessons from two similar services from around the world, Mobile Midwife and BabyCenter, in addition to our own prior experience in Bihar, we were confident Kilkari would be a success. Just to be certain, we ran some tests before rollout and found that we had failed in our vision – and spectacularly so. We weren’t getting through to our main audience, women, as we weren’t using the right channels and language.

In the end, we went back to the drawing board on Kilkari four times, simplifying and stripping down the content time and again, until we got it right. Through repeated prototype-test-redesign cycles, we made the vitally important discovery that our basic assumptions about our audiences were wrong. So we went back to basics and asked ourselves the following questions to push us to rethink our strategy:

1. Is the content relevant and easy to understand?

We discovered that our content confused the audiences we were targeting, who didn’t understand even simple Hindi words like health (swasthya). Men understood more than women – likely due to their greater literacy and mobility – but Kilkari’s female focus meant that this wasn’t particularly helpful.

Audiences also struggled with other concepts we take for granted. They mainly think of time in mornings, afternoons, evenings and nights, but we’d referred to hours and minutes in our programming, time references which simply don’t exist for them.

Finally, we also found that the speed and style of content used for Mobile Kunji and Mobile Academy was overwhelming for Kilkari’s audience. For example, dramatising content confused our listeners, who didn’t understand why there were so many people on the phone, all talking to them at once. We needed to have a single voice and a single take-away, simplified to the most basic information audiences needed.

2. Are we getting through to our target audience?

We primarily wanted to reach women, but discovered that it was mainly men who owned phones with the credit needed to receive messages from Kilkari, a paid subscription-based service.

In response, we used tactics to prompt men to share information with their wives. For example, calls were scheduled for the evening when men were more likely to be at home, increasing the chances that they’d pass on what they heard.

To drive up subscriptions, we also ran promotions targeting men, which presented the Kilkari subscriber as a smart and engaged role model father, who cares about the health and well-being of his family.

3. Can we do more to keep our target audience engaged?

We did a big marketing push for Kilkari, partnering with phone companies to promote the service at 20,000 shops. This went hand-in-hand with community outreach through songs, street theatre, films, quizzes and much else. As a result, we initially got a lot of subscribers, but the drop-out rate was high, suggesting that the service wasn’t relevant to those signing up.

Applying HCD principles, we redefined our audience and rapidly tested solutions to come up with a new and improved marketing strategy. We partnered with community health workers, who were already in contact with the families expecting babies we were trying to reach and so could help us promote Kilkari to its intended audience.

We incentivised health workers by offering them free mobile talk time for every subscription they secured, and gave them even more minutes if subscribers stuck with the service for more than two months.

In the end, our total number of subscriptions dropped slightly, but those who signed up did so for the long haul – our dropout rate fell to less than 10%.

From lab design to adapting for scale and sustainability

Ultimately, the lessons we learned from our mistakes paid off. Flash forward to January 2016, when the Indian health ministry began its national roll out of an adapted version of Kilkari. Kilkari is currently listened to by 1.6 million families in 11 states across India, every week. In a survey of Kilkari’s listeners, three out of four women said they frequently followed advice they’d heard on the service.

We’ll remember Kilkari as the project that taught us the most, not just about how to design for our audiences but also about the value of learning from failure. There’s also the long-lasting satisfaction that comes with finally getting it right.

If you want to find out more about how ��tv Media Action used media and communication at scale to improve maternal, newborn and child health, go to our digital platform, Global Health Stories.

Priyanka Dutt is Country Director of ��tv Media Action’s India office. Priyanka’s most recent publication is Rethinking communication for child and maternal health, which reflects on ��tv Media Action’s Shaping Demand and Practices initiative to improve family health in Bihar, northern India. She tweets as @priydee.

Five questions our data portal can help answer

2017-04-04T06:00:00+00:00

There's a lack of data on what ordinary people think, feel and want in developing countries. Our new Data Portal aims to help fix that. Sonia Whitehead runs through five questions the portal can help answer on governance, media and resilience.

The development world is all aflutter about data. There’s much talk of a data revolution, the sector’s hiring data scientists and the World Bank just launched a new podcast to ‘data crunch the world’.

Not to dampen all this excitement but we need a lot more data about people in the Global South before it can become a transformative force there. Addressing this lack of data will speed up progress on everything from gender to alleviating poverty.

Enter our new Data Portal (view on desktop), which brings together data, reports and visualisations from surveys conducted in 13 developing countries that there aren't a lot of statistics about. Over five years, we asked more than 75,000 (rarely polled) people about what they think, feel and want. The portal covers a range of issues from what they’re most worried about to how interested they are in politics.

We want these insights to help development leaders, practitioners and researchers better understand ordinary people in the developing world so they can produce more effective strategies, projects and communications.

