First dive into vulnerability: Testing our approach at Samastipur

*Photographs will be uploaded later due to technical problems.

Over the last few weeks the UCD for U5MR project has moved from working with secondary data in-studio, to kicking off a process of field inquiry. In the process, we have also decided to rebrand it as “Panch Paar”. Panch Paar in literal translation from hindi means- Crossing over five. The nomenclature apart from being catchy, also underlines the project’s focus on the first 5 year critical period.  

The secondary research phase (http://tinyurl.com/qd5qtyn) helped us build a broad context and gave us a clear picture of the gaps in information we had and how those could be filled. Our approach deals with questions pointed towards unpacking knowledge, attitudes and practices that characterise the system beyond those that might have been captured from a clinical perspective. How is child care understood among communities in Bihar? What are the perceived relationships between Nutrition, Sanitation, Hygiene and Health? Who are the key players and influencers that may have a role to play in shaping these knowledge, attitudes and practices? Our field inquiry aimed to unpack these questions both from a household / community perspective, and from the perspective of service providers.

This initial phase of fieldwork, spanning 2 weeks was envisaged as a pilot through which field strategy and approach was to be refined. In collaboration with our design partners from M4ID, we framed a few objectives for the pilot listed below:      

  • Building and testing early concepts around vulnerability, and key peripheral themes: nutrition, sanitation & hygiene, child care.  
  • Conducting different types of research protocols with various user groups rather than covering ground and a large number of respondents
  • Testing of various tools for research including questionnaires, visual tools and  group activities
  • Building a sense of familiarity with the field context and key stakeholders
  • Start to identify and build relationships on field

This blog documents the preliminary reflection on how our learnings on field have informed our approach, and how it might evolve as field work resumes.

Pilot Field Work Overview

  • Locations: Locations for the study were selected keeping in consideration their proximity (Some close and some far) to public health facilities and the socioeconomic conditions of the community. Fieldwork spanned over 12 days across three blocks in Samastipur district: Rosera, Dalsinghsarai and Bithan.
  • Working groups: We would start early in the morning from our hotel aiming to spend between 3 to 6 hours on field depending on what kind of interactions were planned for the day and how far the villages were. At the village, we would distribute ourselves into teams and head out for our interactions.
  • Regrouping and debriefs: We regroup later in the day and have a detailed debrief around the day’s findings and finalize the plan for the next day.

Sample

  • 4 FGD’s- 2 Males + 2 Females (Households with cases of repeated illness)
  • 8 Home ethnographies
  • 9 Depth interviews- 7 FLW’s + 2 RMP’s

Recruitments

For our first day of fieldwork, the ASHA had arranged respondents for us for a group discussion. The idea was to conduct a focus group (FGD) and then follow up with home ethnographies of selected respondents. This approach did not work out well as FLW’s would typically recruit participants they are familiar with which resulted in cases of morbidity and mortality being inadequately represented.

We have now devised some recruitment strategies we will consider going forward. These are as follows:

    • Self recruitment: While the FLW’s are invaluable in helping us make an entry into the village, from the point of view of observing vulnerability, it is more fruitful to identify and recruit relevant participants ourselves.
    • Spot recruitment at vaccination days (VHSND): Gave us an opportunity to interact directly with the mothers coming in and also pre-screen them
    • Village mapping: With the help of FLW’s we mapped the various communities living in the village and individual cases within these communities of morbidity and mortality. We will focus on such cases in the future.

 

 

Focus Group Discussions / Workshops

We envisaged FGDs as a way to capture community knowledge, attitudes and perceptions around four main themes:  nutrition, sanitation & hygiene and care seeking. They were carried out through structured discussion guides paired with activities using visual tools that could help us probe deeper into the themes.

Learnings from our experience of conducting group discussions:

  • Avoid a crowd: crowds become very difficult to manage. At times it’s better to park the car a little further away and walk to the location.
  • Closed room FGD’s: Closed spaces like verandas reduce disturbances and help the moderator manage the group better
  • Presence of FLW’s: Participant responses may be influenced by the presence of FLWs
  • Improvise and conquer: It is easy to improvise a FGD as many people gathered around us. We have improvised many discussions with men groups that provided useful insights.
  • Be alert to participants’ dynamics: in some cases the flow of the activities provoke certain types of responses and interactions. Researchers have to acknowledge that the setting of the activities influence the responses.

Home Ethnographies

These interactions are long detailed conversations with participants inside their homes. They are loosely structured around defined areas of inquiry and last for about 2-3 hours each. There is a major visual element wherein the researcher takes a walk around the house recording artefacts  and practices that explain their everyday life. We also drew floor plans of homes and marked routes and areas of utility and activity.  

