Communicating Nutrition in Community Settings

Abstract

With co-existence of under-nutrition and obesity among its people, malnutrition afflicts India like a double-edged sword. The search for solutions has often pointed at ‘Nutrition Communication’ as a tool in alleviating malnutrition. This study, through three case studies in India, attempts to critically examine how various organizations engaged in nutrition communication perceive, develop and implement communicative processes. These case studies typically combined data collection methods like information gathering and interviews. We realize nutrition communication programmes are top-down, expert-driven and are often denied planning, evaluation or budgets. We argue that factors such as the organization’s knowledge of the nutrition problem(s), perceptions of the key communicators, their motivation levels and personal biases also affect the design and implementation of nutrition communication programmes.

Keywords

Nutrition communication approaches institutional perspective case studies

Introduction

Effective communication is a necessary if not a sufficient condition in efforts to promote public health nutrition. Nutrition communication, like health communication, includes those set of communication activities aimed at achieving a voluntary change in nutrition related behaviour to improve the nutritional status of the population (Andrien 1994). Although the literature is replete with success stories of communication strategies in promoting behaviours related to dietary change, lifestyles and a wide variety of health aspects like health smoking cessation, family planning, HIV/AIDS (Bertrand et al. 2006; Hornik 2002; Luepker et al. 1994; Rogers & Storey 1987; Snyder 2007; Smitasiri et al. 1993) among people with high motivation and positive expectations that the prescribed changes will improve their health (Bandura 2004), these campaign strategies have been often criticized on the grounds that they emphasize individualism. Scholars have been questioning the commonly used ‘classical’ approaches in health campaigns because there could be contextual differences in settings where these models are applied and there could be flaws in their application as they are usually based on the logic of ‘scientific rationality’ and are based upon individualistic constructs of health risks (Airhihenbuwa 1995; Airhihenbuwa & Obregon 2000; Dutta-Bergman 2005; Lupton 1994). Therefore, there could be a clear absence of cultural contexts in the conceptualizations of health promotion. Extending this argument, Resnicow and Braithwaite (2001) say that many health communication interventions address what they call the ‘surface structure of a culture’ by matching messages and channels to observable social and behavioural characteristics of a culture (like familiar foods, music, language and places), while it may be more important to address the ‘deep structure’, which reflects the social, psychological, environmental, and historical factors. They argue that when health communication addresses surface structure, it may increase receptivity to and acceptance of the communication campaign, but when it also addresses deep structure; it conveys true salience to the community. As a departure from the classical models of health promotion, the notion of participation has also been increasingly gaining momentum as a means of empowerment and nutrition promotion (Gillespie et al. 1996; Khadka 2000) with a premise that people are the real sources of information in their own development, and that their participation is essential across all phases—planning, implementation, and evaluation (Belbase 1994; Bordenave 1994; Servaes 1996a). But, the challenges for health and nutrition professionals are to create manageable environments for meaningful dialogues, and to communicate action-oriented nutrition messages that reflect the community’s values and realities (Gracia & Henry 2000), so that participation acts as a consciousness changing tool rather than raising consciousness (Dutta-Bergman 2004). However, Khadka (2000) laments that many health and nutrition promotion projects still adhere to program-oriented accountability and largely ignore people’s participation in all or most of the phases of communicative process and thus making participation just a rhetoric rather than reality (Khadka 2000).

Snyder (2007) in her review has indicated that health education and communication campaigns, more so nutrition campaigns, when planned carefully can change a wide variety of behaviours. At the same time, she points out that more research is needed to look into different strategies/approaches—such as targeted informal socialization agents, culture sensitivity and participation—in promoting nutrition behaviours. While this is important, we go a step further and argue that there is an equally urgent need to look into the internal and external factors of the communicating organization, such as the organization’s level of knowledge of the nutrition problem(s), the budget, the perceptions of the key human resources on community participation, their motivation levels and personal biases as these affect the communicative processes.

Given this background, the current article, through case studies of three different organizations, attempts to examine how nutrition communication campaigns and activities have been envisaged and what determines the choice of communication approaches. We also attempt to assess the perceptions of the key people engaged in nutrition communication, in each of these organizations, on planning, community participation and outcomes of the programmes through analysis and discussion of narratives that emerge from dialogues we have had with them.

The Context of Nutrition Communication in India

With over 200 million undernourished people on one hand and over 12 per cent of the population overweight/obese population on the other, the country is facing a paradox (FAO 2001; NFHS-III 2007). Despite a surfeit of programme and policy measures, malnutrition continues to afflict the nation’s development as a double edged sword. Studies in the past have indicated that nutrition communication is the weakest link in many of these programmes (Subba Rao 2009), NIPCCD 1992; Sarma et al. 1992; Vijayaraghavan 2008). Today, nutrition communication is part of many development and health programmes across sectors in India (Heaver 2006; Krishanswamy 2008; Paul et al. 2011). As the National Nutrition Policy, 1993, recognizes that ‘…nutrition affects development as much as development affects nutrition…’, nutritional concerns are being integrated into various developmental policies (FNB 1993, 1995) and programmes being taken up at various levels by the Government. Non-Governmental Organizations (NGOs), international organizations and research institutes are also putting in considerable efforts in taking the message of nutrition to the community. Government organizations engaged in nutrition education and communication activities would subscribe to the larger ‘national priorities’ laid down in the government policy documents, which in turn could have been aligned with the global priorities identified by the international organizations and/or UN agencies. The research organizations and civil society can play a very important role in the formation of public opinion through independent groups or associations. Successful experiments in community settings carried out by research sector and public opinion through civil society groups can reach the government and have an impact on its policies and priorities, while contributing to a change in the overall nutrition scenario of the public. These organizations are significant groups as the public often considers them as independent groups and holds their opinions as credible. Thus they remain to be powerful opinion leaders, educators and communicators for the public (Meshesha 2008). It is a common understanding that different nutrition communication programmes by different organizations are likely to adopt different approaches.

Through three case studies, we aim to provide newer insights about how various organizations perceive, develop and implement the communicative processes to promote nutrition. To this end, we set out explore answers to the following questions—what are the perceived nutrition problems to be addressed by nutrition education/communication efforts, who problematizes nutrition for them and what kind of communicative processes are designed, what their perceptions of community participation are, how they attempt to engage the communities and most importantly how the internal dynamics within the organizations affect the choice of their approaches and implementation of nutrition communication programmes.

