In this section we review (i) the determinants that were photographed, (ii) the determinants that arose from the discussions but were not photographed, (iii) how the photographs were used to communicate mothers’ concerns to local level decision makers, and (iv) mothers’ reflections of the process.
Photographed determinants
Mothers identified child malnutrition, mother’s health during pregnancy, and non-communicable diseases as the most significant aspects of child health. Malnutrition among children was of great concern to mothers. Most mothers stated there were different stages of malnourishment ranging from severe to moderate and reported having learned about these stages from health workers. However, they reported that they could not photograph the stages, as they perceived very little difference in physical manifestation of these stages. “We have a lot of malnourished babies but we could not capture this phenomenon well as it is difficult to explain and distinguish their outward manifestation” (Mother 76, Age 24 secondary education, fishing, general caste). Mothers identified the linkage between mother’s ill health and lack of proper care like adequate food, medicine and rest during the pregnancy with the health of the newborn.
Photographs depicted more non-communicable diseases among children, such as physical disability, mental health problems, cancer, and heart problems; in contrast to common communicable diseases like diarrhoea, acute respiratory infections and common cough and cold. “There are quite a few families in my village who have disabled children. But there is no facility treatment for them.” (Mother 12, age 48, secondary education, agriculture, general caste). According to mothers, disabilities and non-communicable diseases are neglected by the health providers and by the community elders. They explained that suitable medical assistance was not available for these conditions.
“This boy has thalassemia. Every time there is a need for blood transfusion, he has to go to Kolkata (nearest large city). Moreover, if he falls sick suddenly, there is no facility at all to provide him a basic treatment.” (Mother 54, age 37, secondary education, agriculturist, Schedule caste)
Mothers identified water and sanitation as one of the biggest factors that affect their children’s health, pointing particularly to the scarcity of fresh drinking water and un-hygienic uses of pond water (Fig. 2). They reported that uneven distribution of the tube wells left them no option but to use water from nearby ponds.
Participants also stated that open defecation is an issue of concern especially for children as they are more prone to get infections from this practice. Even the primary schools and ICDS centres lack toilet facilities, which forces children to defecate in the open (Fig. 3).
Parents’ livelihood was another major issue identified by mothers. They attributed household food insecurity and related malnourishment of children to the uncertain livelihoods of the parents, which increased after cyclone Aila in 2009. They also expressed their concern for the security and care of the children in cases where both parents go out for work, particularly given the risk of drowning in the area (Fig. 4).
Almost all the mothers expressed concern about poor access to health providers and child care sources like ICDS centres). They worried about poor access between islands but also problematic within-village access due to the miserable condition of the roads and the poor availability of transportation (Fig. 5).
The respondents echoed similar concern when they were discussing climate as a factor determining child health. Climatic shocks damage their livelihoods (such as farmland) and destroy their shelters, leading to a direct and indirect effect on the health of the children (Fig. 6). Floods during yearly monsoons increase water borne diseases among the children. Repeated breaching of embankments, erosion of land mass and irregular rainfall indirectly harm the mental and physical well-being of children.
Mothers unanimously agreed on the following social issues affecting the health of mothers and children: early marriage, recurrent pregnancies, and physical stress during pregnancies. During the group discussions, mothers pointed to early marriage as the issue that concerned them the most due to the link between child malnutrition and repeated pregnancies. “This girl is still very young but she is already a mother. Both the mother and child are malnourished.” (Mother 2, age 39, primary education, fisher woman, schedule caste)
Determinants that were not photographed
During the group meetings mothers explained that some important determinants of child health could not be captured through photographs. The first such determinant is the unavailability of the medical practitioners in their respective villages. One mother stated: “We do not have doctors in our village. Even village doctors (informal health practitioners) are not available all the time due to the bad condition of the roads.” (Mother 75, age 32, primary education, fisher woman, schedule caste). Mothers also raised the issue of non-availability of veterinarians for treating their animals, as they are important resources for household food security for the children. “We do not have any veterinary doctor here. In the recent past a lot of livestock have died of unknown ailments and each time we are faced with a loss of the family resource” (Mother 5, age 46, illiterate, crab catcher, schedule tribe).
