STRATEGIE PROM

OR

PRODUCllON, CONSUMPTION, & SUPPLEMENTATION

four Case Studies

Edited by Renata E Seidel

Produced by The Academy for Educational Development

February, 1996 Washmgton, DC

Funded ;ointly by The Nutrition Commumcation Project, The Commumcation and Marketmg for Child Survival Project, and

The Opportumties for Micronutnent Interventions Project Office of Health and Nutrition, Bureau for Global Programs, Field Support, and Research, Umted States Agency for International Development

Table of Contents FOREWORD .............................................. ........... iii ACKNOWLEDGMENTS ............................................. iV

INTRODUCTION .................................................... 1 Margaret Parlato, Renata Seidel

~ase study 1 NIGER Promoting Vitamin A in R:ural Niger: Strategies for Adverse Conditions ...... . 1 Margaret Parlato, Peter Gottert

case stnfy 2 PHILIPPINES Moving to a Long-term Strategy: Increasing Vegetable Gardening and Consumption in the Philippines ............................ 27 Florentino Solon, Henry Briones Jose Rafael Hernandez, Lonna B. Shafritz

case study 3 INDONESIA- ROVITA The Use of Integrated Media for Promotion ofVitamin A Capsule Consumption in Central Java, Indonesia ........................... 43 Thomas K. Reis, Renata E. Seidel, Sartono, Sudaryono, Anne Palmer

case study 4 INDONESIA- SOMAVITA Vitamin A Promotion in Indonesia: Scaling up and Targeting Special Needs .................................... 55 Willard D. Shaw, Cynthia P. Green

FOREWORD

The United States Agency for International Development (USAID) has been mstrumental in supporting research and programs which have established the importance of vitamin A for child survival. If children in developing countries are provided sufficient vitamin A to meet their needs, as many as 4.5 million can be saved during the five years remaining m this cen­tury. A significant number of children will also be spared from blmdness or mcreased sever­ity of common respiratory and diarrheal infections.

Thus, the important question is how to ensure that these children receive sufficient vita­mm A. This can be achieved through a number of complementary approaches including improvmg production, access, and utilization of vnamm A-rich foods; periodically supple­menting the diet with high-dose vitamin A capsules and other pharmaceutical preparations; and fortifymg commonly consumed foods. USAID is actively supportmg efforts to improve the vitamin A status of children by work.mg with institutions m Asia, Africa, and Latin America to promote an optimal mix of these approaches in individual countries.

As described m the followmg four case studies, experiences m three countries-Niger, the Philippines, and Indonesia-reflect the critical importance of focusmg on behav10r change to achieve success in these programs. The principles of behavioral science and soCial mar­keting have contributed to the systematic approaches used in these and other health programs around the world. These examples provide insights for the many other countries that share similar challenges. Moving from such lessons to successful programs brings ever nearer the achievement of the global year 2000 goal of the elimmanon of vitamm A deficiency as a pub­lic health problem, and the consequent saving of millions of children's lives.

!{1 lJ~ DavidOoT Director Office of Health and Nutrition U.S. Agency for International Development

lill

ACKNOWLEDGMENTS

Preparation of these case studies was supported by the United States Agency for International Development (USAID), Office of Health and Nutrmon, under the Nutrmon Communicat1on Project (Contract No. DAN-5ll3-Z-00-7031-00) and the Communication and Marketmg for Child Survival Project (HEALTHCOM), (Contract No. DPE-1018-C-00-5063-00). Both projects were conducted by the Academy for Educational Development. Publication was supported by the Opportunmes for MICronutnent Interventions (OMNI) Project (Contract No. HRN-5122C-00-325-00), managed by John Snow, Inc This publication was produced by the Academy for Educational Development and does not neces­sanly represent the views ofUSAID It may be reproduced 1f credit 1s given.

SpeCial acknowledgments are due to Dr. Eunyong Chung and Dr. Melody Trott m the Office of Health and Nutnt10n for theu v1s1on m puttmg together a jOIIlt publi­cation summanzmg the expenence of two different USAID projects m promotmg v1tamm A. Dr Frances Davidson, Chau of the M1cronutnent Workmg Group, assured its production.

The authors also wish to acknowledge the contnbut1ons of the many md1v1duals and organ1zat10ns who collaborat­ed m conductmg the projects m Niger, the Ph1lippmes, and Indonesia. The work descnbed here 1s the result of theu dedication, creativ1ry, and hard work m findmg ways to improve nutrmon-related behav10r In particular, the authors would like to acknowledge the followmg people who were mstrumental m the design, implementation and evaluation of the projects

Niger From the Ministry of Public Health: Atssa Mamadoulta1bou, A1ssata Gmmba, Habou Kalla, Zemabou Mohamed, and Mounkeila Abdou From the Ministry of Agriculture: Ousmane Abdou From Tahoua Department: Xavier Crespm From Radio Tahoua: Hach1m Mohamed. From the National Center for Health Statistics: Moukeila Abou From Helen Keller International: Else Sanogo-Glenthoj, Issa Camara, and Brah Ferdows From the Academy for Educational Development: Nancy Keith International Consultants: Man-Mmg Hung, Hughes Kone, Rebecca Popenoe, Dandara Kame, Shawn Baker, and Stanley Yoder Thanks to USAID/Niamey for fundmg these efforts and for theu support at all stages Sylva Euan, Carl Adbou Rahmann, Charles Hab1s, and Nancy Lowenthal.

IV

The Philippines From the Vitamin A Expert Group (VAEG): Florentmo S. Solon, Gerardo Bayugo, Demetna Bongga, Rodolfo Florentino, and Rolf Klemm From the National Micronutrient Action Team (NMAT): Jaime Galvez-Tan, Carmencita N. Reod1ca, and Elsa M BayanI From Cagayan de Oro City: Pablo P Magtajas, Ory Mayor, and members of the Cny Council From the City Improvement Office: Ernesto Alepdo, Peter AbejO, and Ledelmma Chua From the Health Department: Rico Jacutm, M1ravel Tangcalagan, Nenita Rabe, and Esperanza Pimentel From City Social Services and Development Office: Elsie Q Labuntog and Myrna Replagao From the Department of Education, Culture, and Sports: Lourdes Pabayo, Virgilio Jumamoy, Gil Constantino, Ysmael Pacana, Lita Munllo, and Edith Lago. From the City Agriculture Productivity Office: Carlo Magno Raagas and Myrna Arrabaca From the Nutrition Center of the Philippines: Laura Tantoy and Bernarda Ueno From the Academy for Educational Development: Willard Shaw, Joseph D1edench, and Robert Letourneau. From USAID/Manila: Patricia Moser and Marichi de Sagun Thanks to USAID/Washington for fundmg these efforts and for their support

Indonesia Among the several thousands of people who helped carry out the v1tamm A acnvmes m Indonesia as descnbed m this document are from the Directorate of Nutrition: Benny Kodyat, Dm1 Lanef, Asm1ra Soetarto, and Suherno From the Center for Health Education: Ida Bagus Mantra and Ruflma Rauf From Health Education/Central Java: Victor Sartono From Community Health: W1dyastut1 W1b1sono and Tnhono. From Fatayat Nadhlatul Ulama: Sn Mulyat1 Asron and Lisa S1aiful From the Diponegoro University: Satoto. From Helen Keller International: Anne Palmer, Steve Wilbur, James Johnson, and Barbara Scholz From the Academy for Educational Development: Tom Reis, Willard Shaw, Mark Rasmuson, Tjep Marku, Indrawatl Josod1ppoero, and Dew1 Widanmgs1h

Cynthia Green and Ronald Parlato put together early drafts of the case studies (Dr. Green for the Ph1hppmes and SOMATIVA, Mr Parlato for Niger) A note of apprec1anon also goes to Amanda Robbms (Academy for Educational Development) for her admm1strauve assistance

INTRODUCTION

ADVANCES IN OUR UNDERSTANDING Of VITAMIN A

In the past decade our appreciation of the impor­tance of vitamin A has grown dramatically. Once valued prmcipally for its role in preventing blmd­ness, vitamm A has been shown by recent scientific studies to increase the body's ability to fight infection and to contribute m critical ways to reducmg child mortality. Vitamin A affects the course and outcome of infectious diseases. Without adequate levels of its protective effects, episodes of diarrhea last longer and childhood illnesses tend to be more severe. In com­munities where vitamm A deficiency 1s common, 23 percent of child deaths have been directly attributed to a lack of the nutrient.1 Furthermore, recent stud­ies suggest a strong assoc1at10n between the vitamin A status of HIV-infected women and reduced trans­mission of the virus from mother to infant.2

Despite advances m our knowledge about the many stnkmg benefits of vitamin A, progress in elimmatmg its deficiency among affected popula­tions has been disappointingly slow. Half a million children become blmd each year and another 231 million are more vulnerable to infectious disease because of inadequate v1tamm A in their diets, resulting in millions of preventable child deaths.3

To date, public health planners have focused on four approaches to addressing the problem:

Margaret Parlato

Renata Seidel

• supplementing the diet with high-dose cap-sules and other pharmaceuticals;

• fortifying commonly consumed foods;

• promotmg changes in dietary practices; and

• improving product10n of and access to vita­min A-rich foods.

Many factors determine what strategy or combina­tion of strategies is most appropriate for a particu­lar country at a particular pomt m time. National programs often employ a mix of strategies depend­ing on the availability of foods in different regions, the status of the food industry, the possibility of increasing production of selected foods in a range of horticultural zones, and the likelihood of increasing consumption among those at greatest risk. Recognition is increasing, however, that food­based strategies are fundamental to long-term pre­vention of vitamm A deficiency.

APPROACHES TD CHANGING BASIC BEHAVIORS

The four case studies mduded here illustrate how communication programs can be designed to improve vitamin A status m different contexts by applymg the principles of behavioral science and social marketmg. These projects, which were funded by the U.S.

I

Agency for International Development, all used a sys­tematic methodology based upon audience/situation research and rigorous plannmg. The different mter­ventions aimed at promotmg carefully selected behav­iors that would increase the VItamin A intake of at-risk populations. Type of program, cultural framework, and foods available in the target areas varied widely, as did the resources available for these interventions.

The Niger case study looks at a pilot proJect to test ways of diversifying food production and family diet under difficult climatic and horticultural condmons. The Philippines study exammes how planners aimed to promote both production and consumption of green leafy vegetables m urban areas, as part of a new national emphasis on dietary solutions to vitamin A deficiency. Two case studies focus on Indonesia. The ROVITA study looks at communication approaches to improve capsule drstnbution. The SOMAVITA project-which followed ROVITA-was a bold three-pronged national effort to test models to change vitamin A consumption patterns; to improve capsule drstnbution nationwide with an emphasis on high-risk provmces (in order to address the immedi­ate problem); and to develop NGO drstnbution and promotion systems in urban areas.

The scale of these projects vaned from a small expenmental effort m Niger reachmg 250,000 peo­ple, to a multi-level program in Indonesia covering a national population of 179 m1ll10n in the capsule distribut10n component and 2.2 million in the dietary change pilots. Lessons learned from these projects are quite different. We hope they will be useful to policy makers and vitamin A program implementors, and can be applied to new contexts.

LESSONS FROM THE FOUR STUDIES

Foods Promotion

Dietary change Interventions are most effective when tailored to well defined geographic areas. Distmct agricultural or cultural zones require strategies geared to those local realities. SOMAVI­TA research revealed that a national program with

I

generic messages was probably not feasible. No sin­gle food could be found that was suitable across provmces Instead, program planners developed a framework that enabled each province to select Its own vitamm A "target food."

Food-based approaches should only be designed when research has shown that mcreasmg produc­tion and consumpt10n is feasible in the particular target area. In the Phrlrppmes and Indonesia, mex­pensrve plant sources of vrtamm A were available year round. In Niger, however, availability was an issue. More costly animal sources of vitamin A had to be promoted during one season m order to cover needs over a 12-month period. Researchers estab­lished that families had disposable mcome during this critical penod following the harvest.

A single food per se is challenging for a foods promotion program. The potential for "taste fatigue" m the audience and vagaries of the seasons

Promoting several toads is a more complex task, hut raises the likelihood at increased consumption.

and the market create maJOr obstacles. Pro­monng several foods rs a more complex task, but raises the likelihood of In­

creased consumption In the Phrlrppmes, the difficulty of focusing messages on several foods was

resolved by turnmg five vegetables mto one product via "MACK-P"-the acronym for these different vitamm A-rich sources. Niger dealt with this dilem­ma by featuring different foods for each season.

Selection of the "nght" foods calls for careful market and audience research. Pertment issues include seasonal availability, vrtamm A content, cost, consumer acceptance, ease of preparat10n and time required, and current consumpt10n level and the possibility of increasing it. Identifymg the nght foods to promote necessitates invesngatmg a range of market, economic, social, and nutnt10nal issues. To avoid getting lost m the sheer complexity of these issues, program mangers should artrculate the specific quest10ns they need to answer.