Materials and Methods

Sample

Three different organizations from three different sectors were purposively selected for ‘case studies’. The Food and Nutrition Board of Government of India was selected from the Government Sector, National Institute of Nutrition (NIN) from Research and Development Sector, and the Deccan Development Society (DDS) from the Voluntary Sector.

Data Collection

The ‘case study method’ was employed for the study. The ‘case study’ is a research strategy which focuses on understanding the dynamics present within a single setting while studying the particularity and complexity of a single case covering its activity within important circumstances (Eisenhardt 2002; Stake 1995, pp. 1–14).

Table 1.

Profile of the Participants of In-depth Interviews

Organization	Participants	Profile
Food and Nutrition Board	Assistant Technical Advisor	Age: 60 years Gender: Male No. of years with organization: 30 years
	Demonstration Officer	Age: 47 yearsGender: MaleNo. of years: 10 years with 4 years in current position
Deccan Development Society	Founder Director	Age: 55 yearsGender: MaleNumber of years: over 20 years
	Agriculture and Nutrition Scientist	Age: 45 yearsGender: FemaleNo. of years: 8 years
National Institute of Nutrition	Scientist	Age: 53 yearsGender: FemaleNo. of years with NIN: 16 years
	Technical Officer	Age: 52 yearsGender: MaleNo. of years with NIN: 24 years

As suggested by Eisenhardt (2002), the case studies combined data collection methods such as information gathering from archives and in-depth interviews with the key people involved in nutrition communication in each organization (Table 1). These interviews were ‘speech events’ closer to friendly conversation than the stimulus–response model found in a survey research interview. They involved asking questions, listening, expressing interest and recording what was said with the consent of the participants. Questions were open-ended with frequent probes and did not follow specific order (Newman 1994).

In preparation for the semi-structured in-depth interviews, a theme guide was prepared. The theme guide listed the topics around which the interviews would focus: (a) various nutrition communication activities of the organization and target audience; (b) whether nutrition communication was a planned effort with a monitoring and evaluation component, budget and specific objectives; (c) indicators for success of the nutrition communication—as laid out in the programme and/or perception; and (d) community participation.

Analysis

In summarizing each of the organizational case studies, a standardized format (Smith 1997) of highlighting key aspects of the nutrition communication programmes was followed, by documenting the nutrition issues being addressed, objectives, target groups, sectors and/or settings involved, strategies used, duration of the project, results from evaluations (if available) and finally the conclusions of the case study from observations and inferences. Efforts were also made to identify funding resources in order to assess the possible effect of resource constraints. Each case study summary is followed by a brief discussion and conclusions.

Results

Case Study 1: Food and Nutrition Board (FNB), Government of India

About FNB

It was established as part of the Department of Food, Ministry of Agriculture in 1964, as a non-statutory ministerial wing with the objective of diversifying Indian diets for improving the nutritional status of the people. After the Government of India adopted the National Nutrition Policy in 1993, FNB was transferred to the Department of Women and Child Development, Ministry of Women and Child Welfare. The infrastructure of FNB comprises of a technical wing at the Centre, four regional offices and quality control laboratories at Delhi, Mumbai, Kolkata and Chennai and 43 Community Food Nutrition and Extension Units (CFNEUs) located in 29 States (FNB 2008). Each CFNEU is equipped with a mobile van, audio-visual equipment and is manned by ‘technically trained’ personnel. FNB Headquarters, through its four Regional Offices, provides the logistic support for the functioning of these units (MoWCD 2004)

The major activities of the Food and Nutrition board are as follows (DWCD Annual Reports 2002–03 to 2007–08):

Nutrition education and training. Nutrition education for people in rural, urban slums and tribal areas is carried out through its 43 CFNEUs. In addition, each CFNEU organizes training programmes for Master Trainers comprising middle level health functionaries who in turn act as trainers for the grassroots-level health functionaries.

Training of home scale preservation of fruits and vegetables and nutrition. These programmes are aimed at women and adolescent girls and are organized not only to promote consumption of fruits and vegetables but also to strengthen their skills in preservation so that it can serve as an income generation activity.

Monitoring of ‘Supplementary Feeding’ and ‘Nutrition and Health Education’ components of ICDS. The CFNEUs are also responsible for monitoring the ‘supplementary nutrition’ and ‘nutrition and health education’ components of the Integrated Child Development Services (ICDS) run by the Government. The observations of the FNB staff during inspections are periodically reviewed at the headquarters and corrective measures are suggested to the respective states (NIPCCD 1992; Sarma et al. 1992).

Mass awareness campaigns. Events like National Nutrition Week (1–7 September), World Breast Feeding Week (1–7 August), World Food Day (16 October), Global Iodine Deficiency Disorder (IDD) Day (21 October), and Universal Children’s Day (14 November) are organized by the CFNEUs in association with the State Governments, educational institutions, NGOs and the media (NIN 2007). These events are marked by workshops, special programmes and exhibitions.

Mass media. Video spots on various topics like ‘Infant and Young Child Feeding’, ‘Preparation of Instant Foods for infants at home’ and ‘Nutrition of the Girl Child’, etc., are telecast through Doordarshan (the national television channel). Audio jingles on a variety of nutrition related topics aimed at women are broadcast through All India Radio.

Development, production and distribution of educational/training material. Popularization of low cost nutritious foods from locally available raw material is one of the mandates to the Board under the National Nutrition Policy 1993 (FNB 1993, 1995). The field units of FNB develop low cost nutritious recipes from locally available foods and disseminate nutrition messages through posters, popular talks and demonstrations.