To mark the launch of the portal, we run through five questions that it can help answer on governance, media and resilience, while also showcasing the different types of content available on the portal.

1. What sources of information do people trust?

Being a media organisation, we wanted to know whether people believe what they hear on the airwaves, see on TV and read online. We found that trust levels in radio are universally high, at over 80% in Kenya, Nigeria and Myanmar, and reaching 90% in Nepal.

However, people are more circumspect about the truthfulness of the internet, with the Burmese especially sceptical, which is concerning given that half of Myanmar's internet users say they go online in order to read the news.

To illustrate these (and other) insights into what media people think of different sources of information, we produced a series of visualisations – some of the ones for Kenya are previewed below (media visual available here, governance one here):

2. How free do people feel to speak their minds?

We asked people in three Asian countries (Bangladesh, Myanmar, Nepal), four African countries (Kenya, Nigeria, Sierra Leone, Tanzania) and the Palestinian territories whether they could 'say what they think'. A majority felt at least somewhat free to speak their minds in all but one of the countries: Myanmar.

But across the eight countries in our governance data set, we found that many people don’t feel they can criticise those in charge. Around a third of Kenyans, Sierra Leoneans, Bangladeshis and Palestinians ‘feel people like them are free to talk negatively about the government in public’; in Tanzania and Myanmar this drops to under one in four.

Nepal is the only place we looked at where a majority (65%) feel at least somewhat able to criticise those in charge. Nigerians are the next most comfortable with openly complaining about their leaders, a little over 40% say they could – though only half that number felt very liberated to do so.

3. Who are the keenest voters?

In six countries, we also asked whether people had voted in the last general election: Bangladesh, Myanmar, Palestine, Sierra Leone, Tanzania and Nigeria.

Sierra Leone came out top, with 90% reporting having voted in the last general election, closely followed by Myanmar at 87% and Tanzania at 86%. (A quick note – we conducted our Burmese survey in 2016, after the victory of Aung San Suu Kyi's National League for Democracy in 2015.)

Turnout was lowest in Bangladesh and the Palestinian territories, where 42% and 45% respectively said they’d cast a ballot in the last national election.

Of course, people don’t just get involved with public life through voting. Meetings, protests, and various forms of communication are all types of political participation. The Sierra Leone visualisation previewed below shows that while only a small proportion of people have been in touch with government officials, nearly two thirds have teamed up with others in their community to solve a problem.

4. How do people feel about those who are different to them?

Historically, Kenya has been the site of ethnicity-based politics and violence. Yet even against this background, well over 80% of Kenyans want to live with people from other ethnic groups and think it's important to know about different cultures and what life is like for those who are different to them (see below).

In a country with over 100 ethnic groups, 97% of people in Myanmar believe that peace relies on mutual respect between people from different ethnic, religious and social groups. Similarly in Nigeria – which has wrestled with religious divides – nine tenths of the population believe that people from different backgrounds have ‘more in common than they think’.

However, a large majority of both Nigerians and Burmese feel that some differences between groups are ‘just too difficult to overcome’.

5. How are people adapting to environmental change?

Building on our Climate Asia project – which examined 33,500 people’s everyday experiences of climate change – we’ve more recently asked Tanzanians and Bangladeshis about how they’re coping with changes to the world around them.

In the drought-ridden areas of Dodoma and Morogoro in Tanzania, more people think agricultural productivity has decreased than increased over the past ten years. They are split as to whether rainfall is higher or lower than it was a decade ago.

Getting their information predominantly from the radio, Tanzanians are making some – though not a lot – of changes in light of the environmental challenges they face. Popular responses include keeping food for longer and finding new water supplies.

In Bangladesh, rainfall, temperatures and extreme weather are all commonly seen to have increased in the past decade. TV is the country's go-to medium for getting information about water, food, energy and extreme weather, considerably more so than the radio, newspaper, friends and family.

Around a third of the population have changed how they live in response to environmental changes; swapping jobs is the most common way of shaking things up.

In addition to all of the data, the portal also hosts a number of other resources:

For extra guidance on navigating the portal, take a look at our ‘How-to’ section, as well as our ‘walkthrough’ and ‘running a query’ videos.

Those interested in how we collected the data should refer to the methodologies and questionnaires available on the right-hand sidebar of each of the thematic pages (media, governance, resilience).

The portal is also home to reports which summarise and analyse data available on the portal. For example, we've produced a report exploring how to better connect with the least politically engaged Kenyans. This is just a flavour of what’s to come, similar reports analysing our governance data in other countries will follow in the coming months.