Communication planners m the programs high­lighted here were able to identify foods which satis­fied these cnteria. However, one difficult "selection" issue emerged. Parents hold firm beliefs about what young children can digest, or what foods are appro­priate for the weanmg age child. In particular, green leafy vegetables (which are a prime source of vitamm A and usually among the best products in terms of availability and cost) are often not fed to this critical group. Messages must address mothers' specific concerns about feedmg selected vitamin A-rich foods to their children. Planners must also adjust their expectations, and not rule out alternatives, (such as animal sources of vitamm A or more expen­s1Ve fruits) when resistance is strong.

Commg up with practical ways to improve vita­mm A intake depends on good consumer pretesting of each candidate food. Messages must also be pretested once foods have been selected. For exam­ple, the Niger program did not reqmre mothers to eat more food m a context where this would seem unreasonable to them. They were rather encour­aged to feed children certain foods more frequently, thus achievmg the same result. Similarly, mothers were not asked to increase the amount of certam mgredients in given recipes, because this too would have seemed unacceptable to them.

Changes in food consumpt10n patterns require shifts m deeply ingramed family habits and cultur­al norms. Programs lasting a smgle year or two may be able to improve targeted behaviors over the short term. Long-term shifts, however, require consistent efforts and momtoring of impact over several years.

Capsule Programs

Capsule programs lend themselves to large, well­conceived nat10nal promotion efforts. Message consistency across broad geographic areas can increase impact (quite unlike the case for dietary change programs). For example, standardization of capsule distribution months-at six-month inter­vals-allowed the SOMAVITA proJeCt to create an "umbrella'' media program at the national level and

INTRODUCTION

helped focus and conserve promotion expenses. At the same time, decentralizing promotion efforts to the provmcial level (through traming and seed grants) supported tailored commumcat10n activities.

A communicat10n program can only be as effec­tive as the service delivery system it supports. The ROVITA and SOMAVITA projects found that tak-

Capsule programs lend themselves ta large, well-conceived national promotion efforts.

mg a consumer per­spective when exam­mmg distnbut10n issues (such as urning and location of cap­sule distribution) altered the way the program should be organized. Studies

showed that only 50 percent of villagers had local health posts where they could obtam capsules. Although the government was committed to expandmg this system, officials also looked square­ly at the current reality and began to mvolve NGOs in house-to-house sweeps and experimented with other new ways to get the product to children

Commitment by service providers is also cntical to

program success. Mid-project monitoring of the SOMAVITA capsule program revealed that govern­ment health workers remained concerned about the safety of various aspects of the new distribution sys­tem, which they believed might lead to some children receiving extra doses. The project therefore developed a booklet for providers on the "Safe Use of High-Dose Vitamm A" to assuage fears about toxic overdose.

Selecting Target Audiences

Every behavior change program must look careful­ly at who makes decisions relative to the actions being promoted. If planners hope a woman will go to the local health post, research should look at who might mfluence her gomg (the husband? a neigh­bor?) In programs which address family food pur­chase, consumption, and distribution patterns, the role of men can be key. The Niger ptoJect built messages upon the realmes of existmg gender roles

I

related to food provision, and encouraged small changes. Messages can be geared to alter family practices to a degree, but not to overhaul them.

Perceptions held by children themselves can also be worth exammmg. In the Philippines, children were selected as a target audience because they make food decis10ns, because parents listen to their preferences, and because children's habits become life-long habits.

Segmenting the Beneficiary Group

The programs studied here all remforced the fact that the "under-five-year-old" is not a single group, but actually several distmct groups. Communication programs face different chal­lenges m attempting to change the behaviors of caretakers with regard to different ages.

Most child survival intervent10ns find that the under-two or the weaning age child is considered vulnerable or special m certain ways, and caretaking practices surroundmg that age are particularly resistant to change. The food promotion programs all found this, and made spe­cial efforts to create messages addressing

Simplicity has its virtues. Highly integrated plans can "backfire" as the complexity of interventions increase.

weanmg age feedmg concerns. However, tradi­tional beliefs about what is appropriate for the young child often contradicted program messages.

A second children's group to emerge with its own unique set of eatmg concerns was the older child. In the Phdippmes, food preparation by mothers was affected by the difficulty they experi­enced m getting children to eat vegetables. The media campaign helped raise the image of green leafy vegetables in the minds of children as well as theu parents. In Indonesia, contests were held to test new recipes with children, m order to identify the tastiest ones.

Capsule programs also found the older child

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required special attent10n because-unlike in many other mterventions-this age group is often the hardest to reach. In Indonesia, the distribu­tion site (posyandu, or village health post) is thought of as a center for younger children because immumzat10n and growth monitoring services are emphasized there. Messages needed to be re-focused so that mothers remembered to bring their four- and five-year-old children to the health posts as well.

Designing Effective Messages

Consistency of messages over time is fundamental to the credibility of public health mtervennons. Vitamin A programs therefore confront a difficult situation. Many countries (such as Indonesia) now find that theu messages are no longer credi­ble precisely because the deficiency has lessened­and blmdness is no longer an everyday remmder of vitamm A's importance Our mcreased under­standing of the role vitamm A plays in strengthen­ing the immune system also reqmres a new look at message content.

When programs try to change the rationale for vitamm A supplementation and consumption, concerted effort must be put into pretestmg new messages among different audiences. Likewise, intensive disseminat10n of the new messages 1s essential. The SOMAVITA proJect found that health professionals were responsive to new mes­sages about v1tamm A's role m reducmg child mor­tality and in treatmg measles However, the same messages will take much longer to become "mem­orable" and convmcmg among village leaders, vol­unteers, and community members.

Getting the Message Out

The effectiveness of mterpersonal communication was illustrated by all of the proJects. These inter­ventions reached outside the health system m order to provide suitably comprehensive and intensive

contact at the household and community levels. The key to outreach in Indonesia was harnessing the energy of a women's relig10us group whose members are credible and trusted by the target audience. In Niger and the Philippines, teachers and agricultural extension agents were trained to

conduct a wide range of activities. The Philippines effectively mobilized local elected officials.

Choosing appropriate media is a complex process and mid-project monitoring will reveal the actual reach and impact of different channels. Each of these programs experienced some "sur­prises." ROVITA found that, although banners are a popular medium in the target area, project banners were largely unsuccessful in reaching women with messages. The Niger project discov­ered that effectiveness of village drama depended upon the size of the village. Dramas were more effective in smaller villages.

Simplicity has its virtues. Highly integrated plans can "backfire" as the complexity of interven­tions increase. Too many media, as well as too much reliance upon intensive local organization and planning, can complicate a program. No pro­gram should be "bigger," or attempt more activities, than can be carefully planned on the basis of research, and can be monitored through simple, systematized checks. The SOMAVITA project experimented with direct mail questionnaires to monitor various aspects of the provincial interven­tions. Although the system initially worked well, planners learned that respondents needed to be var­ied over time as the novelty of filling out and returning paper work wore thin.

FUTURE DIRECTIONS

Evaluation results from the four projects are encour­aging. They demonstrate that changes in dietary practices can be achieved in relatively large-scale programs and within a short time penod. Likewise they show how a rigorous audience focus can yield maJor improvements in capsule coverage. The many similarmes in communication issues across

INTRODUCTION

countries-especially related to beneficiary groups and barriers-should provide useful insights for program planners launching new efforts.

Although much has been accomplished, many challenges remain in the vitamin A communica­tion area. Every country must determine the prop­er mix of strategies, given available resources, for promoting vitamin A production, consumption, and supplementat10n (as well as foruficat10n) so that high-risk groups are reached effectively in the short term, and the vitamin A status of the general population is raised over the long term. To achieve this long-term goal, focus must be put on finding ways to sustain behavior change so that new eating patterns-med out for a few months during a commumcanon program-become routine, rein­forced in myriad ways by the prevailing culture. This will require the efforts not only of communi­cat10n experts, but support for improvements in the complex factors which influence "supply" for a given population.

NOTES

Beaton, G H., R Martorell, K.J. Aronson, B

Edmonston, G McCabe, A C Ross and B Harvey

Effectiveness of Vttamm A Supplementation m the Control of

Young Child Morbzdzty and Mortality zn Developing

Countries ACC/SCN State-of-the-Art Senes: Nutrltlon

Policy D1scuss10n Paper No 13 (Geneva The Umted

Nations, 1993)

2. Semba, RD , P.G M1ottl, J D Ch1phangw1, et al

"Maternal V1tamm A Deficiency and Mother-to-child

Transm1ss10n ofHIV-1 "Lancet343·1593-1597 (1994)

3. UNICEF The State of the World's Chzldren, 1995

(Oxford Oxford Umvers1ty Press, 1995)

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Case study ; ~· NIGER Promoting Vitamin A in Rural Niger: Strategies for Adverse Conditions

Margaret Parlato

Peter Gottert

Promoting Vitamin A in Rural Niger: Strategies for Adverse Conditions

THE SETTING

Niger is a poor, landlocked country in West Africa, with large northern tracts in the Saharan desert. It is home to 7.4 million people whose average annual per capita income is equivalent to only about US $308.

1

Although over 80 percent of the population live directly off the land, a mere 3 percent of Niger's large surface is arable. This

NIGER

Margaret Parlato Peter Gottert

can support only the most critical needs. Little more than a third of the nation's population has access to basic health care. Transport is scarce, and funds for education are limited. Girls' education is almost nonexistent. Scarcely 7 percent of young girls 7 to 12 years old attend pnmary school.3

Health status in general is poor. Life expectancy m 1992 was only 47 years. A high rate of mfant

land is rapidly dedming m agricultural productivity because of mtense farmmg, desertification, and the lack of mvestment m modern farmmg techmques. A rapid­ly growmg population is forcing distnbuuon of the overworked land mto ever smaller parcels. The total fertility rate is 7.4 and the birth rate is 5.4-both among the highest m Afnca.2

Total Population= 7 4 million Population oflnterventton Areas Phase I = 26,000 E:2222ZI

Investment in basic social services is limned. The price of uramum, once a large rev­enue and foreign exchange earner for the country, has fallen precipitously, and the largely agricultural economy

I

Phase II = 250,000

mortality, (134 per 1000 live births) results from acute and chronic diarrheal and respiratory infections, malaria, malnutrition, and increasingly, HIV/ AIDS.4 Serious levels of malnutntion in

Serious levels of malnutrition in Niger are largely due to inadequate food availability.

Niger are largely due to inadequate food availabili­ty. Not only are staple grams in short supply; low mcome levels provide the population with little purchasing power for a vaned diet. A poor balance of payments has also restricted food imports.

Basrc nutnents are m short supply as are essential micronutnents. In 1992, 53 percent of children 12 to 23 months were underweight (based on weight­for-age). Among mfants aged 6 to 11 months, the rate of malnutrmon was 18.6 percent, and by the age of 24 to 36 months, 47.1 percent were already stunted (based on low height-for-age). 5 Complex factors contribute to these rates. Among these are low birth weights (due m part to mothers bemg mal­nourished), non-exclusive breastfeeding in the early months, diarrhea and other mfectious diseases, and problematic weanmg practices. Vitamm A deficien­cy rs also nearly umversal. Estimates m 1991 indi­cated that those at highest nsk included 75 percent of all pregnant women, 66 percent of nursing women, 50 percent of children aged 13-36 months, and 62 percent of children aged 37-72 months.6

THE CHALLENGE

In Niger, as in many other Afncan countries, strate­gies for improvmg health status must deal with these basic realities: low public mvestment m the health sector, a poor and poorly-educated populace, declining personal mcome, and rapidly increasing population size. Furthermore, interventions to encourage families or commumt1es to change their food or health-related habits confront resistance to mnovat1on that emerges naturally from the precari­ousness of life. Any change from tradmonal pat­terns can represent enormous risk.

PROMOTING VITAMIN A IN RURAL NIGER

Withm this context, the Government of Niger has made noteworthy efforts to establish a nutrmon program, but until recently, activities were limited to supplemental feeding and rehabilitat10n. Following a senes of structural changes m 1988, the Mmistry of Public Health expressed interest in expandmg from its traditional nutritional surveil­lance/ rehabilitation focus to a more preventive approach, centered around nutnt10n educat10n and communicat10n.

USAID subsequently encouraged application of low-cost, community-based educational approaches in Niger. The Nutrmon Communicat10n Project (NCP) began m the country m January of 1991 with a focus on the problem of vitamm A deficien­cy among those at highest risk: children six months to six years old, and pregnant and lactating women.

Implementation of the three-and-a-half-year project was the responsibility of the Mm1stry of Public Health, Nutntion D1v1sion. The Academy for Educational Development (AED) provided technical assistance-a total of 35 weeks for design and overall strategic planning as well as techmcal superv1s10n (excludmg evaluat10n). Helen Keller International (HKI) provided day-to-day operational and financial management. A Project Techmcal Committee comprised of members of these core msmut1ons, along with the Ministry of Agriculture and the Ministry of Education, provided a forum for debate about project decisions and actions.

