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5. Communication planning for effective nutrition programmes

ROYAL D. COLLE
Cornell University, Ithaca, New York, USA

Primary health care and nutrition have been linked with communication in a variety of well-publicized projects. Nutrition workers in nine island nations in the South Pacific have used a communication satellite to carry out a maternal and infant nutrition programme; video-tape and television sets are being used in the Philippines to support nutrition workers; from Indonesia to Guatemala, audio cassettes are bringing health, nutrition, and agricultural information to rural families. The list could go on and on. We are witnessing a situation where communication technologies have taken their place alongside food supplements, oral rehydration salts, inoculations, rehabilitation centres, and home gardens as major ingredients in health and nutrition programmes.

The pattern that led to this partnership between communication and nutrition is familiar: expanded demand for services has been confronted by limited resources. Greater priority has been given to preventive approaches. Paraprofessionals such as community health workers or nutrition aides have become the front-line service providers. Meanwhile, the array of communication resources available for development purposes has expanded. There are high technology tools run by experts (for example, the communication satellites, computers, and colour television). And there are less sophisticated channels that can be effectively used by the non-technician: cassettes, puppets, and community workers. Recently, for example, modestly trained teams from Sri Lanka, Bangladesh, and Nepal won prizes in a Worldview International Foundation competition for producing video-tape programmes on development issues. These were not made by professional broadcasters, but by people associated with agriculture, health, and nutrition programmes.

IMPLICATIONS FOR HEALTH AND NUTRITION OFFICIALS

The success in using communication media to support nutrition projects does not mean that decision-makers should run out and buy a communication satellite or an audio cassette to solve the problems of providing effective health and nutrition services. But senior officials do have a substantial role to play in seeing that their programmes gain the full benefit of what an effective communication programme can offer. To do this they need to accept three responsibilities: (1) examine, at the planning stage of any programme, its implications for communication; (2) insist that communication or nutrition education people work within the framework of a communication strategy; and (3) provide communication resources. We will examine each of these in greater detail.

Planning: Policy

It is important to be specific about the word "communication" and about where a communication programme begins. In this paper, we consider communication to be the deliberate process of sharing information in a systematic way. We are concerned particularly with the use of mass media and interpersonal channels to achieve explicit communication goals. These goals are related to a broader policy and a comprehensive strategy that involves other sectors. (The word "sector" is used here to refer to an organized body of personnel, procedures and activities devoted to a specialized field or task, such as health, nutrition, agriculture, education, communication, research, training, etc.) It is at the policy level that the sequence of events leading to an effective communication programme begins (see figure 1).

A policy provides the political force that drives a programme. It usually includes an acknowledgment that a problem needs attention (for example, malnutrition in rural areas), that there is a goal to be reached, and a commitment to use resources to reach that goal. Policies are usually set by politicians or boards of directors, with details on implementation left to others. Some examples of policies in highly simplified form are: increase the nutritional well-being of the poor people of the country; provide primary health care to all the people; increase farmers' income; reduce the rate of population growth; change the nation from a rice-importer to a rice-exporter; achieve self-sufficiency in foods, etc.

Fig. 1.

Next, it is necessary to identify the sectors that will be involved in translating the policy into action. To do this, health and nutrition experts who are involved in planning may need to escape from their conventional thinking about service delivery and explore alternatives. An example could be the use of paraprofessionals. "Paraprofessionals" here refers to the kind of village health worker who generally has less than a year of professional training, and who has a large amount of day-to-day autonomy in providing health and nutrition services to rural low-income populations. This definition and some of the discussion that follows are elaborated in references 1 and 2. While there is a considerable acceptance of various kinds of village-level workers as an extension of the primary health-care system, there is somewhat less success with them than is usually expected. For example, at our workshop, Dr. Amorn Nondasuta indicated that about 60 per cent of village health volunteers are effective. That means a large proportion are not effective. The situation in Thailand is repeated throughout the world. There are various reasons, but the one that emerges prominently is the lack of adequate supervision for community workers.

Inevitably, when people think about supervision, they think of face-to-face contact. If, however, they were to break up "supervision" into its component parts, alternative approaches begin to emerge. What if, in planning a project using community nutrition volunteers, officials were to look at the tasks to be accomplished by supervision? From an analysis of programmes using paraprofessionals, we developed a list of some of the functions of supervision. In reading the list, an official should answer two key questions for each item: Is this important to my programme? What are the alternative ways this can be done ?

