Designing an Intervention to Stimulate Dialogue Regarding Adolescent Health Issues in Rural India

About the Project

The National Adolescent Health Programme in India (Rashtriya Kishor Swasthya Karyakram or RKSK) requires solutions to overcome last-mile challenges in initiating and sustaining a dialogue with adolescents and the community at large, on issues around adolescent health. Last-mile challenges refer to those obstacles which stand despite the existence of necessary resources and infrastructure of the project, and which arise in the final modalities of the implementation of RKSK at the village level.

Sustainable dialogue was particularly difficult in the context of the project which was rural India, as matters of sexuality are considered to be taboo and discussions regarding the same did not take place adequately in schools or even in their own households.

The project aimed to increase the engagement of adolescents with other stakeholders and increase open discussions about adolescent health in rural Madhya Pradesh (a state in India). We were also asked to look at the existing infrastructure and to suggest small incremental improvements as well. The United Nations Population Fund had presented this challenge to us, a group of 3, during the Young India Fellowship which is a highly selective postgraduate fellowship in liberal arts and leadership. The end result was a proposal for a gamified ICT (Information and Communications Technology) solution that used Interactive Voice Response (IVR) phone calls with feature phones. Aspects of the solution we had outlined were implemented as a pilot project in all of rural Madhya Pradesh.

My Role

I took on the role of a visual thinker/communicator and researcher in this project. This involved creating visual artefacts for the team to aid the conceptualization process and for the participants to make it easier for them to express their thoughts.

This Project Demonstrates...

Conducting qualitative research in radically unfamiliar environments and using visual communication methods to overcome communication barriers (I do not speak the native language, Hindi, fluently)
Exploring gamification as a way to engage communities
Handling taboo topics (sexual health) in a context where open communication is difficult for all stakeholders involved
Conducting focus group discussions
Conducting research while taking into consideration the systemic issues present such as discrimination based on age, gender, religion and caste
Exploring the entire system as a whole to look at points of intervention

The Process

This project was taken up before my design education at TU Delft. The process adopted hence would be different if I encounter a similar project in the future. However, I wished to showcase this project to demonstrate my experience in dealing with unfamiliar contexts where the matter of concern is one that the stakeholders find difficult to talk about. It went on for 16 weeks with a group of 3 working on the project for 8 hours per week.

The methods used are predominantly qualitative.

Preliminary Research Into the Context

The UNFPA along with RKSK had worked towards putting in place a number of interventions aimed at stimulating dialogue in the community about adolescent health issues. For us to start the project, we interviewed Dr Nilesh Deshpande, the state programme coordinator of the UNFPA in Madhya Pradesh. The interview and the literature he pointed us to shed light on the existing infrastructure and what are the challenges that they are still facing.

One of their more successful interventions was the Saathiya initiative. This involved having monthly meetings at a nearby school where a peer facilitator or Saathiya would moderate the meeting. These meetings were intended to make it easier for adolescents to openly talk about their doubts or issues regarding issues they would find difficult to bring up with adults.

The Saathiya initiative too was not without issues. The main issues were:

Low acceptance among peers, parents and community at large. The adults themselves were uncomfortable knowing that their children are attending meetings where taboo topics are discussed. They did not see the benefit and rather saw this as a problem.
Low motivation in the absence of incentives
Lack of leadership and soft skills
Low participation among adolescent boys
Discrimination and segregation based on caste, gender and age

In an attempt to make the communication of taboo topics easier, the UNFPA and RKSK were considering the distribution of comic books and showing animated clips during Saathiya meetings which would communicate these hard to discuss topics. To appeal to both young boys and girls, these comics and clips feature two characters named Madhav (A boy) and Muskaan (A girl). Both Madhav and Muskaan would portray how adolescents should ideally deal with and talk about such issues.

The visual below shows an overview of the stakeholders that are associated with adolescents.

To limit the scope of the project, a district in the state of Madhya Pradesh, Chattarpur was selected. All the research activities such as interviews and focus group discussions were conducted in this district.

Context Deep Dive

While the literature provided an idea about how the various stakeholders contribute to various areas of the system put in place by RKSK, it was important for us to understand why the stimulation of dialogue was proving to be difficult. Our guide and point of contact from the UNFPA, also encouraged us to work towards a direction that adds onto the existing Saathiya programme. The section below elaborates on the various activities we undertook and the main insights we obtained from conducting these activities.