Inferences from the Case Study

The nutrition education/communication approach adopted by FNB can be summarized as in Figure 1. Whether it is training of the functionaries or training of the community itself or reaching the message of nutrition to the ‘beneficiaries’ through them, the organization’s approach is ‘top–down’ (Table 2). This model appears to be largely akin with the ‘opinion leader theory’ (Katz & Lazarsfeld 1955), which postulated that interpersonal communication plays a crucial role in channelling and shaping the opinion. FNB’s community nutrition awareness programmes also consider two or more steps in information flow—from the source to opinion leaders, and from leaders to ‘masses’. The programme developers see the malnutrition among the ‘vulnerable’ groups—women and children—as the major nutritional problems to be targeted. Lack of knowledge, among these community members, about nutritious foods, healthy diets and low-cost, locally-available nutritious foods are seen as important reasons for these problems. Therefore, campaign agendas are configured accordingly ignoring people’s conceptions of nutrition and well-being. The community organizing efforts are instigated and led by outside/elite organizers ignoring the engagement of the community itself. Informed by the stimulus–response school of communication, the community is seen as passive respondents to nutrition advocates or trainers who rely on expert knowledge rather than insert lay knowledge into the expert system (Zoller 2005). Even in the context of expert-driven communication strategies, designing of tailored messages has been demonstrated to have increased the relevance of health information to the audiences (Kreuter & Wray (2003)). In case of FNB, there are standardized training programmes on nutrition and health and the communicators carrying out campaigns hardly have any scope for conducting formative research or tailoring the message. Community participation is almost an ‘unknown’ concept among them (refer to Table 2 for views of the key communicators). Moreover, the campaign planners are typically concerned about the numbers (of training programmes, community camps, awareness sessions) and use information heavy-communicative material like charts, posters and flip charts in the community lectures or training of trainers, without considering the varied literacy levels, selectivity in reception, processing and understanding and possible differential meaning making. Valyasevi and Attig (1994) have categorized the nutrition communication approaches, which are dominated by conventional educational approaches that emphasize knowledge transmission and acquisition with an inherent assumption that these would ultimately lead to change in attitudes or behaviours as the ‘Information dissemination’ model of nutrition communication. If there is intermittent use of mass media and educational material like posters in the process of awareness creation, they labelled it as ‘Education Communication’ model. This case study brings to the fore a number of issues like lack of systematic evaluation of the programme on the whole and the communication (rather education) component in specific, complete lack of planned communication effort and an almost elusive feedback mechanism (Refer Table 2). These make it impossible to assess the role of FNB in achieving any knowledge improvement or change in the nutritional status of the community. The key-communicators work against the given targets on behalf of the FNB without any emphasis on ‘learning from the community’ before ‘making the community learn’. There is too much emphasis on the nutrition educator or intervener to create appropriate messages based on his/her expertise and almost instant assessment of the community and its context that he/she is dealing with. This might lead to what Dutta-Bergman (2007) calls ‘othering’ of the cultural participants by portraying the context of the individuals or the community in a system of static categorization that serves as the basis for interventions.

Figure 1.

Flow of Nutrition Information from FNB to the Target Groups—A Thematic Representation

Table 2.

Inferences from In-depth Interviews with Officials of FNB

Themes	Summary/Key Points	Notable Quotes
Nutrition Communication activities and targeting	Emphasis is on training middle-level health functionaries, who are expected to act as master trainers and in turn train the grassroots level health functionaries. Limited staff to carry out training programmes Of late, the mothers’ committee members in various villages are also being ‘trained’ as master trainers. Direct-to-community programmes are aimed at three different groups of audience, namely, mothers of infants, pregnant and lactating women, and adolescent girls. The contents cover locally relevant themes including ‘food fads and fallacies’, ‘nutritious food need not be expensive’, ‘benefits of traditional foods’ and other relevant topics. The target audience for the direct-to-community programmes are mobilized with the help of grassroots level health functionaries—Anganwadi workers. There are often many problems at household level which hinder the participation of women.	We have a standardized training programme on nutrition and health...we also source guest faculty from reputed home science colleges, social and preventive medicine departments of medical colleges or research institutes.About 5 years back, FNB was funding the master trainers to organize second level training programmes for Anganwadi workers, Mothers’ Committees and also Adolescent Girls. But there were instances of misappropriation of finances and hence we have started training the Mothers’ Committees and adolescent girls or the second-level.There is often a problem of men discouraging women from taking part in our community awareness programmes as they (women) would have to forego their daily wages to attend such a programme.
Programme Design and Monitoring & Evaluation	The programme design is uniform for all the CFNEUs. They work against a given target of conducting at least one Training of Trainers Programme per quarter, three orientation training courses per quarter, 10 Direct-to-community Programmes per month, 11 inspections of Anganwadi centres. There is no inherent mechanism for monitoring or evaluation. Evaluation of FNB’s training and communication activity by an external agency is hardly done. One such evaluation was done by the National Institute of Public Cooperation and Child Development (NIPCCD), way back in 1992–93 and 2000.	Only monitoring mechanism that is in place is that each centre has to send reports of the completed programmes along with documentary evidence like photographs to the headquarters in New Delhi. Sending Annual Report of Activities is also mandatory.
Budget for Nutrition Education and Communication Programmes	The staff feel it is too meagre to meet the set targets of training and communication activities set for each CFNEU There is no separate budget for communication activities.	…the annual budget of FNB was a little over `3 crore ($60000) in 2007–08. Now, you can imagine what will come to each unit, which is expected to organize about 4 trainings of trainers, 12 programmes for Anganwadi workers and 120 direct-to-community programmes. But we have to make do with what we get.
Indicators to measure success of training programmes as perceived by them	Pre- and post-course knowledge assessment is carried out by employing questionnaires during the training programmes for middle-level health functionaries In direct-to-community programmes, assessment is done through informal interactions No mechanism to assess whether there was any knowledge gained by the participants or resultant behaviour change	Due to staff constraints, we cannot even go back to the same village once in many years. For instance, we are just five of us (technical staff), supported by five others. Our area of operation includes a vast area. With all the targets that we are expected to meet, we can hardly revisit less than 10% of all villages that we ever went to.
Community participation	The approach in almost all the communication activities is didactic Media preferences of the audiences are not assessed before undertaking programmes. Community participation and community ownership of the programmes are almost unheard of for the Department. The level of participation is only limited to passing on the ‘nutrition knowledge’ to others (middle-level functionaries to Anganwadi workers and through them to rural women).	From my experience, I think they prefer discussions where they can share ideas. But we are hard pressed for time and work with limited staff and shoe-string budgets.