Together with Helen Keller International, the Mm1stry had been active m distnbutmg vitamin A capsules in two of the country's six provmces since 1989. However, as a result of increasmg mterna­tlonal attention on vitamin A and its role in child mortality, the Mm1stry was mterested m re-examm­mg and expandmg its vitamin A program. This new collaborative effort was Niger's first effort to test the feasibility of improving the vitamin A status of vulnerable groups by influencing the purchase and consumpt10n of vitamin A-nch foods as well as their commercial production. The unanswered question was whether a food-based strategy could-with existing water resources and market mfrastructure-presendy be implemented m select­ed ecological zones of the country.

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A PHASED APPROACH

The overall project took place in two phases. The total project period of 40 months was divided mto an experimental phase I conducted in 16 villages (a pop­ulation of about 26,000) and expanded m phase II to 80 villages (a population of about 250,000). Phase I took place from January 1991 to September 1992, and phase II from September 1993 to March 1995.

Project designers embarked upon phase I without assurances that addmonal funding would follow. Smee the funds available were relauvely small and it was lillpor­tant to have results quick-ly, objecuves were focused on certam fundamental issues. A carefully evaluat­ed pilot mtervennon based upon research mto local conditions and prac­tices would determine if adequate, year-round vit­amin A sources were available at an affordable cost; help identify vitamm

Planners wanted ta wark in an area where the eca/agy was mast promising far a taad­based approach ta vitamin A pramatian.

A-rich food sources; develop culturally acceptable strategies for meeting the sharp swings m seasonal avail­ability of vitamm A food sources; and test approaches for delivering messages to the target population.

Tahoua, one of Niger's six provmces, was selected as the project site for a number of important rea­sons. Given the challenging environment and the difficult goal of changmg tradmonal habits, plan­ners wanted to work m a pilot area where vitamin A was known to be a serious public health problem and where the ecology was most promising for a food-based approach to vitamin A promotion. They established a few basic criteria:

• A year-round water supply and the practice of dry season gardening (so that vegetable production was already established and might be increased) Tahoua Province had wells m most villages because of an aggressive well-bmldmg program sponsored by the Government over the preceding five years and numerous ramwater catchment sites that sup­ported dry-season gardens.

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Presence of sufficient water m the target area was important

so that promotion of increased vegetable production would be feasible

• Proximity to the capital, Niamey (425 kilo­meters), and good road access.

• A smgle linguistic zone.

• Previous vitamm A program experience. HKI had supported a Mmistry of Health vitamm A cap­sule distribution program m Tahoua since 1986. This meant that the population had a basic aware­ness of the problem and an mstitutional base had been laid. As an established mternational agency, HKI could serve as field representative for adminis­trative assistance and financial disbursement.

Birn1 N'Konm, the single district (or arrondzsse­ment) selected within this province for phase I activities, also claimed a diversity of village types in terms of size, socto-economic development, water supply, existence of dry-season vegetable gardens, presence or non-presence of a dispensary, and mar­ket availability of vitamm A-rich foods, permitting a certain degree of comparative research.

INVESTIGATING PROBLEMS AND OPTIONS

Although phase I was limited in both size and scope, this mini-project followed a systematic social marketing process. Distinct stages of research, strategic design, implementation, and evaluation provided insights to set the proJect's behavioral tar­gets, audience and communication channels, and laid the foundation for any expanded phase of activity. The first task was to under­stand the context in which current food, consumption, pro­duction, and pur­chase/gathering practices were car­ried out in the target area, and to study how these might be positively influenced.

Initial research led planners to the conclusion that the most promising products would be liver and different kinds of green leaves.

A four-month investigat10n examined soCial, eco­nomic, and market factors affecting nutrltlonal sta­tus.7 Extensive desk research was combined with carefully focused studies. Technical consultants provided bnef but intensive training to a small group of local researchers/ interviewers (including staff of the Ministry of Health) who assisted in carrying out the field studies. The inmal primary research included in-depth interviews, market surveys, observation, ranking techniques, and ethnographies. Re­searchers set out to answer nine impor­tant questions and to determine the proJect's specific behav10ral targets, audiences, and communication chan­nels. In particular, the studies were

PROMOTING VITAMIN A IN RURAL NIGER

• Could vitamin A needs be met in each of the three distinct seasons or would supplements (cap­sules) be needed to achieve full, year-round coverage for the population?

• What quantities of vitamin A-nch foods are being consumed by high-risk groups (children of different ages, pregnant and lactating women)?

• How large a gap exists between actual and optimal levels of vitamin A intake?

• What vitamin A-nch foods are available in different seasons, and what are the richest dietary sources of the micronutnent?

• What constraints exist to increasing consump­tion by the population of different vitamin A-nch foods (cost, taste, preparation time, image, etc.) and whKh foods are the most appropnate from a con­sumer's perspective?

• Are there penods of the year when families have disposable cash and could afford higher-priced animal sources of vitamin A?

• How might commercial dry-season farmers be encouraged to increase their production of vitamin A-nch foods?

• What channels of communication reach the target groups?

• I

• Do available sources of vitamin­A nch foods (markets, gardens, plants grown in the wild, and so forth) supply adequate quantities to meet the popu­lation's needs and how elastic is that supply?

Men make many of the critical food purchasing dectstons in the family Here, a man purchases liver snacks at the market The program attempted to build messages on such already-existing behaviors

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Looking at Leaves and Liver

P reliminary formative research showed that two types of food held the

greatest potential for furnishing increased vitamin A to the pop­ulation. These were a variety of green leaves and liver. A rapid qualitative study then examined the market availability of these foods and investigated what new purchase, preparation, pro­duction, and feeding practices would be feasible to the target groups. The highly focused study was earned out in six vil­lages by a team of four women and two men, and mcluded a mix of methods.

• Individual in-depth mter­views with 216 women and 60 men looked at current beliefs as well purchase and feeding habits, and the practicality of

RESEARCH RESULTS

specific changes. Scaling/rank­ing methods also helped ascer­tain consumer preferences and pick specific vitamin A-rich foods against a number of dif­ferent characteristics.

• Each interview included a 24-hour food recall and food frequency lists. A researcher also measured all vitamin A­rich foods prepared or pur­chased and eaten by the respondent and sample child.

• A researcher weighed all the livers available from butch­ers in the sampled villages, to

find out whether supplies would be sufficient in the tar­get areas if demand actually rose to recommended levels.

•In-depth interviews with butchers, gardeners, leaf sellers, and sauce sellers helped assess

supplies, common units of purchase and costs, seasonal availability, and flexibility to increase production and local market supplies.

• Focus group discussions with men and women identified constraints that might emerge to recommended practices and revealed possible solutions.

•Key-informant interviews with teachers, agricultural agents, nurses, and village health workers provided further insights into local practices.

While many questions looked at "leaves and liver" per se, others investigated commu­nication channels in the popu­lation, as well as training needs for mfluential groups.

The research confirmed that vitamm A deficiency was widespread among women and children in Tahoua Province and that awareness was lacking regarding the dietary needs of these vulnerable groups However, research also revealed that ade­quate vitamin-A rich sources existed; that sources of one kmd or another were available durmg each season; that these foods were within the existing economic (and social) constramts faced by most families; and that they were already eaten by the general population at different times of the year, although not in sufficient quantmes.

kinds of green leaves. In order to design speofic messages, however, they needed to understand the balance of costs, constraints, and changes that might seem reasonable to the target audience and would lead to increased consumpt10n of these foods over the year. In May of 1991, researchers used a special mix of methods to look at these questions m six villages. (See box)

Because of the complexity of dietary practices, the program looked at the knowledge, attitudes, and behaviors of several categories of respondents. Whereas primary beneficiaries were young children and pregnant and lactatmg women, other family and community groups play a major role m what foods are ultimately consumed m the household. This mdudes: men (who do most of the family food purchasing mduding of vitamm A-nch snacks),

Most importantly, mitial research led planners to the conclusion that the most promismg products for an intervention would be liver and different

I

women (who prepare and serve the food and who have their own small, disposable mcomes), commer­cial gardeners (who produce vitamin A-nch foods for sale and home consumpt10n and who have the potential to increase this supply) and health and extens10n agents (who often mtroduce new ideas).

Research revealed that a combmat10n of prac­nces-takmg mto account the seasonality of foods and the availability of cash-would have to be pro­moted m order to increase vitamm A intake through­out the year. (See box)

Green leaves grow wild dunng the rainy season and in the month or so just after that Qune-October). Of

PROMOTING VITAMIN A IN RURAL NIGER

approximately 32 types of edible wild leaves common m the proJect area, at least eight are known to be nch m vitamm A: amaranth, senna, JUte, false sesame, gynandro, purslane, and urena.8 Families harvest these or purchase them at a nominal cost from older women who do the collection, and use them in hot salads or sauces. The 24-hour food recall study found that 71 percent of women and children had eaten green leaves the prev10us day-most m a sauce and the remamder m yamoutse, a salad-like preparation made from greens, oil, spices, and often crushed peanuts. Generally it is made with fresh leaves available durmg the ramy season and is usually consumed as a snack.

In other seasons the dish is

Formative research helped construct thzs chart of vitamin A-rich foods with their respective months of local availability as well as cash flow of househoUls m different seasons

sometimes prepared with whole, dried leaves.

An addmonal 50g of green leaves daily would cost less than one percent of the aver­age weekly food expendi­ture in the target group Consumption of green leaves could therefore be mcreased, but probably only dunng cer­tam months.

Calendar of Vitamin A Sources in Niger

Vitamin A Soul'le Cool Dry Hot Dry Rainy season COOIDFJ Season Season Season

JAN fEI MAR APR MAY JUJU JUIY AUG SEPT OCT Nill DEC

Amaranth ~

Baobab

Senna

Jute lffllliillJ

False Sesame

Gynandro l!l!fii!I>

Red Sorrel illf!Jfifi!;

Drumstick Tree ~

Purslane

Urena~ ~

Cowpea f!llil!J!I

Sweet Potato

Mango

Squash (pumpkin) - ~

Liver

Spending Money

NOTE Heavy Imes represent the avatlabtlzry (for liver and spending money), or natural harvesting period (for vegetableslfiuzts) under rain-fed cultivation Shaded !mes represent the addttzonal ha; vest period far vegetables if watered tn a garden during the dry season

In the post-harvest months, most families snll have some disposable income after they have paid their debts. Com­mumcation planners hypothe­sized that a pomon of this mcome could be spared to pur­chase liver. Liver is one of the most important vitamin A-nch foods consumed m the provmce. While it is not eaten as regularly as green leaves,9 it is a highly-pnzed gnlled snack which men eat m the market and sometimes bring home for their wives and children.

Since liver is an ammal source of vltamm A, it con­tams a pre-formed and readily available form of the vitamm which is stored m the human

I

body; nutritional requirements can be met through con­sumption of small amounts at occa­sional mtervals. One 25g serving of liver every two weeks can provide enough vitamin A to

The overall campaign strategy was based upon three principles: seasonality, regularity, and frequency.

meet 75 percent of a pre-school child's needs dur­ing that penod. 10

Spendmg money 1s available primarily m the post-harvest months of January-May, and in par­ncular, January-March. Consumption of liver could therefore be affordably mcreased precisely during the months when other vitamin A-rich foods are scarce.

In the hot season months (March-May), man­goes are plentiful, providmg an abundant source of vitamin A. Because of their popularity, planners decided messages could be simple reminders to reinforce the habit and to make sure young chil­dren received small slices or mashed portions.

In the cool dry season (November-February) focus was put on increasmg production of greens in dry­season commercial gardens. Squash is available in this season but 1s not widely available and also is not very popular. Planners therefore decided promo­tional messages about squash should be secondary

In fact, the situation in this reg10n of Niger offered many opportunities: the foods that were to be pro­moted were already commonly eaten, thus reducing the extent and nsk of the proposed habit change. The foods were mexpensive, further facilitating the change. The foods promoted were diverse, appealing to both taste and seasonal availability.

The task would be one of education and mfor­mat10n. Research showed clearly that people were unaware of the particular dietary needs of young children, pregnant and nursing mothers, and were unaware of the quannties/frequenc1es required to meet essential needs. Women did not mcrease the quantity of food they ate dunng critical phases of their reproductive lives, and their children's diets were generally madequate.

