Digital solutions to support early child development and nutrition in Telangana, India

• This article describes the development of a digital counselling intervention and of data collection methods in Telangana, India, during the COVID-19 pandemic. 
• The digital intervention leveraged high levels of mobile phone and internet access in Telangana to reach pregnant women and mothers with key messages related to early child development (ECD) and infant and young child feeding (IYCF). 
• While digital counselling is a promising model for reaching women, it should be complemented by interpersonal communication provided by frontline workers.

In India, COVID-19-related restrictions brought community-level service delivery for components under POSHAN Abhiyaan (the National Nutrition Mission) to a standstill. In a rapid online assessment, the Department of Women Development and Child Welfare (DWDCW), the Government of Telangana and the United Nations Children’s Fund (UNICEF) identified that counselling services were unavailable to over 90% of beneficiaries. To respond to this situation, a digital counselling intervention was developed in September 2020 for community-level dissemination, led by the not-for-profit organisation Sangath, as part of the wider Aalana Palana intervention. Aalana Palana aims to design and pilot an integrated early childhood development (ECD) and nutrition video intervention promoting nurturing care in the first 1,000 days of life. It is delivered by Anganwadi workers (AWWs) to healthcare providers and caregivers in the community.  

This article describes the development of the digital counselling intervention and of remote data collection methods in Telangana during the pandemic. 

Development of the digital counselling intervention 

The decision to implement a digital intervention using multimedia formats (video, audio and text) was based on Telangana state’s comparatively high levels of mobile phone and internet access, including amongst women.  

A messaging matrix was produced to guide the generation of video, text and audio messages, and images on several topic areas (e.g., pregnant mother care, complementary feeding, breastfeeding, and wellbeing in the context of COVID-19). Video and audio messages were kept brief (60-120 seconds) to encourage engagement.  

The final set of key messages was shared with AWWs, and two virtual training sessions were held to optimise the circulation of the content, which took place via the following mechanisms: 

• Messages were published on the DWDCW website, on a state-hosted YouTube channel,1 and via social media channels (Facebook and Instagram).
• AWWs forwarded messages to WhatsApp groups for pregnant and breastfeeding women and their family members.
• Text messages were sent to registered mothers.
• AWWs discussed messages with women receiving take-home food rations.
• Direct phone calls were made to target families without internet or smartphone access, and to supplement social media messaging. AWWs also communicated through a satellite television channel.  

Remote data collection  

Coverage and recall of the digital intervention 

A message recall survey was conducted via telephone calls and WhatsApp messages with 5,377 randomly selected pregnant women and mothers of children under two years of age in 16 districts of Telangana. Coverage of the digital counselling intervention was also assessed via tracking the number of WhatsApp groups created that included frontline workers (including AWWs) and families in their catchment area, and by tracking impressions on social media - including views, comments and shares. 

ECD and infant and young child feeding (IYCF) practices during COVID-19 

A random sample of 242 pregnant women and mothers with children aged six to 36 months from the catchment area of 30 Anganwadi Centres (AWCs) were approached for semi-structured telephone interviews. Data were collected on household financial security, IYCF practices, the quality and extent of stimulation available to children at home, healthcare service provision, and exposure to violence. 

Calls were made by a research assistant from Sangath, who obtained and recorded consent over the phone. Given the sensitive nature of certain questions, and specifically those related to violence, information was provided on appropriate helplines and a follow-up was completed to check whether support had been received.  

Digital counselling intervention 

• From September to December 2020, 27,757 WhatsApp groups were created that included AWWs and beneficiaries, representing 78% of AWCs in the state.  
• 227,000 pregnant and lactating women and 423,000 parents and other family members of young children (aged seven to 72 months) were reached through these groups.  

Message recall survey 

• WhatsApp messages reached more than 60% of all registered women beneficiaries in the state. Messages were also received by 100,000 Village Panchayat members, municipality post-holders and women collectives.  
• Approximately 1.5 million people were reached across social media between September and December 2020. 
• An average of 84% of women recalled receiving WhatsApp messages in the week preceding the survey. 
• Among women who recalled the content of these messages, 97% remembered receiving messages related to pregnancy care, 93% remembered receiving messages related to breastfeeding, and 77% remembered receiving messages related to complementary feeding.  
• 88% of women reported sharing messages among their peers and discussing them with AWWs and family members.  

ECD and IYCF during COVID-19 

• 208 out of 242 caregivers who were approached consented to participate in the telephone survey.  
• Approximately 51% of mothers reported receiving support from family members when feeding their children, with paternal participation reported by 18% of mothers.  
• 71% of mothers reported receiving food from AWCs before and during the COVID-19 lockdown. Only 43% were able to get their child vaccinated, and 39% were able to get their child’s height and weight measured both before and during the lockdown. 
• Between 34% and 42% of caregivers reported playing, reading, singing and engaging in other similar activities with their child during the pandemic, but not having engaged in such activities beforehand. 
• According to the responses of the surveyed caregivers, almost two-thirds (63%) of children received the World Health Organization recommended minimum acceptable diet in the 24 hours preceding the survey, 73.5% received four or more food groups, and 92% received the recommended number of meals. 

• High penetration of mobile phones and internet, including among women, enabled the implementation of the digital counselling intervention.  
• Since the messages were delivered digitally, they needed to be understandable and effective in the absence of a facilitator. This required simplification of language, the use of colloquial terms and an explanation of the concepts referred to. For the audio messages, a conversational tone was used to make the messages appealing to caregivers.  
• Customising messages for families’ individual needs was a challenge. Customised tele-calling was carried out in a smaller geographic location to address specific concerns. AWWs also used the digital counselling intervention as a tool to engage community members in discussions and to ensure continuity and uniformity of counselling services. 
• The dissemination of messages on WhatsApp groups enabled two-way interactive communications and created peer networks within communities to support women during pregnancy and after childbirth, even after the lockdown.
• Beneficiaries showed high rates of recall of key messages and high rates of adoption of the promoted behaviours. 
• Respondent fatigue presented a challenge during the telephone survey. At times, this impacted the quality of responses and resulted in the need for repeated phone calls.  

The digital counselling intervention provides a promising model for reaching target audiences with high-dose universal digital messages. While it cannot replace interpersonal communication with frontline workers like AWWs, combining digital messaging with targeted one-on-one counselling presents a potential model for ECD and nutrition interventions.  

The experience of combining Aalana Palana, UNICEF core values and the mission of DWDCW in Telangana, in response to COVID-19, provides lessons that can be expanded to support young children and their caregivers during future disasters.  

For more information, please contact Reetabrata Roy at r.roy@sangath.in.