Learnings from our experience:

  • Rapport building: Conducting home ethnographies with participants we have already informally interacted with is seen to be more suitable than conducting them with fresh participants due to increased familiarity.
  • Distribution of roles: One researcher does most of the questioning and keeps the respondent(s) involved while the others capture visuals in and around the home.  
  • Guides are not set in stone: Researchers should take note of additional inquiry areas that emerge from the interaction (which go beyond the field guide) which helps us map the respondents life stories. These cues can also be incorporated for future interactions.
  • Organic interactions: Walking around the house and questioning at the same time seems more organic to respondents and proved more informative than a seated interview like session.
  • Visual ethnography: pictures and videos capture in the field tell a lot about nutrition and sanitation issues. It is important to capture the right material and devote time for the analysis of it. The person dedicated to visual ethnography looks at things different while going alone through the house and can come out with questions to formulate to the persons in the house.
  • Certain topics are delicate: There is a need to build intimacy with the participants which requires space and time. Researchers have to ensure the environment in conducive for such an interaction (Male members/ neighbours etc. are not around). These topics can range from gender bias, financial constraints etc.

Interactions with Service Providers

These were structured in depth interviews with ASHA’s, AWW’s, ANM’s and RMP’s. Thorough visual documentation was carried out  to capture all tools (charts, registers, forms and equipments) used by them to perform their roles. FLW’s also helped us to map villages and identify homes with cases of mortality, morbidity and good health for recruitment.

Learnings from our experience:

  • Context building: After the first few interactions with FLWs we realised that we are often perceived as people who have come to test their knowledge and skills. The only way to overcome this, was to explain to them in detail the purpose of these interactions and our expectations.
  • Appropriating their tools: We found that most FLWs maintained hand drawn maps of their villages. We used them to understand the distribution of household not only according to health status of children but also caste and economic status.
  • Encouraging their involvement: FLWs seemed to enjoy doing this since it is highly interactive and gives them an opportunity to display what they know best; their village.
  • Gaining their trust: if the team gain their trust, FLW might not follow in every household which allows for a more intimate conversation with the family.

Observation at Service Sites

We attended a FLW meeting conducted at a Health sub centre (HSC). This meeting is held once a month to review the work of all the ASHA’s and Anganwadi Workers in the panchayat (Village level governing body meetings). Through the meeting we understood the activities of FLWs and also identified areas they excel in as well as those where they face problems.

Research instruments

Projective exercises and visual templates were co-designed by Vihara and M4ID teams, keeping in mind the local context to ensure high engagement levels with the participants.   

The pilot phase was a test run for these tools. Continuous iterations have helped us refine these tools and also in some cases, drop the ones which were not working out.

Projective tools

Projective tools are typically used to let participants respond to ambiguous stimuli to reveal hidden emotions and internal conflicts. We used them to capture deep seated perceptions around various actors and factors within the public health ecosystem. We planned to test 3 projectives with the objective to understand relatability and possible areas of optimization. They were as follows

  • Animal associations
  • Colour associations
  • Nutrition cards

Some of the projectives worked very well, while some needed more contextualization. To ensure the participants understood the exercises, we started with a mock analogy of an unrelated category (using animal associations on various brands of motorcycles) at the beginning. The motorbikes worked well with the male participants. For females we were using cosmetics, detergents and other similar categories to build relatability.

Although the animal associations were relatively easy to grasp, it was not the same for colors. Since the interaction with colors is more abstract, it is difficult to map fixed attributes with them. The responses we garnered were relatively more ambiguous and not very conclusive. We are planning to drop it for now.

Visual Documentation templates

We had set out trying to understand a day in the life of the household by using a template of a large clock which could map the various activities in the household and the roles and responsibilities of each family member at different times of the day.

The clock template worked well as an instrument to record data in a systematic manner which can be repeatedly referred to during the course of our interaction. It provides a snapshot of what each family member is up to at various times of the day.

Another visual template that we created during the course of fieldwork is that of a floor plan. This is immensely useful in understanding the broad structure of the house and the logic behind different spaces. It also throws light on certain spaces that are perceived to be the highlight of the house and those that guests are discouraged from accessing.  

In conclusion

With this field visit we embarked the primary research phase. It was an opportunity for us to better understand life in rural Bihar, pilot various approaches and research methodologies and test our visual tools and field guides. The visual tools supported collaborative research activities, some of them being more efficient than others. The field guides in general work well, but we needed to do some editions to make the narrative flow.

The experience has been enriching and we have a lot to take away from it to study further. We are planning the second phase of fieldwork in Samastipur and in Purnea from mid november onwards.

About pratyusha barua

Pratyusha is a Design Researcher at Vihara Innovation Network currently working on the UCDU5M project (User Centered Design for Under 5 Mortality).
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