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STRATEGIC DESIGN PROCESS

Behavioral Goals and Target Audiences

The overall campaign strategy was based upon three principles: seasonality, regularity, and frequency. Messages based upon these principles would in turn lead to greater quantity consumed. Planners selected practices that would, taken together, assure consumption of v1tamm A-rich foods throughout the year with specific foods promoted m each sea­son. In add1t10n, the project promoted the regular consumption of these foods when available. To establish easily memorable dietary patterns, moth­ers were advised to see to it that their children ate greens every day and liver once a week when the father goes to market. Lastly, children and preg­nant and lactatmg women need to consume or be fed enough vitamin A-rich foods. For women, total satisfaction of vitamin A needs may be limned by economIC constraints, but messages could urge eat­ing more-up to realistic limns. Children need to be fed many times durmg the day m view of their small stomach capacmes and immature digestive tracts.

ProJeCt messages focused on promotion of snacks (liver, yamoutse, mangoes), rather than, for example, on eatmg greater quantities ma context where this would seem impossible, or changing tradmonal recipes to mclude "more greens" (which would also be unacceptable). In this way, greater frequency of eating would lead to greater quanmy consumed.

These principles combined to help design spe­cific behavioral objectives for designated target audiences:

1) To encourage husbands to ensure that their wives and children consume a varied diet and suf­ficient quantities of food to assure their good health.

This generic "family responsibility" theme of the communication campaign laid a foundation for messages about the connection between food and health and about specific v1tamm-A related behav­iors. The husband was m fact central to every aspect of the intervention. He 1s traditionally seen as the provider of food for the family. However, this

responsibility is basically understood as synonymous with supplymg grams, or specifically millet-the staple food. The project wished to expand this role so that the husband's attitudes and actions became part of better nutritional practices­in particular, consumption of liver and green leafy vegetables. In this sense the project attempted to begm a shift m cultural norms.

2) To increase the frequency with which fathers buy liver as a snack for their children and their wives.

fu the pnmary purchasers of liver, fathers were selected as the target for this message. (Before the intervention, only one percent of women reported buymg liver as snacks.) The husband/father is there­fore the key provider of vitamin A for the family in the post-harvest period when cash flow is improved and little else is available.

3) To encourage mothers to assure that they and their children eat CFA 5011 worth of liver per week.

Women were encouraged to ask their husbands to brmg home liver snacks from the market; to buy some themselves; and/or to share the liver of animals slaugh­tered for feasts or other special occasions among them­selves and their children. Messages explained the importance of liver for themselves and their children and suggested they share CFA 50 worth of liver with their children every week

4) To encourage mothers to increase the fre­quency of including green leaves in the family diet, so that the quantity of greens eaten by their six-month to six-year old children {as well as by themselves, particularly if they were pregnant or lactating), would increase.

The key behav10ral messages focused on regu­lar consumpt10n: to eat green leaves daily and to

assure that children begmnmg at six months of age eat them daily during the entire year The rationale was that green leaves-either fresh or dried-are available during most of the year. Although the nutritional value of leaves is low durmg the penods of the year when they are consumed dry, emphasis on regularity was retained.

PROMOTING VITAMIN A IN RURAL NIGER

In the ramy season, yamoutse, made from fresh leaves, is a popular snack and offers potential to improve vitamm A intake of vulnerable groups. In most other times of the year, green leaves, usually dned, are added to sauces in very small quantities to flavor and thicken them. They contribute lmle nutrmonal value. In keeping with the strategic ele­ment of seasonality, special focus was given to eat­ing fresh green leaves during the seasons when they are plentiful.

Planners considered trymg to improve the meth­ods used to dry leaves m order to preserve more vit­amin A. The sun drying process used m the reg10n degrades the vitamm A content. However, food experts consulted advised that, given the small quantities m which dried leaves are consumed, this would have little impact on overall vitamm A levels in the diet lncreasmg the quantity of dned leaves used m sauces was also explored but rejected as a strategy. Their high cost would be an obstacle. Also, from the villagers' perspective increasmg the traditional propomon of leaves in sauces would rum the taste and texture.

5) To increase the amount of green leaves culti­vated by dry season farmers.

Commercial dry season production of green leaves was practiced only on a very limited basis in the project zone. Dry season farmers were therefore encouraged to grow greens on the borders of already cultivated land or as an interline crop (rather than to take high-earning cash crops such as omons and peppers out of culuvation). Discussions with agron­omists on the possible problems of co-farming wild greens with traditional garden vegetables mdicated the practices could co-exist.

Messages stressed that green leaves can be sold (during the rainy season, women from the village often harvest wild greens from millet fields and then sell them m the commumty) or can be eaten by the gardeners' families. Although the sale pnce of greens during the early part of the dry season (October) is low because of wild leaf harvesting, the price could go up substantially at the end of the dry season. The profits would be good, smce the investment would be low.

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A woman tn a Tahoua vzllage adds vitamin A-rich yellow squash to the family sauce

Planners also targeted a secondary message at gar­deners, although they felt that only certam of them would be able to adopt it. The message was to encourage the dry-season watering of drumstick trees The tree produces copious and highly-pnzed leaves during the rainy season, but dunng the dry season no leaves grow unless the tree is watered. Watenng, however, is an economic investment. Furthermore, dried drumstick leaves imported from Nigena are already eaten in significant quantities, suggesting that the pnce of the import is reasonable. Residents of Tahoua have gotten used to and now prefer the taste of dried drumstick leaves, thus lower­ing the economic value of fresh leaves to dry season gardeners.

6) To increase the frequency with which squash and mangoes are eaten by children and pregnant and lactating women.

Squash is also available but not grown in all vil­lages-apparently due more to tradmon than to any stnct agncultural or economic consideration. While gardeners in Tahoua produce onions as their principle cash crop in both rainy and dry seasons, different villages diversify wnh peppers, cabbage, tomatoes, or squash. Markets in villages that do produce squash offer the product in small quanti­ties, affordable to most. Although squash "keeps" for a long time it is hard to store (requmng a large

I

amount of space and a special environment) making this vegetable one with a short seasonal availability. Mangoes are already eaten in large quantities dunng the rainy season

Thematic: Treatment of Messages

People in the target area already assooated liver wnh the prevent10n of night blindness. They also associated it with protect10n of "the organism" (a literal translation from the Hausa for an idea of the total person-the individual components of the body and its phys10logy) To promote liver con­sumption, therefore, messages stressed the connec­tion between this food and protect10n of both the eyes and "the organism."

Target groups did not have any appreciation for the nutritional value or health benefits connected with other vitamm A-nch foods. Messages therefore introduced this relat10nship· that green leaves, liver, squash, and mangoes are nutrmous, are beneficial to the eyes, and also in protecting agamst disease.

CONSIDERING COMMUNICATION CHANNELS

Disseminating information-and actually convinc­mg target groups that they should change habitual behav10rs-was a senous challenge. The selected channel(s) needed to have the required reach and credibility among the populat10n, needed to be delivered with a certam level of frequency, and also had to be arranged at a cost which could be sus­tained over time.

Formative research among both men and women had included questions designed to gmde selection of channels that would reach the selected audiences. Given the rural context and the complexity of behav­iors targeted, these questions had as much to do with how people learn, as they did with "media'' per se.

The study looked at some basic questions. How do women and men learn new practices and under what circumstances might they be convmced to change their practices? Are women getting new health informat10n primanly from health profes­sionals or from other women, for example? Are

men gettmg new ideas about gardenmg from the agricultural profess10nals or from other gardeners? Are men at all aware of biomedical mformation about mother and child nutrition? Would they be wrllmg to make changes in household practices because a health professional advised them to do so? Would they make changes because therr wives came home from the dispensary and reported advice from the nurse? 12

Data mdrcated that few people visit the health care system and these few come for curative rather than preventive treatment. Community health care work­ers are overworked and underpaid, as in so many countries. The health mfrastructure could therefore not serve as a solid foundation for communication. Only about 40 percent of households owned a func­tioning radro, with listenership rates varymg by sex.11

At the time of phase I research, the most popular radio station for residents of Tahoua Provmce was in another country-Nigena. Only 7 per­cent of women said they watched telev1-s1on. The usefulness of pnnt materials was severely limited by the low literacy rate; m Niger, 96 percent of women aged 35 to 49 have never been to school.

Drama is an ideal vehicle tor presentation of the family dynamics involved in decision making.

How, then, given a limited project budget, a lim­ited time frame, and a limited health infrastructure, could mformation on an important but rather com­plex topic be presented widely and m some depth? Communicatron planners decided to test the potential of a smgle communrcation channel-vil­lage drama-which built upon a traditional medi­um but incorporated changes that would allow for local management/superv1s10n and a systematic means of conveymg project messages wrthm the designated population.

Itinerant drama troupes m West Africa have been successful as message earners because therr perfor­mances are denved from long-standmg traditions (of story-tellers, or grzots, and song and dance per-

PROMOTING VITAMIN A JN RURAL NIGER

formances that convey local myth and history), and also because they reach areas where radio and tele­vision have not yet penetrated Drama groups have the potential to reach women as well as men.

Drama rs an ideal vehicle for presentation of the family dynamics involved in decision makmg.

Village dtamas provided an entertaznzng way to convey mes­sages about family food deczstons

Actors convey specific mformanon (for example, about the importance of vitamin A-rich foods in a child's diet); they can also reenact familiar encoun­ters between husband and wife about scarce house­hold finances and improved diet, child reanng and mtra-famrly authority, and suggest resolutron and compromise.

ltmerant troupes, however, have certam disad­vantages. They are expensive, can be difficult to manage and supervise, and may have a limited range, given the socral, cultural, and ethnic diversi­ty of the country.

The project med out a new approach-village drama-to take advantage of the strengths but avoid some of the problems associated with Itiner­ant groups. It focused on the motivation and trammg of local amateur actors to create and per­form skits based upon the project's messages. Village volunteers were organrzed into drama teams, trained m the use of dramatic techniques to convey informatron about vitamm A-rich foods (liver and green leafy vegetables m particular), and

I

Trazmng through role playing helped amateur actors learn how to dramatize pro;ect messages

provided supervision and techmcal support. The goal was to build on traditional culture, to engage local commumties m developmg theu own health education programs, and to create an mteractive vehicle for providing mformation and encourage­ment to adopt new practrces.

PHASE I IMPLEMENTATION

Training and Launching of Village Teams

Crucial to the success of this activity was a well­designed training and supervision program and an orientat10n/launch of efforts withm mdivid­ual communrties. Planners also wanted to assure that local authorities had a sense of program ownership. Their support was essential for gain­ing village-level pamcipation.

I

How to Create a Village Drama

In order to help train the volunteer the­ater members, the village encadreurs were given an assortment of role play scenarios

to practice and elaborate on through their own imaginations. Here is a sample:

Title: A Nursing Mother Talks to her Husband

Situation: A husband brings millet to his wife in the morning and she asks for money to

buy additional food. The husband does not have confidence in his wife.

Role A: Moussa: You are the father of the family and you leave your house during the day. Each morning you bring your wife mil­let for the day and you place it at her feet. You do not have confidence in her. Each time she asks you for money for food, you refuse because you are convinced she intends to buy a talisman to protect her from having you take a second wife.

Role B: Rabi: You are a nursing mother and yesterday at the dispensary the nurse told you that you must prepare 50 francs of liver for yourself and your children once a week and eat green leafy vegetables every day. This morning when your husband brings you the millet, you ask him for money to purchase liver and greens.

In each village, government health workers, teachers, and agricultural extension agents were designated as encadreurs ( tramers/ supervisors) responsible for forming and loosely managmg the drama teams. Half of the villages had no encadreurs, so health or agricultural workers from nearby villages were recruited. Members of the proJect committee from Niamey assisted the local leaders m the creation of drama teams and the selection of actors. Participation was completely

voluntary. Actors were chosen on the basis of their interest and willingness to contnbute, not necessanly past experience or talent.

The project technical committee trained the encadreurs in a five-day workshop and supervised them every other month. Training included:

• an orientat10n about the importance of vita­min A to child survival and information about vitamin A-rich foods;

• maJOr messages to be included in individual dramas;

• the overall communication strategy and the thematic context for different messages;

• repennon of model dramatic scenarios;

• training principles for village drama teams (focusing on the amateur level of participants, their inexpenence with health or other development themes, but also their spontaneity and innovativeness);

• supervisory/administrative requirements: how many times to visit the troupe; what to observe; how to provide construcnve advice; how to keep good records, and so forth.

The project technical committee concluded that special focus needed to he placed on the weaning infant.

Encadreurs received a Role Play Guide to assist in their train­ing sessions and supervisory visits. (See box.) They then trained village teams over a penod of five days, including both "classroom" instruc­

tion and practical training. At the end of train­ing, each village drama team was to have developed a complete skit. Teams were then asked to carry out at least one performance (three ten­minute skits) per week over a period of four months.

Encadreurs received a small per diem to cover food and transport while on supervisory missions. The volunteer teams received non-cash incentives such as T-shirts and diplomas.

PROMOTING VITAMIN A JN RURAL NIGER

REVIEW AND STRATEGY REFINEMENT

An evaluation conducted after the end of phase I indicated that the drama skits were popular and well-attended: 61 percent of men and 34 percent of women saw at least one play during the campaign. 14 In all 16 villages, dramas were per­formed regularly-an average of one performance per week.