The list is as follows:

1. Legitimization. Convincing villagers that the village health worker who was once one of them now has the skills to handle matters of life and death.
2. Protecting role integrity. Helping define the limits of the demands that can be made on paraprofessionals.
3. Motivation. Sustaining enthusiasm for work where isolation and lack of rewards and compensation often make the original glamour of the job fade.
4. Monitoring and control. Checking on performance and collecting data related to services.
5. Education and guidance. Improving and expanding the services provided. 6. Technical assistance. Providing help for specific cases.
6. Linkage. Helping paraprofessionals establish and maintain contact with human and material resources vital to the task.
7. Evaluation. Making judgements concerning paraprofessionals' performance.

Some of these functions can be performed by other than face-to-face supervision. It should be evident that radio, video, and audio cassettes or television could play a major role in at least five of these. This would influence the planning for on-site visits by professional staff and for other logistics resources. It seems appropriate to propose that, in many ways, supervision is communication. Thus, in planning a village-level nutrition programme using field-workers, officials should not only think of conventional supervisors such as health personnel, but also consider the potential role of a communication sector. This is an example of the official's first responsibility in making communication effective: examining, at the planning stage, how and when communication fits into the overall programme.

Planning: Comprehensive Strategy

What programme planners or project leaders need to do at this stage is to develop a comprehensive strategy, indicating the major approach to be used, and the sectors needed to reach the policy goals. Inevitably communication will be one of those sectors, and that means that the health and nutrition decision-makers must themselves know more about communication than simply having a "bedside manner," or invite a communications person to participate in the planning.

The way this comprehensive strategy operates is dramatically portrayed by the Masagana 99 rice production effort in the Philippines. The policy was to make the nation a rice-exporter rather than a vice-importer. From among the approaches that might have been used, the planners decided to increase rice production. To translate the policy into action, the government concentrated on four sectors: a new rice technology, a new credit system for farmers, an enhanced agricultural extension system, and an ambitious communication and promotion programme. Like pieces of a puzzle, they fit together to make a comprehensive strategy for reaching a goal. (See P. Whit-more, in this volume, for a practical and systematic way of making a preliminary analysis of the various sectors that might be involved in an effort to change nutrition-related behaviour.)

One can also see the implications of different comprehensive strategies by looking at the official government plans for reducing the rate of population growth in two nations: Pakistan and Egypt. While the policy goals are the same, their approaches for reaching the goals are quite different. Pakistan emphasizes the health and welfare sectors; Egypt's nine-point plan includes agriculture, health, employment for women, industrialization, and social security. Both include a communication sector (see figures 2 and 3).

In summary, to develop effective communication in nutrition improvement and related programmes, the communication factor muct be built in at the beginning of the overall planning when major decisions are being made concerning the approaches to be used and resources to be allocated.

Working within a Communication Strategy: The Second Responsibility

Several years ago, the government of a Latin American country undertook a major nationwide nutrition programme. Quite properly, mass media and interpersonal communication components were included in the overall planning. However, these were carried out by two different agencies. The mass communication people launched an extensive media campaign that did not match the interpersonal communication being done in towns and villages by community nutrition and health workers. Nor had those front-line people been alerted to what was being done by the mass media. The nutrition communication phase of the project was a disaster. Resources were wasted, morale was destroyed, and the victims were not only the families who should have benefited from the programme, but professional people throughout the system, from senior nutrition officials to community health workers. There was no strategy.

All sectors in the comprehensive strategy have their own individual strategies, whether it is research, training, communication, distribution, or some other major activity. Programme leaders should insist that such strategies be made explicit. There are several major advantages in doing this with the communication sector. For example, a communication strategy:

Fig. 2. Population programme in Egypt.

Fig. 3. Population programme in Pakistan.

• provides a blueprint for action, showing where the communication sector is supposed to be heading and when;
• helps leaders examine and plan for resource needs;
• forces leaders to set priorities, because everything that might be done cannot be done at the same time, especially with limited resources;
• helps co-workers and staff understand where their efforts fit into the communication programme and the overall scheme;
• promotes co-ordination within the communication component, and among sectors.