On each thematic page, there are reports and tools to support practitioners to use media for development. For example, we’ve featured the communication toolkit from our Climate Asia project, which includes a guide on how to talk about climate change in an accessible and engaging way, as well as a set of cards (with instructions) for co-creating a communication strategy with partners and your target audience.

Sonia Whitehead is ��tv Media Action's Head of Research Programmes, overseeing research across Africa, Asia and the Middle East.

Pointing the needle to a future in which gender is not destiny

2017-02-21T09:41:15+00:00

Kathryn Tomlinson reports back from the 2017 NEEDLE Conference, ��tv Media Action India’s conclave on media, communication and development. This year’s focus was on gender and the media.

A needle is a nondescript yet indispensable object. It stitches, it weaves, it injects, it points, it guides.

Over 300 people in Delhi this February were prodded with a giant NEEDLE, ��tv Media Action India’s third communication conclave, a forum in which experts from across the media, communications, advertising, development and government sectors are challenged to explore how media and communications can bring about change. This year, NEEDLE 2017 explored how the Indian media can improve the representation and engagement of women in all aspects of the world around them. We were challenged to “move the needle to a world in which gender is not destiny”.

Pin pricks of progress?

Consuming media in India, be that YouTube videos, television shows or the news, it’s hard to not be stunned at the dichotomy between what we say is possible for women today – that they can ascend to positions of leadership, launch their own successful businesses, sit at the board table equally with men – and how women are actually depicted in the media.

Much of NEEDLE 2017 was thus about pin pointing our position on a road to progress. India is far from the beginning of this journey; huge strides have been made in recent decades in the ways that women are represented in media and engage in public life in India. Film-maker Shoojit Sircar noted that when he started out, only the Costume Assistant was a woman. Now, most of his heads of department are female. Ashvini Yardi, who was seven months pregnant and in hospital when she took the call asking her to take over running ZEE TV, similarly observed that only a few years ago, women were not even allowed to do the make-up.

The way women – and gender issues, more broadly – are featured in content has also moved forward in recent years. Breakthrough India’s Sonali Khan showed an ad depicting the true story of the first man to beat the thali [a metal platter] in his village to celebrate the birth of his daughter (which until then had only been done to celebrate male births). ��tv Media Action's own TV series AdhaFull (which follows three young people challenging gender stereotypes as they solve crimes) can disrupt traditional gender stereotypes, creating a new normal around what it means to be a girl or a woman in India. Soap operas are much less regressive in their representation of women than they are sometimes mocked to be: there is always a woman who stands up, without aggression, to defend herself. It feels like a realistic portrait of Indian female strength, not a Western one.

But there is still a way to go. In conservative communities, film-maker, author and activist Archana Kapoor told of the multiple hurdles radio stations face to get women’s voices on air and the resulting harassment those female callers face from men: “You’ve been heard all over Mewat, nobody’s going to marry you now!” Her examples echoed the reminder given by Zainab, a young woman from 60km outside Delhi who opened the event and told us that while her household has a TV, when the (male) neighbours come round to watch it, women are not allowed to be present. Girls are not even allowed mobile phones in her community lest they get “led down bad paths.” So only 60km away from this vibrant urban capital, media has a far greater distance to travel to point the needle towards access to information, let alone gender equality.

Listening to all of this, I felt a mass of contradictions: we had speaker after influential female speaker featured at this conference – two thirds of our panellists were female. And this incredibly efficient event was organised by a largely female management team from ��tv Media Action’s India office. But there's still a long, long way to go to build an India in which a girl is consistently valued.

How the needle stitches

The power of NEEDLE derives partly from the impressive speakers it is able to bring together as well as what they say on stage. But it's also about convening the best and brightest minds working in media and communication, development and industry together in one room to focus on the representation and engagement of women in everything that happens in India.

In this vein, I was also moved by the number of male speakers who reflected on how they have come to recognise gender inequality in their personal lives. Shoojit Sircar shared his wife’s musing that we can send a mission to Mars, but somehow still find ourselves debating gender inequality. Another was shocked to realise that his mother's activities had always been focused on her husband and children, rather than her even having her own ambitions. Again and again what these speakers demonstrated was that gender equality begins at home. And media and communications reach deep into the home.

Most of all, I was impressed by the straight talking I witnessed at NEEDLE. Esoteric terminology such as 'gender mainstreaming', 'the gender lens' and 'gender-sensitive indicators' were largely absent. That’s indicative of NEEDLE’s underlying approach: to make this conversation deliberately accessible to as wide a spectrum of people as possible in India. And that’s where I saw the future – for the policy makers, practitioners and researchers seeking to improve India – and the world – for women and girls alike. We must speak in straightforward terms about our vision and in so doing bring others with us to ensure that gender is not destiny.

Kathryn Tomlinson is ��tv Media Action’s Regional Director for Asia.