Most importantly, the percent of women who reported that they ate liver in the past week rose from 52 percent to 69 percent; and the percent of women who indicated they gave liver to their children in the past week rose from 51 percent to 65 percent. Research also revealed some prob­lems, however. The evaluation showed that con­sumpnon of both greens and liver was rising less among children than among adults, and that the youngest children were not being fed more. Consumption of greens was shown to be particu­larly lagging. The project technical committee concluded that special focus needed to be placed on the weaning infant.

Other changes were suggested m the manage­ment and institutional support of the village drama activities. The system of non-resident encadreurs worked poorly. Health encadreurs, in parncular, made infrequent visits to project vil­lages other than theu own, ostensibly due to their already heavy workload and the lack of transport. Village drama teams expressed the need for more regular supervision and for some kind of stipend. Planners decided it was essential that encadreurs be identified within each village; that more teachers and agncultural agents be recruited; and that a district-based training and supervision framework be established.

Only a few of the original 16 village drama teams recruited women actors. Male actors played roles created for women. Although this added a certain local flavor and humor in some cases, pro­ject personnel decided it also detracted from the potential impact of some household interactions, and inclusion of women was crmcal. They pro­posed that women should be involved in all village drama teams in the future.

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PHASE II

New Villages, New Design

A second phase of proJeCt fundmg provided the opportumty to apply lessons from phase I to a larger area (80 villages in four distncts) and to refine project messages, improve local supervis10n, and test a more extensive media mix. Phase II began with a two-week qualitative study to exam­me the vitamm A context and explore some issues related to infant feedmg 15 m the new areas. A baselme study1 6 was also conducted m two of the four arrondzssements mduded m the expanded area. The mformanon was also used for planning purposes. The baseline survey consisted of 474 mterviews (375 women and 99 men) earned out in 15 villages.

Counseling cards displayed 16 baste pro;ect messages Pzctu1ed here are cards showing a father who has purchased liver

snacks and a mothe1 who ts gathering wild greens

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The results confirmed that additional emphasis should be put on the weanmg child, and also on the importance of feeding green leaves and mangoes A new message emphasized that a child could digest mangoes if well mashed and fed in small quantities (Fibrous mangoes m large quantities will, m fact, cause diarrhea in infants as well as older children, but small slices will provide minimum daily reqmrements of vitamin A without side effects.) The ethnographic study found that liver ts mashed between the fingers to make it edible for weamng age children

In addition, the technical committee decided to give more emphasis to the message about dry season watering of drumstick trees. During phase I, tt seemed to be the message most easily accepted by gardeners.

The greater number of villages provided the chance to look in more detail at the effectiveness of the volunteer drama teams and also to improve supervis10n of the teams and test the feasibility of managing these activities on a larger scale Given the greater project area, a dose and formalized man­agement structure was essential. The Director of Medical Service of Tahoua maintamed liaison with the heads of the Education and Agncultural Services at the district level. The project provided all district officers with a bnefing and detailed oper­ational gmde for the proJect

Medeczn Chefs (chief medical officers) of the four arrondzssements were key operat10nal managers of the proJect. They were responsible for reachmg agreements with counterparts m agnculture and educanon. These officials then recruited local gov­ernment personnel-health workers, agricultural extension agents, teachers-as encadreurs and supervised their activltles.

Of the 80 villages selected for the phase II mter­vention, only 40 of the larger ones were chosen to have village drama teams. In adopting this expen­mental design, planners hoped to be able to exam­me the effecnveness of the medium m light of overall differences in knowledge and behavioral change in the villages with and without drama, and to assess 1f village-drama could be managed effi­ciently m a larger-scale project

PROMOTING VITAMIN A IN RURAL NIGER

Expanded Media Mix

Dunng this second phase project designers added other media to mcrease the outreach of volunteers m the communities. The new media mix mcluded a combmation of chan­nels designed to remforce basic messages with greater frequency and vanety Village drama remamed central to the strategy m half of the villages. All of the villages were exposed to the new media. A new FM radio station, Radio Tahoua, was m need of pro­grammmg and was therefore wdlmg to pro­duce and air vitamm A spots and programs at low cost. By the start of phase II, the station had already gamed popularity through its broadcastmg of the local news.

Radio Tahoua visited each village and taped the locally produced dramas

for weekly broadcasts

Both drama and non-drama villages organized interpersonal education on vitamm A and related food issues. Dunng phase II, the terms of reference for encadreurs were expanded to mclude counselmg and group discuss10ns about vitamm A. The vol­unteers received special trainmg m these areas and were asked to conduct a minimum of one commu­mty group discussion per week, as well as individ­ual counselmg.

Flipchart-size counseling cards supported the face-to-face counseling The two-sided cards fea­tured large illustrations of the six basic vitamin A

::.::.-

Women members of theater teams proudly display their

cewficates of partmpatzon, which they received at theater

Jestwals

messages with written remmders on the back to gmde the person delivering the counselmg session

Postcard-size counseling cards, reproductions of the larger originals, were supplied as reference guides for the village drama teams. In addition, the project reproduced 80,000 postcards and distnbuted these to the population of the target area to encourage an "each one, teach one" dissemmation of messages.

Radio dramas were recorded m the villages with drama teams. A recordmg team from Rad10 Tahoua went to about 30 villages and taped at least one per­formance m each. They broadcast a total of 42 different ten-mmute skits, one per week for ten­and-a-half months. In addition, the team went to non-drama villages and recorded mterpersonal edu­cation sess10ns for broadcast as well. This assured that drama as well as non-drama communmes had the benefit of the publinty and public enthusiasm generated by the visit of a radio recordmg team, and of hearing themselves on the air. Each broadcast clearly identified the village and the actors or vol­unteers, which served as an important mcentive to those mvolved and to the commumty as a whole.

Radio spots based on the srx core messages of the project were broadcast twice a day, srx days a week, for three months.

Dunng phase II, village drama ran for four to six months m 40 villages; mterpersonal educat10n activmes were earned out for six to eight months

I

dependmg on the village; and radio broadcasts ran for ten months. This provided about 12 months of promotional activmes.

Together, the media offered complementary strengths (entertamment and inter-community discuss10n, depth of issue development and expla­nanon, frequency and reach of "remmder" mes­sages). The hope was that this media mix would encourage diffus10n of messages throughout the community, thus creatmg a general awareness and acceptance of new ideas as well as adopnon of behav10rs by individuals.

EVALUATION AND CONCLUSIONS

The project conducted a detailed evaluanon for the phase II mtervention in an equal number of villages and m the same arrondissements as the baseline sur­vey.17 (Respondents mcluded 406 women and 311 men.) The post-survey measured the changes in knowledge, attitudes, and reported pracnces among the population m general and compared changes in

Both men and women reported brzngzng liver snacks more often from the market place to share at home

the two categones of villages (drama villages and non-drama villages). A qualitative component con­sisted of interviews with encadreurs, village drama team actors, and Ministry supervisors from the provmcial and distnct level.

I

Overall Knowledge and Reported Behavioral Change

Knowledge of the importance of vrtamm A-nch foods mcreased significantly The percentage of women who cited vitamm A-rich foods as impor­tant for the health of children one to two years mcreased from 32 to 57 percent.

The evaluanon showed important increases m both purchasing and consumption behav10r for liver. Prior to the phase II campaign, 43 percent of women said they had eaten liver in the past week; after the campaign, 73 percent of women reported this behavior. The percentage of women who indi­cated that their children ate liver mcreased from 37 percent to 49 percent.

The number of men who said they brought home liver m the week previous more than doubled, from 6 percent to 15 percent. The percentage of women who reported that their husbands brought home liver increased from 6 percent to 26 percent; and the per­centage of women who indicated they themselves brought home liver (purchased with their own money) increased from less than 1 percent to 12 percent.

Data regarding consumpt10n of green leaves also showed improvement. The percentage of children reported eating fresh green leaves in the preceding week increased from 57 percent to 94 percent. The percentage of women who reported that their hus­bands brought home vitamin A-nch snacks increased from 11 percent to 47 percent, while the purchase of yamoutse increased from 1 percent to 15 percent However, the proiect goal to encourage mothers to start givmg greens at six months of age met with lim­ited success. The survey found that only 59 percent of women reported introducing greens at the correct age,

overall, BO percent of men and 40 percent of women heard or saw same element of the educational program.

compared to 52 per­cent at baseline. This seems to mdICate that the message was not effectively communi­cated or that resistance to it remamed strong Changes m reported consumption of squash and fuut were insigmf-

Women's Reported Vitamin A-Related Practices During the Previous Week

100%

80% .... ~ 'E ~ 60% ... ... E ; 'li:i 40% -... ... "" ~ ... a. 20%

0%

• Pre Intervention Post lntervenli1n

PROMOTING VITAMIN A IN RURAL NIGER

Exposure to Media

Overall, 60 percent of men and 40 per­cent of women heard or saw some ele­ment of the educational program. Exposure to radio among women was encouragmg. A total of 21 percent of women mterviewed heard skits on the radio and 20 percent said they heard radio spots. This represents a very large

Served children fresh greens

Ate liver V1tamm A-nch snacks bought

by husband

Bought V1tamm A-nch snacks wnh

number of those women who reported that they had listened to radio in the week prior to the evaluation (29 per­cent). Of those mterviewed, 26 percent stated that they saw counselmg cards. This is a relatively low figure, however, smce 1t comcides with the 27 percent who said they saw a skit m the drama-vil­lages. The evaluation mdicated that vol­unteers generally used the counselmg cards most often after a skit performance,

n = 375 pre-intervention; n = 406 post-intervention Changes in these practices are significant at p < .01.

own money

suggesting that at least in the drama vil­lages, mterpersonal education was not

Source P Stanley Yoder, 1995 carried out in the intensive way planned The percent of women who saw skits

icant. The null effect for squash was perhaps due to the fact that the vegetable is not grown in all villages. The lack of impact on frmt consumption was affect­ed by the season of the year when the survey was con­ducted (December). Mangoes, for example, the prmcipal fruit, were not available then.

Dry season cultivation of greens remamed low. Similarly, gardeners reporting cultivation of squash remamed low.

As part of a larger program in Tahoua, Helen Keller International and the Ministry of Health con­ducted a linked household food consumption survey in January 1995 usmg the HKI food frequency method.18 The survey documents improvement in consumption of vitamm A-nch foods by preschool children.19 At the baseline m January 1994, popula­tions in only three of the 15 commumties studied were not at risk of vitamm A deficiency. One year later, five additional communities had increased their consumption to adequate levels.

was lower than expected, given the fre­quency of performance (once a week), their novel­ty, and the fact that they were performed free and with local actors.

Villages that had pamcipated m phase I showed sigmficantly higher levels of knowledge and behav­ior change. However, whereas m phase I the village

drama teams had a

Mare precise and refined media planning could significantly increase the reach and effectiveness at communication programs in rural areas at West Africa.

measurable effect on knowledge and behav-10rs, phase II revealed a different picture. New villages without drama teams did sig­mfican tl y better on both measurements of knowledge and report­ed behavioral change than new villages with these teams. 20 This is mitially surpnsmg

I

because the drama-villages were of higher socio­economic levels, and they also had the benefit of exposure through more media.

Several explanations are possible. Perhaps most important, villages selected for drama teams were generally larger than those m the non-drama group, and also larger than those selected m phase I. Diffusion of messages-and especially of messages through drama-was probably not as effective in those villages. The evaluation showed that drama teams tended to perform m their own neighbor­hoods. The smaller size of the non-drama villages may have resulted m an active word-of-mouth shar­ing of ideas: messages about vitamin A received by some members of the commumty may have been shared and discussed with others, creatmg an ener­gized commumcations environment, whereas in the larger drama villages the concepts were less fully shared and discussed.

LESSONS LEARNED

Although the mtervention m Niger was designed for a difficult and umque environment, and both messages and media were tailored for a distinct population, a number of lessons emerged whtch are applicable to other vitamm A social marketing programs.

• A food-based approach to improvmg the vita­mm A status of a populat10n ts feasible m certain zones of the country with adequate water and an ex1stmg base of commercial dry-season vegetable production.

• Obtainmg the nght kind of mformation on which to base a commumcat1on strategy does not have to be a time consuming, costly, and compli­cated undertaking. Use of a short list of highly spe­cific questions to gmde formative research can keep researchers focused on essential issues-that ts, only those required to identify realistic and concrete behavioral targets, the right target groups, and ways of reaching them. The project found surpnsmgly lmle "wastage" in its research efforts. Most of the

I

information collected fed directly mto crucial deci­sion makmg.

This project did not hire any research or adver­tising firms. Internat10nal specialists were able to design necessary research studies and tram local interviewers, many of whom were Mm1stry of Health personnel.