Case Study-2: Deccan Development Society (DDS)—A Voluntary Organization

About DDS

This is an NGO based in Zaheerabad area of Medak district in the south Indian state of Andhra Pradesh, India. Established in 1983, this organization is working in over 75 villages and 5,000 women members and aims to bring the village groups (Sanghams) together into a strong pressure group for women, dalits (socially marginalized) and the poor, and to facilitate debate, discussion and education that will encourage food security, sovereignty and autonomy over local resources. The society claims to be promoting people oriented participative development in the areas of food security, agriculture and education. It is also trying to reverse the historical process of shift in food habits (from traditional millet staples to rice/wheat promoted by the government public distribution system [PDS]), degradation of environment and people’s livelihood system in this region (Deccan Development Society 2009). Listed below are the initiatives of the Society:

Autonomous communities. The women of DDS Sanghams have been actively working towards autonomy over food production, seeds and natural resources. Since 1995, DDS Sanghams have been running an ‘alternative public distribution system’, which is a self-provisioning food system based on local production, storage and distribution of grains. By bringing cultivable fallow land under production, the women have been focusing on mixed cropping, cultivation of native varieties of grains and millets.

Community gene banks. Promoting food sovereignty being one of the important efforts of DDS, over 1,500 women farmers of DDS Sanghams are engaged in growing diverse crops on their marginalized lands. They have established village level Community Gene Funds through which the seeds kept aside from the produce every year are offered back to the villages.

Autonomy over market. Since 1999, the women of DDS have worked on creating a market comprising self-produced food crops. A mobile van selling the locally grown food grains was introduced in 2001 to provide people easier access to the produce (Mazhar et al. 2007). Films on local cuisine and cookbooks using ingredients based on the crops.

Household food security. Through this programme, the Sangham women take charge of large pieces of land on lease from the land owners who were unable to utilize their land for food production. On an average, each Sangham woman member of the land lease group works on the leased land for four to five days a season and in return earns enough food crop as remuneration. This food would last for their families for over a one month.

Autonomous media—the community media centre. The Society conducted video training workshops for women who learnt about recording and editing on simple home video systems. The women made over 100 films on issues ranging from food and seed sovereignty to water and urban displacement. The community FM radio centre is yet another step in this endeavour. With a 100-watt transmitter the radio programmes reach 30-km radius covering up to 100 villages. From 15 October 2008, ‘Sangham Radio’ went on air becoming the first community radio station in India (Pavarala and Malik 2007). The Communication Initiative Network 2009). This radio programmes are made on local foods, health, education, agriculture etc.

Popularizing local foods and promoting the nutritious ones . These initiatives of the society are run through Participatory Rural Appraisal (PRA), which aims at learning from people and helping them spread the knowledge among themselves (Satheesh 2002). To popularize locally grown grains, uncultivated greens, traditional foods and millet based preparations, a wide range of nutrition communication activities were carried out among diverse audience (Table 3).

Table 3.

Communication Activities Employed by DDS to Popularize Millet-based Foods

Communication Activity	Media Used	Target Group	Key Messages
Education on nutritional values of traditional food preparations of the region	Comparative charts depicting the nutritional values of traditional food preparations with millets against the nutritional values of rice, wheat and refined wheat preparations were displayed in schools in villages	School children	Traditional foods of the region (prepared with locally grown coarse millets, grains) are nutritionally superior to those prepared from rice or wheat
Education on uncultivated greens of the region	Specimens of the green leafy vegetables were displayed in the schools and colleges along with their nutritional benefits. Often these were accompanied by a talk by the scientist	School and college students	The uncultivated greens that are consumed in the region are rich in many nutrients as proven by scientific testsNeed to include them in day-to-day diet
Films shows on the traditional foods and their nutritional importance	Video Films made by the Sangham women made in Telugu (the local language): Mana vantalu Mana pantalu (Our Recipes and our Crops) Aaku Kuralu (Leafy vegetables)—4 versions	School and college students and rural women	Traditional foods of the region (with coarse millets, grains)—their preparation and nutritional advantagesThe uncultivated greens consumed in the region are rich in many nutrients as proven by scientific testsNeed to include them in daily diets
Programmes on community radio	Radio talks and discussion programme	Rural women	All the above points along side promoting bio diversity and cultivation of traditional food crops
School visits	Inter-personal communication and group discussions by the rural women, who go round the village and collect the greens and explain their medicinal and nutritive values. Distribution of menu cards. Quiz programmes on traditional foods.	School children and rural womenParents	Less known green leafy vegetables and uncultivated greens which were being used in these areas earlier have medicinal values and nutrientsRecipes with millets and greens
Scientific publications and position papers	Dissemination in conferences, seminars and other forums by the board members/scientists	Scientists, policy makers and development agencies	All the above and related activities of the society
Jatras and community festivals (Pata Pantala Panduga—Traditional Crops Festival)	An exhibition and village celebration where biodiversity, traditional food festivals, local crops and medicinal plants and their uses are all exhibited at village sitesDiscussions and inter-personal and group interactions with people of different villages	All the villagers	All the aboveInformation sharing, exchange views and discussion/interactions on various issues like crop biodiversity, knowledge about traditional foods, recipes and their health benefits

Sources: Salomeyesudas & Satheesh 2009; Satheesh & Salomeyesudas 2003; Schmid et al. 2006.