The generation gap between the mothers-in-laws and daughters-in-laws emerged as an important issue regarding child care. Mothers stressed that mothers-in-laws did not understand the need for general cleanliness of children and their traditional practices during child illness were a cause of concern. “I repeatedly told my mother-in-law to wash the vegetables properly with tap water before cooking the food. But she just won’t listen to me. I have started to prepare food separately for my boy”(Mother 10, age 27, secondary education, housewife, general caste).
Another factor that could not be photographed was domestic violence and harsh treatment from mothers-in-laws. Mothers stated that they usually did not get sufficient rest and proper nutritional care during their pregnancy due to harsh treatment from their mothers-in-laws. As a result, mothers perceived that this led to women giving birth to malnourished children. “The women have to fetch water from a distant source even in their last few months of pregnancy. They force themselves to do so to avoid the quarrels with the mother-in-law” (Mother 49, age 31, secondary educated, agriculturist, schedule caste). Mothers also raised their concern about the fact that some women were even beaten by their in-laws.
Interaction with the local decision makers
Mothers used their photographs as tool to discuss child health determinants through a series of interactions with local decision makers in all three blocks, both at the village level and block level. A total of 138 local decision makers were present in the six interface meetings across three blocks. During the interactions, one representative selected by the mothers presented the significant determinants of child health by displaying the photos through a projector. An important criterion of selecting the presenter was outspokenness and the ability to communicate her group’s concerns effectively to the target audience members.
The number of pictures to be presented for a particular determinant was decided by the mothers as per the available time slot with the local decision makers. Mothers also initiated a discussion with the facilitation of the researchers regarding those issues that they were unable to capture through photographs. During the interaction, mothers not only informed local decision makers of the issues but also initiated dialogue on community-based solutions for the problems. During all the interface meetings, mothers took the lead role in initiating dialogues with the local decision makers. All mothers who presented in the interface meetings unanimously agreed that the photographs were helpful to establish their viewpoints more strongly as proof of their statements.
“As we were showing the photographs, the Panchayat Pradhan [leader] realized that our village’s road is not concrete and gets muddy during the monsoon. He promised to make it concrete before the next monsoon.” (Mother 23, age 33, secondary education, agriculturist, schedule caste)
Additionally, local decision makers provided valuable feedbacks on the problems and agreed to take action or make linkages with other decision-makers. The block level decision makers agreed that the interface meetings provided an opportunity to improve their connection with communities, especially those that lived in hard-to reach areas. Most of decision makers stated that it was helpful to see the photos and hear the community’s perceptions of child health issues to better understand gaps in the existing programmes and develop plans for future programs. An NGO leader in one of the research blocks stated: “It is good to see the problems of the remote pockets of the block, where we usually could not go due to inaccessibility. On this platform we have been able to see, hear and discuss what the community wants and what we can do to solve their problems” (Local decision maker 2, NGO head). A leader of a gram panchayat, the lowest level administrative unit, noted: “The village under my jurisdiction is very remote. I did not know that the road was in such bad condition. I will try to make it concrete before monsoon”(Local decision maker 5, Panchayat Pradhan).
The solutions discussed and developed with the mothers and local decision makers varied from one study area to another. For the issue of child malnutrition, a doctor at an NGO run clinic stated they would provide nutritional supplements to the children of the particular study village: “We cannot address the issue on a wide scale. However, we will try our best to provide the nutritional supplement to the children through the Angwanwadi workers” (local decision maker 8, doctor of a NGO run health facility of a deltaic study village). As a solution to the tube well scarcity, Panchayat members in one village agreed to allocate some budget towards increasing the number of tube wells in the village: “The mothers have raised an important issue. I am glad that they have taken the picture of the issue of tube well scarcity of the village. I will try my best to extend my support in this regard” (local decision maker 9, Panchayat member of a study village).
Frontline health workers such as ANMs and Accredited Social Health Activists (ASHA) also expressed their support by promising to generate awareness among the mothers-in-laws by counselling them separately on hygienic practices and child care.
Local decision makers were unanimous that the community needed to continue photovoice processes at different levels to create greater impact and generate awareness among others for more sustainable action. According to them, presenting photographs provided evidence of the actual situation that the respondents wanted to communicate. They added that organizing similar interface meetings at higher levels would enable district and state level decision makers to better understand community issues. Panchayat members agreed to take the discussion forward with the photovoice mothers in their scheduled monthly meetings. At the same time, local decision makers stated that the interfaces should be taken to the village level, so that the rest of the community members could be motivated by seeing the photographs into communicating their challenges in the same way.