• Village drama can be an energizing force for commumty involvement and a powerful way to build interest m a nutrition issue. Adequate super­vision-probably on a monthly basis-is required to keep up motivat10n of volunteer actors and assure that the content of performances is on track. Program managers must devote funding and per­sonnel for this critical function and must also momtor implementation closely.

• Careful planning at the village level can s1g­nifican dy extend the reach and effecnveness of commumcation activities. For example, rural groups appear to respond favorably to activity goals that are challengmg yet reahsnc. When allowed to set their own acnv1ty goals, drama groups performed more frequently than when goals were set for them by the national team. Smee the dynamics of larger villages (over 2,500 people) differ significantly from smaller villages, reachmg a high percentage of the populat10n requires an implementation plan whtch specifically mcludes act1v1t1es m each village neighborhood.

• Mass media can provide important motiva­tional support to community-led activities and also extend the number of people reached by village level events. When a radio announcer mtroduces a drama performance m a remote village, for exam­ple, credibility of the event mcreases enormously, as does enthusiasm among those who contribute to the field activities.

• More precise and refined media planning could mcrease the reach and effectiveness of com­mumcation programs m rural areas of West Africa. Village size, for example, appears to be a key factor in how mformat10n flows and the kind of media mix that is most effective. (The lesson from this mtervention was that the impact of drama groups will drop substantially wtth the size

of a village rf local plannmg does not ensure wide coverage. Rad10 coverage also vaned with village size, with more listeners m larger villages.) Overall access and exposure to mass media and commum­ty events also varied extraordmanly by gender. Careful audience segmentatron by village unit and also by gender could be expected to improve the impact of commumcanon efforts.

• A pilot project that rt rs limited in scope and earned out over a short penod can be a powerful on-the-job trammg arena for agencies havmg little prevrous expenence designmg communication pro­grams. A pilot project allows staff to go through all essential steps-from plannmg to evaluanon-in rapid succession. The format provides feedback on what works and doesn't work. Unseasoned staff can gam confidence and experience.

Although the Niger program was m many ways a lesson in how to design strategies for adverse con­dn10ns, this challenge also helped keep the pro­gram focused on essential principles: that research must be carefully targeted; that programs must be "commumty owned"; that costs must be sustain­able; and that insmutionalrzatron of systematic approaches among local professronals rs key to long-term success.

NOTES Umted Nations Development Programme and The

World Bank, African Development Indicators (New York and Washmgton, DC 1992)

2 Mm1stere des Fmances et du Plan, Enquete Demographique et de Sante, Niger, 1992 (Columbia, MD Macro International, Inc, 1993)

3. Ibid

4 Ibid

5 Ibid

6 Hung, Man-Mmg, Report on the Availabzlity and Consumption ofVttaminA-Rich Foods in Mger(Washmgton, DC: Academy for Educational Development, 1991)

PROMOTING VITAMIN A IN RURAL NIGER

7 The results of two maJor studies conducted as part of the project provided the basis for program plannmg: Hung, Ibid

Keith, Nancy, Field Research in Birm N'Konnz Vitamin A Communication Pro;ect (Washmgton, DC Academy for Educational Development, March-June 1991)

8. Wilson, A., Gathered FoodJ m West Africa A Neglected Component of Village Food Economy (M Sc TheSJS, Cal1forma Polytechmc State Umvers1ty, 1989)

9 Hung, op cit (Only 8 9 percent of a combmed total of pregnant and lactatmg women and children 6 to 72 months old reported consumption of liver m the previous 24-hour penod )

10 Hung, op cit

11 At the nme of this study US $1 was eqmvalent to about 250 CFA.

12 Keith, op cit

13 Baker, Shawn et al , Enquete de Base Sur !es Connazssances, !es Attitudes et !es Pratzques en Matiere de Vttamine A, Arrondzssements de Birnt N'Konnz et Ille/a (Washmgton, DC Academy for Educational Development, January 1994)

14 Kone, Hughes, Evaluation du Pro;et de Communication Sociale en Vttamme A (Washmgton, DC Academy for Educational Development, December 1992)

15 Popenoe, Rebecca, Republic of Mger· Formative Research Vitamin A Social Marketing P1o;ect (Washmgton, DC Academy for Educational Development, January 1993)

16 Baker, op cit

17 Yoder, P Stanley, Fmal Evaluation Report, Vitamin A Promotion Pro;ect, Niger, Phase II (Washmgton, DC: Academy for Educational Development, January 1995)

18 The HKI/Food Frequency Method uses cutoff scores for frequency of consumption of vitamm A-nch foods that have been validated agamst WHO cntena for the prevalence oflow­serum retmol (a b1olog1cal mdJCator of v1tamm A deficiency)

19. Berger, Susan E, Preliminary Results of Study Conducted m Tahoua District, January 1994 and January 1995 (New York Helen Keller International, 1995)

20 Yoder, op cit

------------------ ---

Margaret Parlato and Peter Gottert are with the Academy for

Educational Development m "Washington, DC

I

Case study PHillP

Increasing Vegetable Gardening and Conswnption · the Philippines

Rorentino Solon Herny Briones Jose Rafael Hernandez Lonna B. Shafiitz

Moving to a Long-term Strategy: Increasing Vegetable Gardening and Consumption in the Philippines

INTRODUCTION

Each day 17 Filipino children become blind due to vitamm A deficiency, even though foods rich m v1ta­mm A are abundant throughout the country and cost little or are commonly available m the backyard. Many more children have subclmICal levels of vitamm A deficiency that weaken therr resistance to childhood diseases. One m 20 Frhpmo children under age seven has some form of v1tamm A deficrency, accordmg to

the 1993 national nutrmon survey. 1

To address this public health problem, the Ph1hppme government has mcluded v1tamm A pro­mot10n as a key component of the Ph1hppme Food and Nutrition Plan for 1993-1998. This plan calls for drstnbution of megadose (200,000 IU) vitamm A capsules to children aged one to four dunng 1993 through 1995 Capsule drstnbunon rs mtegrated by the Department of Health mto the Nanonal Immumzation Day (m March) and the National Micronutrient Day, better known as Araw ng Sangkap Pmoy (m October). In addmon, a branded non-refrigerated marganne, which rs fortified with v1tamm A, 1s commercrally available nationwide and rs purchased by low-mcome famil1es. 2

However, the government's long-term strategy is to change dietary patterns through comprehensive nutrmon educat10n/commumcation. By promot­mg consumption of v1tamm A-nch foods supple­mented by fortified margarme, the government

I

Florentino Solon Henry Briones

Jose Rafael Hernandez Lonna B. Shafritz

PHILIPPINES Total Population= 60.7 million Intervention (Cagayan de Oro) = 399,000 Comparison Site (General Santos) = 250,000

plans to gradually phase out capsule distribution. These efforts are aimed at eliminating vitamin A deficiency by the year 2000. The plan is to initially develop social marketmg strategies in growing urban areas. An

The government's long­term strategy is to change dietary patterns through comprehensive nutrition education/ communication.

inter-agency National Micronutnent Action Team (consisting of major domestic and international NGOs active in the field) is charged with imple­menting nutrition education/communication to support the National Micronutrient Program.

As part of this longer-term approach, the Nutrmon Center of the Philippines carried out an intervention to test the feasibility of promoting both consumpt10n and product10n of green leafy vegetables in a rapidly growing urban area of the Philippines. The Vitamin A Expert Group (a sub­committee of the National Micronutrient Action Team) and the Center designed the proJect in a series of consultative meetings and a three-day workshop during November and December 1993. The HEALTHCOM project, funded by the U.S. Agency for lnternat10nal Development and con­ducted by the Academy for Educat10nal Development, provided technical assistance in social marketing, administrative management, and a full-time resident adviser assisted by two field coordinators. (Local costs of the proJeCt totalled about US $450,000.)

Project leaders selected two cities on the southern island of Mindanao to serve as intervention and control sites. They wanted to test their approach in comparable medmm-sized cities that were growing rapidly. The intervention city needed to have ade­quate local broadcast media and cinemas; the con­trol would be in a different administrative health region and would be isolated from the other's radio and televis10n signals. These cities, located on the "garden island," normally receive sufficient average annual rainfall to support a gardening component. Support from local government officials was also

MOVING TO A LONG-TERM STRATEGY

essential. To keep costs down and enhance the pro­ject's prospects for both impact and sustainability, proJect planners wanted to integrate the campaign into the programs of various local government agencies. From the outset, the proJeCt was con­ceived of as a significant community mobilization program, paired with a multi-media campaign.

The cities selected, Cagayan de Oro (for inter­vention) and General Santos City (for comparison), have populat10ns of 399,000 and 250,000, respec­tively. In such densely settled areas, many low­income residents are malnourished. The Cagayan de Oro City Nutrition Governing Board assumed responsibility for actually implementing the pro­ject. Several city agencies undertook to organize special activities, including the City Health Office, Schools DivlSlon, Agriculture Office, Social Services and Development Office, and City Improvement Office. The Association of Barangay (or ward) Captains also played an active role.

AUDIENCE RESEARCH

Prev10us surveys had identified various causes of inadequate intake of vitamin A-rich foods. Parents explained that they seldom serve green leafy and yellow vegetables because their preschool children refuse to eat them. Mothers were not well informed about the health problems associated with vitamin A deficiency and the importance of consuming foods rich in this vitamin. Pnor to the campaign, the amount of green leafy and yellow vegetables grown for home consumpt10n had been low.

Specific information about knowledge, attitudes, and practices related to vitamm A and dietary patterns in the intervention city was needed, and the proJeCt commissioned a baseline survey m August/September 1994. Consumer Pulse Research, Inc., a marketing research firm, designed and earned out the formative research.3 In both the experimental and control areas, stratified, random samples of 300 women were selected. Respondents were all from the lower-middle and low-income groups, and were all mothers of children aged one to six. The survey included a 24-hour dietary recall

I

and collection of information on consumption of green leafy vegetables m the previous week. The quest10nnaire also focused on knowledge of vitamm A and specific green leafy vegetables, attitudes toward these vegetables, their different sources and supplies, mothers' experience with vitamin A cap­sules, and their sources of information and media use. The researchers also examined gardens in homes, communities, and schools to determme the amount of the green leafy vegetables bemg pro­duced (based on the number of plants and size of areas planted).

The baselme find­ings indicated that most households ate green leafy vegeta­bles regularly but that children aged one to six and preg­nant and lactatmg

About 28 percent at the children aged one ta six had inadequate intake at vitamin A~rich toads.

women consumed less than other household mem­bers. About 28 percent of the children aged one to six had inadequate intake of vitamm A-rich foods, based on their mothers' reports of food eaten m the previous 24 hours.

lnterestmgly, a high percentage of households mterviewed said they had some kmd of vegetable garden. Only 27 percent of those in outlymg rural areas and 20 percent of those m the city proper said they had no vegetable garden.

The survey also provided mformat10n about the prevalence of different media in the intervention area. Of households interviewed, 73 percent owned rad10s and 41 percent owned televisions. Exposure to these media was higher than owner­ship, however. Only 17 percent said they never lis­tened to the radio. In outlying rural areas, 58 per­cent said they never watched television whereas only 15 percent m the city proper said they never watched. Exposure to movies was low. In outlymg rural areas, 82 percent of households said they had not seen a movie in the last six months; 60 percent of urban dwellers said they had not watched Exposure to pnnt materials was also somewhat low, with 58 percent of those interviewed saymg they never read newspapers.

I

STRATEGIC DESIGN PROCESS

Defining the "Product" and the Objectives

An effective communication strategy requires sim­ple, act10n-oriented messages concerning an easily remembered "product." The program implemen­tors actually identified several products that could be promoted together in order to increase vitamm A consumption. These vegetables included Malunggay leaves, Alugbati, Camote tops, Kangkong, and Pechay. These vegetables were selected because they are widely acceptable, readily available throughout Mmdanao (and most other reg10ns of the country), and affordable to people of all income levels. Only pechay reqmres much labor to culti­vate. All five are very nch m vitamin A.•

In order to transform these five products mto one simple and memorable one, the team decided to coin a new acronym, MACK-P, from then mitial letters. In the campaign, the first vegetable­malunggay--received special attention.

Malunggay (drumstick or horse-radish tree) leaves are nch in vitamm A and calcium and are easy to grow Because the plant is found m most back yards, malunggay is one of the more pop­ular vegetables. It can be prepared in many different ways-as a base for stews or mixed with other veg­etables. However, it can turn bitter if 1t is not fresh, is over-cooked, or is past its

An effective communication strategy requires simple, actian­ariented messages about an easily remembered "product."

prime. One potential barrier to general consumption of malunggay is a somewhat poor image: many people think of it as a food for the poor.

Alugbatz (malabar mghtshade) and camote (sweet potato) tops are excellent sources of vitamin A and are common m the central part of the country. Kangkong (swamp cabbage) is also a good source of vitamin A, but suffers from a different kmd of poor image. It is often thought of as food for hogs.