Inferences from the Case Study

The communication approach being adopted by DDS attempts to be ‘participatory’ since it engages in considering the viewpoint of the local groups of the public (Servaes 2002), DDS focuses on ‘learning from the people’ through a wide range of activities and incorporating these considerations into the programme design. The intent obviously is not to confront the people with their inappropriate beliefs, perceptions or resource constraints, but to use these beliefs to build food security and sovereignty (Table 4). The model also focuses on changing the environment in which people see themselves. Social mobilization is being achieved through creating a local need and demand for change. While doing so the model also seems to underline the understanding that ‘people’ (for food and nutrition communication) does not only mean vulnerable target groups as in most nutrition communication programmes of the state, but involves a cross section of groups within a setting. The role of Sanghams in engaging marginalized groups such as women and subaltern social groups (as Dalits), engaging them, empowering them and making them autonomous by building a sense of belief and confidence in their traditional food systems, foods and recipes as against the ‘elite’ or ‘Government’ ones is significant. The approach in doing so is not only participatory but also culture-centred (Dutta-Bergman 2005, 2007) as the thrust for constructing the problems and exploring the solutions comes from within the communities. Here the role of the NGO is of facilitation through group discussions, community meetings and collective identification of problems acknowledging community’s capabilities to determine sustainable solutions. The Sangam, through focus group discussions and PRA has helped community members critically reflect on their experiences and understand the reasons for failures and success of government’s agriculture, food and health interventions. The alternative PDS (APDS) and the community media initiatives are very much helpful in facilitating the shift from the non-nutritious ‘elite’ foods or ‘Government’ foods (as the local women call rice, wheat, refined flours and others distributed in PDS) to the more traditional millets and greens. The role of the NGO in substantiating the traditional nutritional perceptions of the local foods with validated scientific information on the nutritional values of these foods (Salomeyesudas & Satheesh, 2009; Satheesh & Salomeyesudas, 2003; Schmid et al. 2006), has definitely gone a long way in building confidence of the people in their traditional knowledge. While doing this, the NGO also helps mobilize favourable opinions from various quarters (the scientific community, donors, Government, etc).

However, nutrition communication per se is not a planned effort by the NGO or by Sanghams, but it forms an integral part of the efforts to promote local foods and agricultural practices. This in a way is an outcome of the expertise located within the community and is driven by the community’s understanding of what went wrong in their food system, how the traditional agriculture practices have faded, how consumption patterns have changed, how their traditional foods have been replaced by the ‘government’ foods. The solutions also emerged from within the community to promote the traditional food systems, revive the forgotten crops and greens and through concerted efforts like APDS. The very presence of these alternative voices, location of health and nutrition in the alternative articulation of food security and food sovereignty could build resistance in the dominant discursive space of health promotion. On the other hand this activism (as Zoller (2005) defines it) could build animosity against or resistance to the so-called elite or government foods, eventually leading to rift between an activist community and dominant centres of power.

While the participatory approach allows involvement of the people in programme planning and implementation, the mechanism for evaluation of the impact, effect or effectiveness of the food and nutrition communication programmes appears to be weak or almost non-existent (Table 4).

Table 4.

Inferences from the In-depth Interviews with Key Communicators at DDS

Themes	Summary/Key Points	Notable Quotes
Nutrition Communication activities and targeting	No specific programmes for food and nutrition communication. Food and nutrition forms an integral part of many broader issues like biodiversity and food sovereignty. The approach is participatory and aims at learning from people about their perceptions of the nutritional values of the local foods and helping them spread the knowledge among themselves Although few organized efforts were made to educate/communicate traditional nutrition knowledge to the community (Table 3), group discussions were perceived to be effective means The community radio and film making are important sources of exchange of information. The issues related to food and nutrition and the forgotten millets, less known greens are also presented in these. The Café Ethnic initiative in itself is a method of communicating the nutritional richness of the ethnic food preparations. A typical menu card at the restaurant clearly indicates the ingredients, method of preparation and the nutritive values.	The local classification of nutritional value of foods was based on ‘heat’ and ‘cold’ elements. Based on these, the localities recommend different foods for different human body types and for different seasons. For instance, finger millet is suggested for winter because it is considered a ‘hot’ food. Similarly, little millet is suggested for summers.We learnt from them (villagers) about 200 Green Leafy Vegetables (GLVs) that they use and most of them are unknown to us. We collected people’s views on health benefits of these GLVs and our agriculture scientists got them analysed for their nutritive values only to find that they surprisingly matched with the virtues listed by the women. For instance, if they said that consuming ‘x’ variety of GLV, ‘manchiga raktam padtadi’ (increases the content of blood) we found that it was indeed rich in dietary iron.Food festivals showcasing recipes millets and forgotten greens went a long way in popularizing the local nutrition knowledge.‘Patapantala Parichayam’ (An introduction to the forgotten crops) is an important film made by the women.
Programme Design and Monitoring & Evaluation	The programme design is participatory in nature. ‘Learning from the community’ forms the basis for all programmes. Perceptions of the local people on the nutritional values of the foods and traditional cooking practices are the bases for activities aimed at promoting food security. No specific evaluation was carried out assess the impact or outcome of food and nutrition communication activities.	No we have never carried out evaluation in an organized manner! From the way the traditional crops are grown, foods are consumed and the alternative PDS that has been developed by women, the failure of intellectual, ‘tablet’ kind of communication and the success of participatory approach is reiterated.
Financial allocation for nutrition communication	No separate allocation for nutrition communication activities. The autonomous media initiatives of the organization have been funded by a number of agencies, including UNESCO, but the funding remains limited to providing equipment and training to the women. The issues on which programmes are made would be decided by the women.	The ‘Sangham’ women identify the uncultivated lands in their respective villages, and their sanghams provide loans after wealth ranking is done by the women. The women grow millets and repay the loan. ‘Jowar’ (Sorghum) ration cards are also issued and that promotes consumption of the millets grown.Separate budget for nutrition communication? Cannot tell! It could be about 5 per cent of the total budget depending on the project and who is funding it!
Indicators of success of food and nutrition communication efforts	They (the interviewees) felt that a number of qualitative changes among the villagers food habits and food intakes are attributable to these efforts	The very initiative of the alternative PDS and the growing demand for the millets and traditional recipes in the DDS villages is an indication that the village women have articulated their concern on Nutrition and said emphatically that rice had destroyed their traditional food habits.The sangham shops where the sale of millets has gone up can be seen as proxies to indicate that the consumption patterns and food preferences have changed.
Community Participation	As documented earlier, community participation is the basis of all efforts of the DDS activities. Women play invaluable role in conserving traditional foods and transmitting knowledge about nutritional values of these foods. The traditional knowledge, foods and dietary habits passed on to them (villagers) for generations, are being steadily relegated, marginalised and sometimes undermined by the popular media as well as the Government ‘welfare’ schemes. The participatory approaches employed by the DDS women in documenting this traditional knowledge and spreading it through a string of related activities seem to have established that food and nutrition issues are intertwined with a number of other aspects that relate to ensuring availability, accessibility and use of the foods.	We were surprised to note that when the farmer women of this region spoke about the nutritional qualities of the uncultivated greens or of the millets, there seemed to emerge a regular consensus among groups. For instance the feeling of strength in the body provided by consuming certain greens was associated by many women with the process of blood formation. To our surprise many of the greens that they were referring to proved to be rich in iron. Do they need any external ‘intervention’, we just tried to help them spread their ‘traditional’ knowledge to the others.