What might senior persons in nutrition programmes expect of the communication sector in developing a strategy? First, they should expect those responsible for the communication sector to understand the policy and comprehensive strategy that govern the overall effort. With this background, the communication specialist should start a five step process, as show in figure 4.

Fig. 4

The analysis (step 1) must clearly identify the communication "programmatic" problems. Supervision was an example discussed earlier. In the Masagana 99 case, the first step was gaining farmer acceptance and compliance with new agricultural programmes. In population programmes, it is often a problem of closing the gap between knowledge and practice of family planning.

Analysis of the problem(s) should include careful examination of the target group, the channels available and their capacities (see the summary chart in Appendix 1), and whatever additional background or "situational" information is available that will aid in making intelligent decisions. This includes demographic information on population involved, taboos, data on previous communication programmes, community social structure and typical life-styles, availability of resources, transportation, what the population needs to know, and what their priorities are. In many cases this step will include travelling to communities to talk to people and to observe conditions in the community; systematically gathering data (e.g. research); contacting specialists (such as those in agriculture or advertising); and reading reports and other documents available from ministries, international agencies, and libraries (see N. Rizvi's paper in this volume). From this array of material, a number of alternative approaches to the communication problems can be proposed, along with reasonable estimates of their advantages, disadvantages, and general consequences.

The communication specialist should be able to use this analysis to generate a strategy (step 2). That communication strategy should be laid out on paper so it can be reviewed by programme officials and representatives of related sectors. Putting it on paper should not imply that the strategy is fixed for the life of the project. A strategy must be dynamic for two major reasons: (1) formative evaluation may reveal flaws or suggest alternative actions, and (2) the situation on which the strategy was originally based is constantly changing - especially if the strategy is successful.

Strategy Elements

What follows are the kinds of elements that programme officials should insist be dealt with explicitly by the top managers in the communication sector. Anything less means that the overall programme could be jeopardized.

1. Principal Objectives

The strategy should begin with the principal communication objectives. Some may be quite general, others may be specific enough to be quantifiable. Those objectives that are quantifiable can be used in developing the summative evaluation. Table 1, taken from a health project, suggests the variety of objectives that might appear in a strategy.

2. Best Tentative Solutions

From among those potential approaches identified in the analysis, the communication expert must propose one or several that are most appropriate for the principal objectives. It might be stated, for example, that mass media will be used to build awareness and a climate of acceptance for a new food, while community health workers will concentrate on persuasion and demonstrations in meetings with small groups and families in villages. But the approaches will be integrated.

Table 1. Health project specific communication objectives

1. Change people's attitudes about desirable family size.
2. Inform, educate, and motivate families so they will follow good maternal and child health practices, and will plan their families.
3. Inform people about the availability of maternal and child health (MCH) and family planning (FP) services so that they will know where to get assistance. and so that more effective use will be made of medical clinics.
4. Provide reassurance and support for people who use contraceptive practices, so that they will continue their use.
5. Support the training of the health staffs of public agencies so they can be effective sources and conveyors of information as well as services for the public with whom they have contact.
6. Give communication support to the community promoters who carry out face-to-face motivation, so that their efforts will be both efficient and effective.
7. Create a supportive social climate for the discussion and practice of family planning.
8. Create sensitivity and support among leaders, influential people. and decision-makers for the goals of the MCH/FP project.

3. Audiences

In all audiences, persons should be identified with an explicit statement as to why each is important to the strategy. Often these are clearly specified in the objectives; however, there may be intermediate persons who need to be reached in order to reach a specific target group. For example, to reach high-level officials, it may be necessary to enlist the support of persons working in the mass media. Children may be used as channels to reach parents, or local leaders to reach village men: The use of the word "audience" and "target groups" implies a top-down model for diffusing information. This is not to ignore the potential of indigenous knowledge in the fields of nutrition and health, but a nutrition agency may need to collect and validate that information and then diffuse it from the validating agency. Also, developing a strategy and identifying audiences or the public does not preclude an approach in which community participation is stressed. Some of our experience in India taught us that Indian farmers' resistance to planting new seed varieties could be traced to their wives, who favoured the texture of food prepared using traditional varieties.