Program staff check the price of a bundle of malunggay-the ''M" in ''MACK-P"-as part of a market survey

Many people mistakenly believe that the type of kangkong that is grown in swampy areas causes schistosomiasis (a parasitic infectton of the blood vessels and organs) and carries other worms as well.

Pechay (Chinese cabbage) contains vitamins A and C as well as calcmm and iron. It is well-liked and is considered a prestig10us food. Because it is labor-intensive to grow and commands a high pnce in the market, people mostly grow it to sell rather than for home consumption.

The MACK-P acronym also reflected the rank­ing of the five vegetables in regard to thetr vitamin A content. For example, malunggay has twice the Vitamin A content as camote and four times more than pechay.

Project planners set three major behavioral goals for the intervention:

• increase the frequency of consumption of the five green leafy vegetables by 25 percent among children aged one to six and among pregnant and/or lactating women,

• increase the production of the five MACK-P vegetables in household and institutional gardens by 25 percent;

• increase the frequency of purchasing MACK-P vegetables by 25 percent.

MOVING TO A LONG-TERM STRATEGY

In addmon, the project aimed to improve knowl­edge about vitamin A-rich foods and attitudes toward the spectfic MACK-P group, as a founda­tion for these behav10ral changes.

Audience Segmentation

Given the complexity of changing food consump­tion as well as production behav10rs, the project selected a number of different target audiences Primary audiences were those at nsk, or those who influence their diets:

II parents of children aged 6 months to 14 years old;

• pregnant and lactating women; and

• school children.

Parents are obv10usly the key decis10n-makers regarding food purchased, produced m a garden, and served at home. Pregnant and lactatmg women nounsh their children m the womb or through breastmilk and are the primary source of vitamin A for infants. School children

Improving the image at green leafy vegetables among children themselves would also help "empower" the toad provider.

were another signifi­cant target group m the intervent10n. Lifelong eating habits are shaped early. Children are exposed to advertismg and store displays pro­moting junk food, but may lack infor­mation on healthy foods. They can be

effective voices in carrying messages to adults, and are the parents of the future and the trend setters for the next generation. Formative research showed that mothers thought their chil­dren disliked vegetables, and found this a barri­er to servmg them. Improvmg the image of green leafy vegetables among children them­selves would therefore also help "empower" the food provider.

I

The proJeCt also focused mtens1ve efforts on a number of secondary audiences:

• local government officials, who provided logistical support to the campaign and were mstru­mental m commumty mobilization;

IB government frontline workers and commum­ty volunteers who are the main sources of knowl­edge on nutrmon and served as active promoters wtthm the commumty;

IB vegetable growers and vendors, m order to encourage them to produce and sell the MACK-P vegetables; and

• owners of small eaten es ( carenderta) and food vendors, since poor families and workers often pur­chase cooked food.

Messages

Tactical messages m the intervention focused on eating, plantmg, and purchasing MACK-P vegeta­bles. The most simple, direct message designed for broadcast media, which served as the taglme for all rad10 and television spots, was "Eat malunggay and other vegetables nch m vitamm A every day!" Messages for print, mterpersonal, and various com-

Children were an important target audience m the interven­tion Televmon commercials were pretested with them as well as adults

I

mumty-level channels were more detailed. For example, they provided mstructtons on procedures for gardeners who wished to plant green leafy veg­etables, and recipes for mothers who wished to

serve a balanced diet with MACK-P. Vanous thematic messages supported the actton­

onented recommendat10ns by focusmg on the ben­efits of MACK-P. Campaign matenals stressed that malunggay and the other green leafy vegetables con­tam v1tamm A and that v1tamm A 1s good for the eyes and helps children to grow tall and strong. Prevent10n of mghtblmdness and promot10n of greater height were linked to MACK-P throughout the campaign "Mighty Malunggay," a super hero, mcarnated these protecttve qualities, and became the star of TV spots and also booklets for parents. Some materials refuted the belief that kangkong causes sch1stosomias1s.

Media Mix and Promotional Plans

ProJect planners selected a media "mix" based upon the prevalence of different channels and a strong emphasis on commumty mobilization. Broadcast

Various thematic messages supported the action-oriented recommendations by focusing on the benefits at MACK·P.

media therefore served not only to dissemi­nate basic messages, but also to support local vitamin A promotional events through live coverage of events, special mterv1ews, and enter­tainmen ti mformatton approaches. Rad10 was selected as the

primary broadcast medmm due to its high owner­ship and listenersh1p. Telev1s10n and cmema spots were aimed at delivenng addmonal impact. The proJect hired Well Adverttsmg Company to design the broadcast and pnnt materials for the campaign.

Much of the work of sttmulatmg awareness and demand for the intervent10n's goals, however, fell on the shoulders of mynad local government agen­cies and commumty organizations. The City

Government of Cagayan De Oro signed a Memorandum of Agreement with the Nutrition Center of the Philippines in August of 1994, defin­ing the role of the city government and the various technical agencies in implementing the social mar­keting activities. In effect, the city government, personified by the Office of the Mayor, took on the social marketing ofMACK-P as its own project and mobilized its resources to support the actual design of local project activities. Lme agencies m health, education, social wel-fare, agriculture, and nu trmon subsequently mobilized their own staffs to conduct these events and to carry out energetic mterper­sonal outreach in the communities.

One of the unique aspects of this project

Radio was selected as the primary broadcast medium due to its high ownership and listenership.

was the extraordmary decentralizat10n of plannmg Each of the agencies developed its own implemen­tation and momtonng plans, which were reviewed at the central project level.

Advocacy sessions with these different groups from the very outset were essential to help assure their support and enthusiasm. The sessions began in June at higher levels with the City Mayor, City Council Members, and heads of techmcal agencies. In August, the proJeCt held such sess10ns among the captams of the 80 wards withm the Cagayan de Oro City.

Training for Community Outreach

Although traimng of relevant service providers to deliver mterpersonal messages is an important part of any social marketmg program, traming had a broad role m the promotion of MACK-P. In August, a core group of 14 techmcal staff from the various agencies partiopated in a week-long plan­ning/traming exercise in order to ensure unified messages and approaches at the community level. During the workshop, participants developed their

MOVING TO A LONG-TERM STRATEGY

own plans for their agencies to conduct events geared to their particular target audiences. (For example, the City Division Office of Schools pro­posed "MACK-P Corners" in school rooms and visual aids to be used by both teachers and pupils.) The partiopants also finalized plans for "echo" trainmg of their respective field workers.

In the followmg two months, each agency con­ducted a senes of traming sessions for their own frontline workers and community-based volunteers in order to orient them to the project and train them m outreach techmques. Training for these workers was extensive:

• The City Division of Schools conducted ses­sions in nine district schools, reaching 1,419 teachers, 56 school administrators, and nine district super­visors.

lmong Basahon Pagdasig sa mga Pamilya sa Pagkaon ug Pagtanom ug Malunggay Atbp.

Thts booklet for ctty workers provided ideas about how to plan creative MACK-P "events" zn their dzjferent departments

I

II The City Health Office trained 147 staff members, including medical officers, public health nurses, nutntiomsts, rural health midwives, and samtary mspectors. In addition, the Health Office trained 85 commumty-based health volunteers (who cover about 25 families each), and 71 Avon ladies (cosmetic salespersons).

Ill The City Improvement Office trained 106 commumty-based volunteer workers for nutrition.

II The City Agriculture Office tramed 38 agn­cultural specialists. In turn, this group trained about 700 members of the Farmers' Association and 485 members of the Rural Improvement Club (com­posed of women farmers).

Ill The Department of Social Services and Development tramed 21 social workers and field supervisors as well as 79 day care workers.

"MACK-P Corners" dzsplaymg the five vegetables and explam­mg thezr benefits appeared m school rooms across the czty

All of these workers learned what roles they could personally take to bring MACK-P "alive" in a range of creative ways. For example, the City Health Office gave sess10ns on vitamin A health issues, tips on health center displays and gardens, recipes which could be used in innovative "food stalls," and methods for distnbutmg a proposed parent's guide.

I

By mobilizing these different agencies to come up with their own events, the project assured mter­personal commumcatlon (whether one-on-one or one-to-group) to the full range of target audiences. The health workers would reach pregnant and lac­tatmg women, preschoolers and their mothers and fathers; social welfare workers would reach three­to six-year-olds and their mothers; educators would reach seven- to fourteen-year-olds in the public schools and in turn their families; and agricultural workers would reach mdividual farmers, farmers' associations, and women's orgamzations in the dif­ferent barangays (wards).

IMPLEMENTATION

Special Activities

Community activities brought the basic campaign message, "Plant and eat MACK-P" vividly mto the minds of cltlzens. MACK-P was present through­out the city:

In Schools. Teachers, pupils, and parents partic­ipated in classroom and school garden activmes. Teachers and their students organized displays about the five green leafy vegetables m 1,386 class­rooms m the city's 47 public elementary schools. Grades five and six students created ongmal MACK-P recipes and held cook.mg demonstra­tions. Grades three and four students participated in MACK-P jingle singing contests Quiz shows on the benefits of eating MACK-P were held for grades four through six. Many of the schools had gardens

Community activities brought the basic campaign message, "Plant and eat MACK-P" vividly into the minds

at citizens.

and planted these with MACK-P. Some used the produce to

feed malnourished pupils or sold it to the community. School actlvltles reached about 55,000 school chil­dren. Seventy kinder­garten classes with nearly 1,800 pupils also participated.

Students m grades three and four partzczpated zn MACK-P

pngle-szngzng contests

Via health centers. Health workers set up eight displays and 18 gardens containing the MACK-P vegetables m the city's 47 health cen­ters. Some centers participated in rad10 quiz shows and recipe contests. Health workers also persuaded 20 small eatenes (carenderia) in the public market to sell dishes containing the MACK-P vegetables.

Through farmers' groups. Agricultural workers encouraged communities to establish communal gardens on vacant public and pnvate lands. In rural districts where land was available, volunteers and citizens planted 21 communal gardens. The farmers' association and women's groups assisted families m eight rural districts to establish home gardens. Agricultural workers provided seeds and cuttings of the MACK-P vegetables.

At day care centers.

MOVING TOA LONG-TERM STRATEGY

To encourage broad pamcipation, most agencies arranged contests at each level (for example in schools or wards) and culmmatmg at the city level in creation of recipes for MACK-P, song-wntmg, gardening, and so forth, and gave special pnzes (T­shirts, cash and certificates) to the best displays and wmners of competitions.

Broadcast Media

Broadcast matenals prepared for the campaign tar­geted multiple audiences. Four televis10n spots on the benefits of vitamin A were designed to appeal to parents and children. Two of these spots were also shown m cinemas as "infomercials." The popular animated Mighty Malunggay spot featured the super hero saving a little boy who, trippmg over a trash can, falls in the way of an oncoming truck. After understanding that the boy has nightblindness due to a deficiency of vitamm A, Mighty Malunggay convmces him to eat MACK-P. Fence of Life used a background of nursery rhymes and a stylized panorama of children to emphasize the key benefits (good eyesight and good health) of eating and planting MACK-P.

Two radio spots adapted the storylines of Mighty Mulunggay and Fence of Life. In addition, the pro­ject promoted rad10 coverage of campaign activities throughout the city. Coverage mcluded live reporting

of special events, on-the­spot interviews, question­and-answer programs, qmz shows, recipe contests, and announcements about local activities. With the help of parents,

day care workers set up displays and gardens con­tammg the MACK-P veg­etables. They also orga­mzed "family fun quiz shows" with parent-child teams m 95 day care cen­ters. These activities reached about 2,000 chil­dren and their parents.

Health centers sponsored radzo quzz shows and recipe contests "MACK-P wzth coconut oil" shown here, won a top prize

A national research company, Trends-MBL, Inc., pretested both radio and television spots through four focus group discussions of local moth­ers aged 18 to 45 and children aged seven to nine. Pamcipants were all from lower-middle and

I

Pretesting-Understanding the Mother's Perspective

retesting of radio and televis10n spots revealed points needing refine­

ment, and also provided valuable new insights into mothers' views on food preparation and eating habits.

In the target households, food purchases consume more than half the family income. Mothers wished they could afford to serve more meat, which they regarded as essential to a healthy diet, and associated eating lots of vegetables with being poor. However, they were aware that vegetables contain vitamins and other nutrients, and made an effort to serve them to their children-sometimes offer­ing bribes or camouflaging the vegetables.

Mothers were grateful that the project's television and radio spots remforced the idea of servmg vegetables to children. They wanted their

children to see the spots in order to offset junk food commercials. They liked the message that providing nutritious food does not have to cost a lot of money, and felt vindicated for serv­ing malunggay, which is usu­ally the cheapest vegetable available.