Some decision makers expressed interest in undertaking a similar kind of exercise to express their own perspectives on child health. Local decision makers stated that their perceptions should be compared with the perception of the community “We may take similar pictures but our interpretation would be different” (local decision maker 76, informal healthcare provider of a study village).
Women’s reflections on photovoice
For most mothers, the photovoice project was an experience that boosted their self-confidence. In the course of the project, they went from being hesitant about speaking to voicing their perceptions with clarity and conviction. A few of the initial concerns common to all participants were: feelings of awkwardness in handling an electronic device for the first time; keeping a valuable from an outsider for days; a sense that taking photographs is a man’s job; concern about what would happen if they could not fulfil the project’s goal; feeling inferior for being illiterate; and being unsure whether the results could be communicated to the target audience.
Many of the mothers stated that they overcame these concerns and joined the project because they saw in it an opportunity to articulate their requirements to local decision makers: “Through this technique if we get some facilities that would be a real benefit for our children” (Mother 71, age 34, secondary education, service, general caste). Mothers also stated that photovoice gave them the opportunity to sit together with fellow women to discuss the determinants of child health and come to a consensus regarding the problems. They stated that the entire process of taking photographs, discussing issues in front of others and taking decisions on what to present to the decision makers, was an empowering experience, especially for those who had never stepped beyond their courtyard:
“The process has given us, especially those who have always been confined within the household, the opportunity to discuss things relevant for our children with others.” (Mother 13, age 36, secondary education, service, schedule caste)
“I had never left my island before. But thanks to this process I went to attend an interface meeting with my husband in the block town. I felt good about it.” (Mother 3, age 43, primary education, fisher woman, schedule caste)
Mothers also agreed that being a member of the same community, they usually turn a blind eye to issues like open defection, using pond water or early marriage. However, when they discuss these things with pictures with other women, it generates awareness and consensus amongst them.
“I saw the reality but I was not very clear about the implications. When I saw other’s photos, it was like a realization of some issues that are really bad for our children.” (Mother 20, age 37, primary education, fisher woman, general caste)
Participant also expressed mixed feelings and challenges while doing the exercise. Most of them stated there was no such objection from the families especially from the in-laws.
“I felt good. My family was also supportive” (Mother 43, age 23, secondary education, housewife, schedule caste)
However, some of them reported objections and demoralization from family members. However, most families allowed the daughter-in-law to participate when they realised that their neighbours too would participate and that the discussions would be on child health.
“My husband was very demoralizing at the beginning. I made him understand that when my neighbours are taking part in the same thing through forming a group, why shouldn’t I?” (Mother 57, age 41, secondary education, housewife, general caste).
In some cases, fellow photovoice mother group members spoke to the family to persuade them:
“My mother-in-law was strictly against my participation in photovoice. My husband has migrated to another city. I could not make her understand the importance. She even refused to listen to the persuasion of the IIHMR team. Then a few fellow group members came and counselled my mother-in-law. She then realized that there was no harm in my joining the project as other women from our neighbourhood would be doing the same thing.” (Mother 36, age 21, secondary education, agriculturist, schedule caste)
Nevertheless there was more photographs from the educated voices belonging to the upper layers of society, which was dominated by the general caste women, compared to illiterate and primary educated women from lower castes (i.e. SC and ST). Examining the number of photos taken against the livelihoods of the participants showed that mothers who had their own agricultural holdings and housewives were able to commit more time in taking photographs compared to fisherwomen, crab collectors and daily labourers, who had strenuous livelihoods. We also noted variation in which determinants were captured in the photographs according to participants’ livelihood options and educational status. Housewives, agriculturists and daily labourers photographed water and sanitation issues more often than mothers in other occupations. Crab collectors and fisherwomen gave more stress on livelihood options and embankments respectively (Fig. 7). Illiterate participants focused more on hazardous livelihoods (Fig. 8), while participants with primary and secondary education prioritized water and sanitation issues. Poor access to health services was discussed most by participants with secondary education, although the issue was also captured by the others.