Case Study 3: National Institute of Nutrition (NIN)—Research and Development

About NIN

The National Institute of Nutrition (NIN) is India’s premier nutrition research institute, working under the aegis of the Indian Council of Medical Research (ICMR), Department of Health Research in the Ministry of Health and Family Welfare, Government of India. The emphasis of NIN’s research work is on problem-oriented research, with a view to discovering practical solutions to nutrition problems that can be applied within the existing socio-economic framework of the country (Dube 1993, pp. 1–7; Narsinga Rao 2005). The activities of NIN can broadly be categorized in to laboratory research, clinical research, community-based research, nutrition education and communication. NIN’s approach to nutrition research is multi-pronged encompassing diverse disciplines. For instance, lab-based research covers a wide spectrum of areas like bio-chemistry, biophysics, molecular biology, endocrinology, food chemistry etc. Similarly, clinical research covers areas like maternal and child nutrition, microbiological studies and a range of pathology services alongside rendering nutritional rehabilitation services to malnourished children and pregnant women in some hospitals meant for women and children. The community-based studies include studies on prevalence of various nutritional deficiencies, operational research, programme evaluations and others. Information, education and communication, capacity-building through training activities are among the most important activities of the Institute. The main aim of these activities is to take the ‘fruits of nutrition research to the community’ (Dube 1993, p. 6). The wing that spearheads this activity is the ‘Extension and Training Division’. The Division’s activities are multi-pronged encompassing the following:

Nutrition communication research. Community-based research involving both quantitative and qualitative research techniques; media research including target audience segmentation, content analysis, message designing, monitoring and evaluation; use of social marketing strategies; networking with international organizations and other NGOs.

Human resource development through training programmes. The regular and ad hoc intensive training programmes in nutrition, aim to provide the participants with exposure to the latest developments in nutrition science with particular reference to nutritional disorders and strategies for their prevention and control, in order to enable them develop necessary skills to plan, implement and evaluate nutrition programmes; and to enhance capabilities of personnel involved in implementing nutrition programmes.

Nutrition Information dissemination by publishing periodicals and books; conducting nutrition education in various community settings; producing educational aids like posters, charts, instructional CDs and TV films; using print, radio and TV as channels; utilization of traditional folk forms; organizing special events; posters and lectures in a modestly stocked nutrition museum at NIN (NIN, 2001a; Subba Rao & Sesikeran 2011).

Inferences from the Case Study

The institute with its ‘community studies’ arm is one of the chief sources of information to the government on the prevalent nutritional disorders among various population groups in the country, thus carrying out an agenda setting function for the government. The government programmes and plans rely heavily on the Institute’s studies to identify problem areas and vulnerable groups. However, these again get fed back into the Institute’s agenda with Government or funding agencies’ priority areas for action. As NIN operates in tandem with the priorities set by the state–centre of authority, it has to invariably work in a predetermined framework of problematized issues, priorities and solutions. The Institute views promoting food based approaches as a priority for information dissemination, but there was hardly any attempt to understand the larger political and policy issues that led to the shift in the traditional food systems and nutrition transition.

The nutrition communication or education efforts of NIN seem to be in the ‘communication–effects’ perspective, predominantly with an implicit assumption that isolated individuals are relevant behavioural units. Many communication efforts seem to be viewing the effects (in terms of knowledge gain/behaviour adoption) from the sender’s perspective and do not seem to have examined the unintended consequences of communication considering that the individuals are not atomized units unconnected and uninfluenced by the context (Table 5). The term that is repeatedly used by the key communicators in NIN during in-depth interviews with them was the Information, Education and Communication (IEC) approach. According to them, there are three underlying components that promote awareness among the ‘common people’. First, by providing information, that is, facts and issues to the attention of audience would stimulate discussion in extension and awareness programmes. Next, the education component would foster knowledge and understanding of problems and possible solutions through formal and non-formal education. Finally, the communication component by the way of research efforts, tries to influence attitudes and bring about a desired and voluntary change in behaviour (Table 5). However, the nutrition education/communication programmes are still rooted in the ‘extension’ mode and do not seem to address issues beyond mere sensitization, information dumping or awareness creation. The larger perspective of understanding the context of the audience and advocating for creation of enabling environment for bringing about the desired behaviour change seems to be lacking. Therefore, NIN’s communication research projects are usually directed at understanding the uses of different media/approaches to disseminate nutrition messages in different settings and they neither examine these in larger social settings nor make them self-sustaining (as they are not owned up by communities) (Table 5).

Since capacity building and extension activities use inter-personal communication supported by media such as posters, brochures, flip charts and films, they can be broadly characterized under the ‘Education Communication Approach’ defined by Valyasevi and Attig (1994). Some of the research projects of NIN (Subba Rao et al. 2006, 2009; Raghunatha Rao et al. 2007; Vijayapushpam et al. 2009, 2010) entailed limited participation of the community for understanding their media preferences and engaging them to use the communication material for further dissemination of knowledge. Other projects (Vijayapushpam et al. 2008, 2010; Subba Rao et al. 2007 a, b; Subba Rao & Sesikeran 2011; Ramdasmurthy et al. 1978, 1992a, 1992b; Rau 1994) seemed to be subscribing to the two-step/multi-step flow of communication approach by attempting to reach the primary target through ‘agents of change’—like school teachers or student-volunteers, etc. These approaches heavily relied on inter-personal communication and showed that person-to-person communication is still a very effective means of providing nutrition education. They also demonstrated the effectiveness of multi-media approach to complement interpersonal communication. However, conscious effort is made by the communicators or the interveners to entail community participation in communicative processes, but it is only to make the communicative process culture sensitive by conducting formative research, interactions with the potential audience through surveys and engaging them in identifying appropriate media or channels for information delivery (refer to Table 5). This approach again locates the expertise outside the cultural spaces of the audience and the experts are typically removed from the actual context. But the selection of specific communication approaches by the communicators here is not primarily based on their analytical or normative values, but rather, on institutional factors and expectations such as the logistic compulsions, limited manpower, prospects of getting financial support, clearance from SAC and career upgradation.