4. Media/Channels

In the analysis section, it was important to list systematically all the media available. To this should be added those that might be introduced, since innovative uses of media such as nutri-vans, as illustrated by Solon et al. elsewhere in this volume, and audio cassettes [3] are unlikely to be suggested by identifying only the media existing in a rural community. The task here is to use appropriate criteria for selecting from among those possibilities. Some of the criteria include: appropriateness for the audience, initial and continuing costs, technical support ("infrastructure") required, opportunities for participation, etc. Various media have characteristics that make them more appropriate than others for communication with audiences. Table 2 indicates some factors that influence media selection.

It is important to understand what the best media are for doing particular jobs. UNICEF's Project Support Communication Section in Bangkok has produced a Media Selection Wheel that matches media with communication ("learning") objectives. It also introduces various '' selection factors" such as flexibility of use, equipment required, degree of initial and continuing costs, etc., to help planners make more careful decisions.

Table 2. Media selection

Certain media

• have better outreach than others;
• are more amenable to local control than others;
• are more complex to use than others;
• cost much less than others;
• are more suited to providing a given type of information than others;
• are better at attracting and holding the audience's attention than others;
• are more dependent on special audience abilities for understanding;
• may lack credibility with special populations;
• are more participatory than others;
• have political advantages over others.

Source: Adapted from H.E. Perret, Applied Communications Technology in Rural Development (Academy for Educational Development. Washington. D.C.. 1976).

A worksheet for media selection (fig. 5) provides a simple but systematic scheme for selecting different media. The communication specialist can list the criteria that are most important to the situation, taken into consideration the communication objectives, populations involved, the kinds of information to be communicated, and such factors as speed required and area to be covered. Numbers can be used to indicate how well each of the media listed meets the criteria. There is no absolute numerical total that will tell one which media to use, but this planning operation will assist in making a more rational decision.

5. Theme/Message

The principal content for the communication programme must be identified, and it must be authenticated by the proper technical specialists (for example, agronomists, nutritionists, etc.). At this stage it is usually enough to indicate the major themes that will be used, keeping in mind that it may be important to distinguish between messages designed to inform or reinforce (cognitive), those intended to move a person to action (motivational), and those essential for carrying out actions (behavioural).

It is important to be specific about three dimensions of the content. These are: (1) What is the overall "inventory" of information that audiences need to have to do what is expected of them? (2) How much of this do most of them already have? (3) What is the balance (i.e. the gap between 1 and 2) ? This is the content that needs to be emphasized in laying out the strategy, remembering that even some of what is already known may need to be reviewed or used as an entry point for the newer material.

6. Schedule

The communication activities to be undertaken should be put into a general timetable. Scheduling of themes is influenced by various factors: the logical development of the overall message, e.g. awareness-motivation-behaviour; circumstances of related sectors, e.g. the agricultural calendar, or distribution of health materials, or the deployment of community workers; and so on. This timetable should be developed co-operatively with other sectors.

Fig. 5. Worksheet for media selection.

RS = Radio spots
P = Posters
C = Cinema advertisement
R = Radio programme
FW = Field-workers
IM = Indigenous media
AC = Audio cassette

Fig. 6. Scheduling: messages/media.

Figure 6 is a worksheet for planning themes and media according to different periods in the overall programme. Using the worksheet, the communication people can schedule particular themes for particular periods or phases of the programme.

There are two "facilitating" strategies that need to be included with the overall communicating strategy. These include (1) a plan for mobilizing resources and (2) a plan for doing formative evaluation (research). First, as regards resources, if radio broadcasts (or other media) are to be used, these questions need to be asked: Who will do it? How will it be done? The attempt to answer these questions may suggest some resource needs: a script-writer, performers, recording facilities, money to purchase time, listening group leaders, or persuasive efforts applied to broadcast station officials, etc. These should be carefully calculated and provision made for obtaining the resources before going into the implementation activities that require them. Anticipation of needed resources - from spare parts to training staff will increase the chances of effective communication.

The formative evaluation plan must indicate how information on the communication efforts will be collected, processed, and fed back into the strategy or implementation phases. (See D. Foote's paper on evaluation models in this volume.)

