Rethinking Communication for Maternal and Child Health: Lessons from the Shaping Demand and Practices Project in Bihar, Northern India

"Between 2011 and 2015, BBC Media Action and its partners implemented a... project to improve family health in Bihar, one of the poorest and most populous states in India. Called Shaping Demand and Practices (SDP), the initiative formed part of the larger Ananya programme, collaboration between the Bill & Melinda Gates Foundation, the government of Bihar and other partners."

This practice briefing from BBC Media Action documents a particular approach to project design in Norther India and its subsequent implementation of SDP in a highly challenging environment for developing health communication solutions that could be scaled up nationally. To enhance the Gates Foundation's 5-year Ananya (Hindi for “unique”) effort, BBC Media Action agreed to work with "communication to generate demand for health services and to strengthen health-seeking behaviours." The focus was on the practice of 11 "priority health behaviours" (detailed on page 10) proven to save lives across the critical 1,000 days for maternal and child health.

SDP aimed to empower married women, encourage support from men, and actively engage families, for example, mother's-in-law, who are critical influencers in behaviour. The project used, for example:  public service advertising; radio broadcast and listeners' groups; street theatre and rural activation campaigning through television and events; communication tools for health workers, like dolls and mobile phone recordings; health worker training; and mobile health services like Mobile Kunji, Mobile Academy, and Kilkari (see related summaries below). The project outputs are now being transitioned to the government of Bihar and implemented elsewhere in India.

The briefing discusses project impact through measurement of project area change against overall change in infant, under-five, and maternal mortality in the state. Studies found improvements such as: 

• Higher levels of birth preparedness practices.
• A positive impact on some newborn care practices but not on others.
• Significant impacts on some complementary feeding practices.
• An increase in the use of modern contraceptive methods, yet, no significant improvement in vaccination rates.

"Within this context, data suggests that exposure to the interventions delivered by the SDP project was associated with improved health worker performance and healthy behaviour within families." Studies of Mobile Kunji correlated its use by health workers with improved delivery preparation and complementary feeding, as well as longer and better interactions between healthworkers and families and increased family knowledge on topics discussed.

Less closely studied, but showing association with improved health behaviours were SDP's TV advertisements, radio programmes, street theatre, and audio-visual vans. These kinds of positive evaluation results supported scale up, for example, the adoption of communication elements by the governments of Uttar Pradesh and Odisha. The Union Minister of Health and Family Welfare launched a national platform to prepare for scale up across the country, potentially reaching 9.5 million women.

The briefing finds that there were five intertwined success factors underpinning the project, namely:

• "Employing fresh thinking about potential communication platforms to ensure that all possible opportunities for audience interaction were exploited
• Using a human-centred design approach that involved immersive research into people’s lives and the testing and refinement of communication solutions to ensure impact
• Maintaining a rigorous focus on the “art and craft” of designing health communication outputs, drawing on creativity and experiences drawn from working with mass media to maximise audience engagement
• Devising new tools and approaches to reinvigorate the role that frontline health workers play in driving population-level behaviour change
• Commitment to partnerships with state and national government, rooted in the co-design of project outputs, to ensure that the results were sustained after the lifetime of the project"

Challenges included: 

• reaching audiences in "vast and poorly connected settings", demanding multi-pronged communication strategies; 
• state funding limitations that limited broadcast exposure,  demanding focusing on:
•  "strategically leveraging alternative platforms for the dissemination of mass media content to achieve cost-effectiveness
•  ...placing even greater emphasis than originally planned on interpersonal communication, the pivotal role of FLWs and community outreach
•  ...pursu[ing] a multi-pronged communication approach to ensure maximum reach and exposure, despite the limited reach of some individual platforms

The challenges sparked innovation, including: listening groups (nearly 56,000 self-help groups) and groups in 81 girls' boarding schools. Health worker success in the use of Mobile Kunij sparked development of new tools like the plastic “diarrhoea doll” that could be filled with oral rehydration solution. Community engagement included rethinking video van and speaker van use, engaging villagers with theatre and games, experimenting with tablet based apps to take content to courtyards outside village centres. Effective characteristics of street theatre were: "• Repeat visits, [i.e.,] bringing three different plays to the same communities over 18 months

• A cast of characters that stays constant across the three plays
• Creative scripts, using cliffhangers and other devices used in TV drama storylines
• Echoing and reinforcing the ‘big creative ideas’ conveyed in the SDP TV advertising campaigns"

Design theory was based upon an adapted version of Stanford University’s five modes of design thinking "empathise, define, ideate, prototype, test". By engaging creative ideas - using insight as a base instead of messaging as a base, the project found more engagement of women. By using consistent characters, serialised storytelling, and audio-visual materials, the project increased audience engagement with media. Design and functionality were centralised, and healthworker engagement was increased through a focus on "professional pride, credibility and empowerment". Project sustainability was achieved by a structured process of co-development with government counterparts as full participants. "Flexibility and experimentation were also key",  along with capacity strengthening. Transitioning to full government ownership was made more difficult by high turnover of officials and will require more analysis when it is fully complete. The document concludes that partnerships with government are essential to ensure a lasting legacy for health programmes at scale.