Table 5.

Inferences from In-depth Interviews with Key Communicators in NIN

Theme	Summary/Key Points	Notable Quotes
Nutrition Communication activities and targeting	Activities are multi-pronged involving simple information dissemination, training, as well as nutrition education and communication research. While unstructured nutrition communication programmes/IEC activities are usually aimed at diverse groups of audiences, the communication activities carried out among various communities as part of the research projects are specifically targeted. However even in unstructured extension programmes, ‘suitable’ media (as perceived by the communicators) are chosen to ‘convey’ the messages to different target groups Human resource development through nutrition education in structured training programmes as one of the important activities of the Extension and Training Division that spearheads the communication activities of NIN	I can divide the nutrition education and communication activities that I undertake into two categories—structured and unstructured. Structured Communication activities are those done as part of our research projects, which involve planning, collecting baseline data, communication material preparation, pre-testing and communicating, etc., the unstructured ones are like the community awareness programmes, lectures, radio talks, conducting exhibitions, etc., in different community settings.For instance, when community awareness lectures are carried out say in villages or slums, there is likelihood that men, women and children from different sections attend. Our lectures should cover all aspects for all groups. But I am not sure how well they are received by each group! (smiles...)Communication in research projects is usually structured and targeted. For instance my earlier research projects dealt with school children, then, obviously their teachers and school children themselves were our target audience. When I dealt with the University student-volunteers, though our focus was to reach the rural and slum-dwelling women, our primary target was student volunteers who in turn were expected to take the message of nutrition to the women. So it varies from project to project.I try to use suitable media to different target groups. It usually depends on the education level of the target groups. For example, for school children I have been using CD ROMs, slides and charts coupled with lectures. For student volunteers I used, folk art form in a recent project, otherwise I use folders, charts and flip charts. When dealing with women I use flex sheet charts and flip charts as support to the interactive discussion method of information sharing.
Programme Design, Monitoring and Evaluation	No specific programme design for the Institute’s ‘routine extension activities’, which involve community awareness programme, radio talks, extension talks, exhibitions etc. However, nutrition communication research studies have a specific programme planning and they differ from project to project. The study protocols are usually approved by a group of experts in the Scientific Advisory Committee (SAC) of the Institute. The respondents agreed that many of the recent studies have dealt with knowledge dissemination using different media and assessing the impact of such nutrition education/communication on knowledge levels of the ‘study subjects’. The training programmes of the Institute have an in-built mechanism for periodic evaluation of course structure, content, utility, perceived benefits etc. It is usually carried out using ‘appropriate’ instruments like questionnaires, which are administered to the participants at entry and at immediate post-training period. Over a decade ago, some follow-up evaluation studies (by Mohanram et al. 1997) looked into the perceptions of the trainees on relevance of the course in their day-to-day functioning after joining their official positions. None was carried out in the last one decade.	The study design was in a way similar in some of my recent studies. They all involved baseline data collection, (usually) based on knowledge about the nutrition topic of interest, identifying lacunae in knowledge, development of communication material, using it as an intervention and assessing its impact in terms of knowledge improvement.
Budget for nutrition communication activities	Funding for the research projects is either from “intramural (from ICMR or NIN sources) or extramural sources (other external funding agencies)”. So far many nutrition education and communication research projects have been funded from internal sources No special allocation is made in annual budget neither for routine extension nor communication activities except for printing of books and training programmes. Need based allocation is made based on the extension activities proposed from time-to-time.	So far all my research projects, for that matter almost all the research work done in the last decade was funded from intramural sources. Once the SAC approves a study protocol; it will get some sanction from the Institute’s funds. However, if the amount is really high, then they (SAC members) suggest that we should try out elsewhere. For my studies, although I faced some problems of inadequate funding I resolved them with the help of my superiors.
Indicators/Measures of success	No specific efforts to measure success of extension activities The communication activities carried out as part of structured communication research projects have a set of indicators to assess the impact/success. Usually it is knowledge improvement, which is analyzed using knowledge scores.	It’s often difficult to estimate success of an extension activity like a lecture or an exhibition or community awareness programme. If such programme can result in a positive change in their behaviour or lifestyle, then I consider it successful… when we seldom get an opportunity to visit the same place or meet the same group.In most research projects, if there is statistically significant improvement (in knowledge scores) after the education/communication intervention, we conclude that it has been successful.
Community Participation	Very little scope for community participation. However, they are consciously putting in efforts to make even the routine extension activities, interactive and relevant to the audience. Various research projects have varied levels of community participation. However, it is largely elusive	In fact community participation is limited to interacting with them. From my side, I try to do need based communication. Most of them (audience) are illiterate, they hardly have any knowledge of nutrition; how can we involve them?In the current project dealing with student-volunteers and rural women, we made efforts to understand their media preferences and design the communication material accordingly.In some school-based nutrition education studies, we involved teachers right from the beginning, teachers were trained in the media they preferred, they were involved in preparation of educational material and they were actually asked to adopt the same material to the school children.

Discussion

The three case studies presented different institutional perspectives on nutrition communication. Although nutrition communication is one of the primary activities of both FNB and NIN, the methods adopted are predominantly rooted in top–down approaches with information dissemination as an important objective. The capacity building and community oriented extension activities of NIN or the awareness programmes and demonstrations of FNB largely adopt inter-personal or face-to-face communication aided with a range of small media (like folders, charts and folk dance forms in local languages). Many researchers have concluded that inter-personal or face-to-face communication is widely used and plays a key role in health communication (Poitrow et al. 1997, p. 189). Smith (1997), who analyzed nine case studies on nutrition communication approaches in different countries, concluded that ‘it is generally agreed that interpersonal methods conducted in local communities are appropriate to address the common problems of nutrition, and no doubt will continue to be, a major focus for nutrition education programs’.

Given the fact that most studies by NIN have aimed to look at short-term effects of communication and education activities, it can be argued that this perhaps is a valid approach as Yarbourgh (1981) in his review of ‘Communication Theory and Nutrition Education Research’ argues, ‘despite the limits of communication effects approach, it is probably unexcelled for evaluation of relatively short-term communication and education campaigns. This approach provides a relatively simple way to determine who responded in what way to our efforts’.