The Remaining Steps

We have moved through the first two steps of the process suggested earlier (fig. 4). The third step, implementation, is the most visible part of the communication sector's activities. This is where messages are designed, posters printed, cassettes distributed, etc. These details are vitally important, but of less concern to high-level programme officials than the more macrolevel planning and strategy process discussed earlier. (See J.E. Andersen's paper in this volume for useful ideas on some aspects of implementation. )

Obviously, the programme official will have an interest in both the implementation and summative evaluation phases, expecially that they be carried out in a manner faithful to the strategy. The results of the summative evaluation (step 4) - if they are to be useful at all - need to be followed by an explicit statement as to future action to be taken (step 5). How, for example, do the results influence the initiation or completion of another strategy, or a decision to restate the communication problem?

Dealing with audiences and channels and messages may seem quite distant from issues such as nutrient deficiencies, diarrhoea, and the weight-for-height charts that nutritionists may be more comfortable with, but it bears repeating that effective communication methods may be as vital to improving the nutritional status of a population as a sanitary water supply or special formula supplements. That is why leaders of community or national nutrition programmes must demand the kind of detailed planning for the communication sector that is outlined above. This leads us to the third responsibility that nutrition officials have.

Mobilizing Resources

It is a rare agency that has all the resources it needs or wants to carry out its mission. The communication sector in a nutrition programme is quite likely to suffer in resource allocations because microphones or cassette tapes or projectors seem less vital than vaccines, vitamins, and medicines. In addition, the health and medical items are more visible symbols of health-care services offered by the health establishment. If, however, nutrition programme leaders have accepted and committed themselves to the first two responsibilities outlined above, it is imperative that they give higher priority to providing reasonable resources for communication activities.

Examination of budget allocations for nutrition and health education communication suggests that these kinds of activities tend to get token amounts of money, or what is left over after other needs have been met. One reason is that, in planning and budgeting activities, there are seldom advocates speaking as forcefully for the communication sector as those speaking for the medical, health, and nutrition sectors and the conventional resources they require. If there is to be effective communication for nutrition in primary health programmes the medical doctors and nutrition experts who are most influential in allocation of resources will need to lobby for additional resources for communication, or increase the priority of communication resources in the competition for what overall support is available.

In addition, more attention needs to be paid to the development of human communication resources within the nutrition establishment. It is a sad state of affairs when persons whose principal activity is based largely on communication have little professional training to do that kind of work. What is the balance between technical training and communication training for those persons who work directly with the public? Too frequently we assume that communication is "natural," and that to have effective extension agents and nutrition aides it is only necessary to provide them with technical information.

What can be done? Nutrition and health officials need to initiate or support efforts to examine the job responsibilities of the people working on their programmes to discover if and where communication plays a significant role in their activities. Does their successful performance depend on effective communication? This was done in Thailand, where the Ministry of Health now uses the phrase "village health communicator" to describe one of the two kinds of health volunteers working at the community level. The re-examination of job tasks should lead to a systematic effort, through in-service training, to upgrade health-care workers' skills for communicating about nutrition and related topics. This should be a priority issue.

In reviewing these three responsibilities for bringing about more effective communication for nutrition in primary health care, it should be clear that senior-level health and nutrition professionals need not change the nature of their careers and become communication experts. But they do need to understand enough about what can be done with communication so that, in their influential positions, they can demand systematic, quality planning and performance from the communication sector, and, given the expectation that it is forthcoming, support resource allocations for both vitamins and video cassettes.

ACKNOWLEDGEMENTS

The author wishes to acknowledge the contributions of Njoku E. Awa, Ronald E. Ostman, Donald F. Schwartz, and J. Paul Yarbrough to this paper.

REFERENCES

1. R.D. Colle, "Tasks Required for Technical Management and Supervision in Rural Health and Development Programs," in The Training and Support of Primary Health Care Workers (National Council for International Health, Washington, D.C., 1981).

2. M.J. Esman, R.D. Colle, N.T. Uphoff, et al., Paraprofessionals in Rural Development, A Stateof-the-Art (Center for International Studies, Cornell University, Ithaca, N.Y., 1980).

3. P. Winichagoon et al., "A Cassette-tape Recorder Technique as an Approach to Nutrition

Education of Rural Mothers in Northeast Thailand," mimeo (Institute of Nutrition, Mahidol

University, Bangkok, 1983).

4. Shawki M. Barghouti, Reaching Rural Families in East Africa (PBFL/FAO, Nairobi, 1973).

APPENDIX 1. Summary Chart of Communication and Education Techniques

Source: Reference 4.

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