Interviewing RKSK Councillors

Interviewing RKSK Trainers who train peer educators

Interviewing and observing peer educators

While the counsellors and trainers were able to express themselves as they spoke about topics the community considered taboo such as issues pertaining to adolescent health, for adolescents it was evidently difficult. This was mentioned by the counsellors and trainers and further was evident as we interacted with adolescents themselves. To overcome this, we decided to resort to visual means to communicate with adolescents. The style adopted for these visuals were toon-like to make it less intimidating.

Drawing scenarios on the blackboard

Hand drawn question booklets provided to adolescents

As the images indicate, the blackboard was used to explain scenarios to adolescents and to know their thoughts. Further, I created a small illustrated booklet of questions to understand the attitudes and behaviours of adolescents when it came to matters pertaining to their health, their peers and the Saathiya programme. As far as adolescents are concerned RKSK and the Saathiya programme were the same as this was their main interaction with the same.

Results and Insights

From the research activities that were carried out, several insights were gathered. They are:

Reasons for active participation of adolescent girls:

Provides them a safe space to discuss about topics
The meetings are seen as a way to move ahead in society
There is a marked increase in confidence in girls who are part of the programme
There is an increase in awareness compared to those who are not part of the programme

Reasons adolescent boys are reluctant to participate in the programme:

Boys are reluctant to talk to female counsellors
They feel that these programmes are for women
Considers talking about their health emasculating
They would rather play/work

Cultural norms that hinder discussions:

Taboo topics are not discussed at home
Parents do not want to take responsibility for sex education
Parents would rather have their children focus on work
Contraception is considered taboo
School teachers do not think sex health should be taught in schools

Conceptualization of Possible Points of Intervention

Based on our insights, the team brainstormed and identified possible add-ons and improvements in the existing set--up. This was also done with the intention of identifying what could be the concept that we as a team suggest to the UNFPA. The images below indicate the ideas we thought about. Please click on any of the images below for a better look.

The circles around the 'sticky notes' indicate the ideas that we thought could be consolidated to lead to the concept we would propose.

Final Concept

Engaging a district-wide community with a solution would prove to be a challenge. In the region, at the time internet penetration was low and most people still used feature phones. Adolescents in most cases did not have cell phones of their own either. Given that the scale of the problem was large and we had minimal time, the focus was directed towards discussions about taboo topics at home. This was because, for any large scale interventions to work, attitudes must change at the adolescent's household first.

Overview

Elaborating on Elements

In this section, I elaborate on the elements present in the overview below and on the intention behind the same.

1. Distribution of Comics to Adolescents During the Saathiya Meetings:

As the UNFPA and RKSK had planned, comics would be distributed at Saathiya meetings. In the comics, the main characters of the story Madhav and Muskaan would through the story raise issues pertaining to adolescent health.

These comics would be taken home by adolescents.

2. Self-registration Using the Number Found on the Comic Book:

A number would be found on the comic book using which the adolescent would have to make the missed phone call from their parents' feature phone as in most cases they would not have one of their own. The image on the book promises that there is a surprise to be won if one calls on the number.

Borrowing the phone for this from the parent initiates the communication as they explain why the need the same.

3. Receiving the Surprise Phone-call:

The phone call acts as a discussion prompt about the contents of the story in the book. The parent might receive a surprise phone call at any time from an IVR (Interactive Voice Response) system acting as Madhav and Muskaan who would ask the parent about important insights from the stories in the form of a multiple-choice question.

4. Small Rewards to Incentivize Dialogue:

The parent on answering the question correctly receives a certain amount of money as talk-time.

Every parent and their adolescent child could have the answer to the question. This is intended to stimulate a discussion amongst community members about these story instances which in the process would indirectly be educating them about adolescent health.

Final Thoughts

This project was an incredible learning experience and my first attempt at trying to tackle wicked problems. The complexity of such problems and the process of generating possible solutions for one of the many possible points of intervention was an interesting challenge and has gotten me immensely passionate about wicked problems. The scope of the project permitted time only till the concept submission. After this, it was taken forward and aspects of the same was implemented by the UNFPA in the state of Madhya Pradesh.

I had a hard time communicating as my Hindi at the time wasn't adequate as I am from the southern part of India. I learnt the value of being vulnerable to both participants and my teammates. While one of the teammates was fluent in Hindi, I depended on my visual skills to quickly break barriers and communicate ideas.

This project was the one that drove me to pursue a masters degree that focused on human experiences in the context of their surroundings which eventually led me to find TU Delft's Industrial Design Engineering MSc - Design for Interaction track.