Although DDS adopts participatory approach, its primary focus is not on food and nutrition. The organization views food and nutrition communication as one of the tools to engage women in achieving the broader goal of women empowerment. The food and nutrition communication efforts are largely concentrated in reviving the traditional agriculture practices and thereby the traditional food habits in the region. This model truly meets the participatory approach, described by Boeren (1992), by stimulating critical analysis, to develop confidence and awareness by organizing groups and communities. Likewise, Servaes (1996b) says that participatory development requires the acknowledgement that the ‘receiving community’ has the knowledge and ability to develop themselves and their environment. But others (Brownlee-Greaves 1999; Dudley 1993) have raised concerns about placing a great amount of knowledge and capacity within the hands of the ‘community’, which sometimes needs external inputs for ‘right’ awareness.

It is possible that the participatory approach adopted by DDS is successful because of the limited area of operation of the NGO and its Sanghams. But this evidence is barely enough to conclude its effectiveness on a broader canvas. This seems to be an inherent limitation of participatory approaches to development communication (Waisbord 2005).

One question that needs to be explored is whether the results from this community empowerment and participation project be trickled up or trickled-across, resulting in the uptake of the people’s knowledge into the health and nutrition science as well as policies or movement ‘across’ into other settings. There could be persuasive explanations and findings about ‘what works’ in small-scale community projects but the concern about scaling them up for broader application still persists.

Yet another important observation is that most of the nutrition communication activities of all the three organizations lack evaluation components right from the planning stage. This makes it difficult to attribute any change be it in behaviour or in improvement of nutritional status to a particular communication process. The evaluation component present in the research projects of NIN in a way makes it possible to attribute change in the identified variables to a particular communication process in empirical terms, but this is obviously absent in the approaches adopted by other two organizations.

However, nutrition being an almost ubiquitous topic in developmental and health programmes of many organizations in the country it should be understood that there is a multitude of players, campaigns and messages from different quarters bombarding the community members. As Wittea et al. (1996), point out, different communications about health could either create chaos or can independently work together or have an synergistic effect to influence health and/or health related behaviour of individuals or communities. On the other hand as Cho and Solomon (2007) indicate, they could have varied unintended effects such as obfuscation, dissonance, boomerang, apprehension and desensitization.

The current study is constrained due to the fact that the audiences that have been targeted by the nutrition communication programmers in the above cases were not interviewed and their perspectives regarding the campaigns, messages, channels and meaning making could not be ascertained. However, the study indicates that it could be worthwhile to delineate the implementers (like the Demonstration Officers, educators in FNB) and interveners (like Scientists and Extension Personnel of NIN) from the programme developer (communicators or organizations) as the ultimate execution of the communicative process rests on the shoulders of the implementers/interveners who only act on behalf of the organization and they may or may not be as passionate or motivated as their programme developer. Our discussions with them (refer to Tables 2 and 5) indicate that they are usually concerned about targets, bureaucratic dynamics, institutional procedures, their individual ideological convictions, career upgradation, etc.

Summary and Conclusions

From these case studies, it can be concluded that the institutional goals and dynamics and budgetary constraints determine the use of communication approaches. The selection of specific communication approaches is purely based on institutional factors and expectations. The bureaucratic requirements and target-oriented tasks favour the use of informational models in FNB leaving no scope for participatory approaches to communication. The standard institutional procedures of NIN in a way are based on the understanding and use of communication as a set of technical skills to disseminate messages. Behaviour change appears to be the ultimate fix of communicating nutrition information ignoring local knowledge, with apparent assumptions—‘people are not aware’ or ‘what they know is wrong’. Despite the cross-pollination of models and multi-strategy interventions, the institutional choices of approaches to nutrition communication seem to emphasize on individual knowledge changes (with an assumption that knowledge gain would lead to behaviour change), while underplaying the need to address larger political/policy issues that affect the quality of life. This location of the behaviour in the individual is problematic because it ignores the role of context and structure in which the individuals exist, and is only cognitively oriented. Such approaches continue to be mainly concerned with measuring the success of different ‘intervention strategies’. These diverse intervention strategies have often been seen as alternatives to extant nutrition communication approaches.

In efforts related to promoting nutrition, communication’s role should be seen as beyond merely producing materials for information dissemination or as a mere optional line in the programmes, but it should become a fundamental component of all health and nutrition programmes, with appropriate provision for budget and a strong evaluation component incorporated right at the planning stage.

Examining the context in which the organizations function, for government and research organizations, the framework is created by the centres of authority (such as state, UN agencies or funding agencies), which often define, problematize nutrition priorities and frame solutions. The institutions in different sectors that operate in tandem with the priorities set by the state or centres of authority have to invariably work in a predetermined framework. They are usually dogged by factors like bureaucratic dynamics, institutional procedures, ideological convictions of the policy makers, available funding, power hierarchies and changing national and international health priorities. Juxtaposing these with DDS’s participatory approaches that base themselves on articulations that emerge from within the cultures, one finds that the problems or priorities are configured and reconfigured by the community and solutions emerge from within the context in which the individuals function. In such a case the organizations become mere facilitators. However, if the priorities or solutions emerging from the community are not in tandem with those problematized and prioritized by the dominant centres of authority, conflicting messages could emanate and throw people in quandary. The centres of authority (such as state), which often define and problematize nutrition priorities should at least cease from framing solutions so as to create an environment for the organizations to explore and experiment with various approaches. If this is not done immediately, the current dichotomy of some efforts aiming to preserve and strengthen local beliefs/practices and the others aiming to almost replace them with ‘scientific’ knowledge may end up in causing mere cacophony of conflicting messages rather than alleviating people from the maladies of malnutrition.

It will be a worthy effort for communication researchers to understand how various socio-cultural and economic considerations influence the choice of approaches for communicating nutrition information. Considering that the nutrition communication processes are largely determined by the choice of approach, which, in turn, is determined by the context of not only the community members but also the organizations and the implementers/interveners who work on their behalf, there is a need for expanding the locus of nutrition communication research to study all these. In doing so it could be worthwhile to delineate the implementers and interveners from the programme developers and analyze how their motivation levels and personal biases affect the communicative processes.

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