Neither mothers nor chil­dren in the pretest groups understood the concept of nightblindness well. How­ever, mothers were willing to accept the message that increased intake of vitamin A "makes the eyesight clear," whereas children were more interested in "makes one tall." In the original Mighty Mulunggay spot, children thought that the boy stum­bled on a stone because he was weak. The storyline was changed (to have him run into a trash can) in order to make it more dear that his eyesight was poor. Children liked the super-hero Mighty

Malunggay and wanted to be strong and smart like him.

Pretesting identified prob­lems with the translation into the local dialect, the accent of the speakers, and the density of 15-second spots. Although the transla­tor was a native Cebuano speaker, he was from a slightly different region than the target area. Even such fundamental phrases as "clear eyesight" (which in one dialect can be interpret­ed as "dagger looks"), "full of vitamin A," and "night­blindness" needed to be refined for the target audi­ence. Some participants said that the messages in the 15-second spots were too complicated to be under­stood in such a brief time. Key concepts were therefore re-cast so that meaning was unmistakable in the dialect of that geographic locale, and the short spots were simplified.

Radio·hroadcasters devoted nearly IB hours of tree air time to interviews and live coverage of MACK·P

events.

low-income groups because these popu­lations were at great­est risk of vitamm A deficiency.5 Results led to a number of refinements in the spots.

The project held a media launch and press conference in

November 1994. The resultmg publicity included 22 live reports on rad10 and television and three feature articles m local newspapers about the special events A delayed start of implementation (resultmg from a lengthy contractmg process for the media produc­tion) limited the media campaign to only 13 weeks mstead of the six months origmally planned. Still, media coverage dunng this penod was mtensive. Nine radio stations aired campaign spots more than 5,000 times; three televis10n stations aired spots 445 times; and six cmemas showed spots 1,600 times.

I

In addition, radio broadcasters devoted nearly 19 hours of free air time to mterviews and live cover­age m order to promote MACK-P events.

Print Materials

Three major print materials, broadly disseminated, pnmanly supported the mterpersonal activities and community events. A guide for parents entitled "Malunggay and Other Green Leafy Vegetables: Your Key to a Healthier Family'' contamed mfor­mation about vltamm A, the consequences and symptoms of vitamin A deficiency, reopes usmg the five MACK-P vegetables, and food prescription slips. The handy charts allowed parents to virnalize the quality and quantity of food needed to provide children with a balanced diet. More than 45,000 copies were distributed to parents by commumty­based health and nutrition volunteers, teachers, and workers in day care and health centers. Frontline workers and volunteers also received a special gmde. "Your Gmde m Motivatmg the Family to Eat and

A simple booklet for parents featured Mighty Malunggay explaining the benefits of vitamin A and how to increase both consumption and home production

MOVING TO A LONG-TER!d STRATEGY

Thts colorful "food prescrzptzon slip" helped parents visua­lize the appropriate quantities of foods for different ages

Plant Malunggay and Other Vegetables" stated the project objectives, campaign messages, and the specific respons1billtles and acuviues of each 1mplementmg agency. More than 3,052 frontline workers and commumty volunteers received cop1e5. Durmg the launchmg ceremony in November, media representatives (radio, televis10n, and pnnt) received copies of a "Broadcaster's Manual" which briefly outlmed project messages and gave support­ing background informauon.

MONITORING

Each local government agency periodically mom­tored its own campaign activmes and compared results to the plans they had developed In addi­tion, project management staff and techmcal advisers paid unannounced vmts to schools, day care centers, health centers, and radio and televis10n stations. For example, teachers v1s1ted houses of studens and kept charts at the local schools.

I

Learning to Garden via the Radio

T o encourage broad cover­age of vitamin A activities and issues, the project gave

radio broadcasters a manual with sample "scripts" of inter­views. In the one that follows, a mother calls in to ask advice on how to grow vegetables when she has very little space. "Mrs. Pineda" has four active children and finds the rising cost of vegetables a worry.

Radio Expert Response: Mrs. Pineda, Believe it or not, you can still have your own veg­etable garden even in a small, limited space. You can plan them m pots, plastic bags, or tin cans. Here are three very easy steps you can follow:

1. Fill container with soil mixed with dry manure or

RESULTS

compost about six inches thick.

2. Stick three to four stems of malunggay about three inches deep into the soil.

3. Water regularly.

The method of planting pechay is slightly different from the other vegetables but it's still easy to do:

1. Prepare a container or seedbed that can hold soil two inches thick.

2. Pulverize the soil and sprin­kle thinly with seeds.

3. Cover the seeds thinly with soil.

4. After three weeks, transfer seedlings in plastic containers,

tin cans, or pots, or in a garden plot.

For planting m plastic containers, tin cans or pots, JUSt follow the same steps as in planting alug­bati, camote tops, and kangkong.

1. Fill container with soil mixed with dry manure of compost about six inches thick.

2. Stick three to four stems about three inches deep into the soil.

3. Water regularly.

You see, it's really easy to plan and maintain a vegetable garden. Start one today and enjoy a great harvest of fresh, budget-saving vegetables the soonest!

A post-campaign survey consisted of interviews with 300 women-mothers of children aged one to six-each m Cagayan de Oro and the control site, General Santos City, during February/March 1995.6 The survey found that the project had achieved most of its obJectives.

area; consumpt10n of the other two vegetables increased slightly. The control area saw less than 10 percent increases for two vegetables and no change or declines for the other three.

The proportion of intervent10n children aged one to six who had eaten green leafy vegetables m the 24 hours before the survey rose from 35 percent to 42 percent after the campaign-a 20 percent increase after three months of media pro­motion and five months of mterpersonal and special events. Most mothers reported that they increased children's consumption of the MACK-P vegetables by serving dishes made from their usual recipes more frequently, rather than trymg new recipes.

Consumption of all five MACK-P vegetables m the week prior to the survey increased markedly among children aged one to six and among preg­nant and lactatmg women m the experimental area. Household consumption m the previous week of three of the five MACK-P vegetables rose by more than 25 percent m the experimental

I

Intervention households revealed more favorable amtudes toward vegetables after the campaign. A higher propomon of mothers agreed that daily serv­mgs of vegetables are necessary and that green leafy vegetables will make preschool children grow tall, whereas the control area showed little change m these pamcular atutudes. Children's dislike of veg­etables was sull the mam reason cited for not serv­ing the MACK-P vegetables.

Among children aged one to six, vitamin A intake from plant sources (based on 24-hour food recall) mcreased by 12 percent m the expenmental area but decreased by 48 per-cent in the control area. Both areas were affected by a drought during the interven­tion period, which unfortunately makes it difficult to draw useful compansons between the causes of food consumption patterns m these areas. This could explam the fact that children's consump-

The proportion at intervention children aged one ta six who had eaten green leafy vegetables in the 24 hours before the survey rose tram 35 percent to 42 percent.

tion of MACK-P remained lower than that of other household members.

The campaign did not generate as much behav-10ral change among mothers regarding feeding of 6-to 11-month-olds. Although the sample size was small and conclusions must be tentative, the data mdicated that few of these very young children were fed MACK-P despite mothers' own declarations that mfants need vitamm A more than other family mem­bers. The chief barrier remains a widespread belief among parents that green leafy vegetables cause diar­rhea at this age.

After the campaign, more households in the experimental area were growing each of the five MACK-P vegetables, whereas an mcrease in house­hold gardening was found for only one vegetable in the control area. Increases in the experimental area ranged from 37 percent to 700 percent. The eval­uation noted an increase in production of MACK-P

MOVING TO A LONG-TERM STRATEGY

Home production of MACK-P vegetables increased substan­tially through promotion ofszmple methods, such as growing of peachay zn sand bags, as shown here

m schools, day care centers, and health centers m Cagayan de Oro City, which increased the overall availability of MACK-P. However, the drought during this period inhibited planting and reduced crop yields in both areas.

The campaign achieved excellent coverage, reach­mg many survey respondents through multiple chan­nels. The propomon of mothers who said they had seen or heard information about green leafy vegeta­bles rose from 36 percent before the campaign to 95 percent following the campaign. More than half the respondents had heard or seen the rad10 and televi­sion spots. Although few volunteered that print materials were a source of their information about MACK-P, more than one-third recalled receivmg such matenals when asked directly. Nearly one m four heard about the MACK-P vegetables from gov­ernment workers, especially midwives and commu­nity health volunteers. Interpersonal sources reached more of the rural audiences, while mass media (radio and television) reached more urban residents.

The project also brought financial benefits to par­ticipating agencies and families. One elementary school prmcipal reported that fewer children needed supplementary food at school and that school atten­dance improved. Her school earned money from selling extra produce in the market and used it to

buy more seedlmgs and planting materials and to defray costs of parties for each class.

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LESSONS LEARNED

The project demonstrated that an intense, albeit brief campaign can mfluence food ch01ces-indud­mg both consumption and production practices­when all elements of a social marketing approach are set in motion. In particular, this mtervention illustrated the importance of local government and community support mechanisms. Clear advocacy and leadership from the top, support through the various agencies, and collaborative implementat10n of the project gave it visibility throughout the com­mumty, and also meant that "success" was widely owned by all of those mvolved. Such par­ticipation is essential to sustammg gains and applymg lessons to future goals.

Moreover, because the pilot was a jomt effort with the National Micro­nutrient Act10n Team ( consistmg of the

The project demonstrated that an intense, albeit brief campaign can influence food choices.

Undersecretary of Health for Health Education and major domestic and mternational nutrition NGOs), it is receivmg attent10n from national deci­sion makers and the results will be applied toward larger efforts.

Other key insights can be applied to programs throughout the world:

• A multi-media, multi-channel program can bring about changes m deeply ingramed behav10rs when messages are consistent and reinforcing. This project demonstrated once more the impact that community volunteers and health workers can have in complementing media coverage and help­mg to clarify complicated messages In this case, mterpersonal channels had greater reach m outly­ing rural areas, whereas mass media had greater reach in the city proper.

• Experience m this project confirmed the importance of pretesting all materials-including

I

translations Only the target audience can confirm that mtended meanings have been conveyed. If 15-second radio or television spots are to be used, messages should be simple and dear

• Targeting messages to elementary school chil­dren can influence their own attitudes and behav­iors, as well as influence or support those of their parents. Children m Cagayan de Oro City liked the super-hero character and nursery-rhyme pngles created for the campaign. Mothers said that the campaign made it easier for them to convince their children to eat green leafy vegetables.

• The very young child (6 to 11 months old) was a difficult target group in the MACK-P project, and has been m many projects around the world. The belief that green leafy vegetables are hard to digest or cause diarrhea among the very young is a serious barrier. Message strategies need to focus strongly upon this key age group when feeding of solids starts, and on the particular barriers to healthful dietary practices.

• Nutrit10n-related programs can have spillover effects which increase the likelihood of sustainabil­ity; for example, income generation from the sale of vitamin A-rich vegetables m this project helped buy new materials and provided a reward for those working on the project. The major long-term ben­efit of this project may have been to convmce mothers that inexpensive, home-grown foods can provide a well-balanced, healthy diet. In addmon, the prospect of earning mcome from MACK-P veg­etable sales mcreased the likelihood that schools, households, and other groups will continue grow­ing these vegetables.

• The number of objectives, audiences, behav­iors, and products mduded in the campaign added to the complexity of the research process m this mtervention. Research results were delayed partly due to this complexity. Seemmgly carefully integrated plans can "backfire" as the complexity of an mtervention mcreases Simplicity has its own virtues, which should be factored mto plannmg.

• The process of obtaming contract approvals, and also the time required to learn the results of research, can always be expected to take longer than ongmally planned. Project planners need to bmld

The very young child [B ta 11 months aid} was a difficult target group in the MACK-P project, and has /Jeen in many projects

around the world.

in extra time to allow for possible delays m both these areas. At the same time, mobi­hzmg support for streamlining these processes is important for increasing effi­ciency of social mar­keting efforts over time. In general, tight umelines can only be met in project sites where significant

mstitut10nahzation of the sooal marketing process has already occurred, and counterpart orgamzauons can provide full commitment and support.

NOTES Food and Nutrition Research Institute. Fourth

National Nutrition Survey, 1993 (Mamla: FNRI, 1994)

PROFILES, a computenzed nutrinon model, calculated

child deaths based on the prevalence rates for v1tamm A

deficiency reported by the survey (Academy for

Educanonal Development, 1995)

2. Nanonw1de marketmg was mmated after an effecnve

field tnal descnbed in Solon, Florentmo, Evaluation of the

Effect of Margarine Fortified with Vitamin A on the Vitamin

A Status of Selected Sub;ects in a Community (Makan

Nutntion Center of the Ph1hppmes, 1993)

3 Consumer Pulse, Inc. Data Tables, Knowledge, Attitude,

and Practice Survey on the Consumption of Malunggay Atbp

(available from the Academy for Educational

Development· February 15, 1995)

4 Each 100 grams cooked would provide an eqmvalent of

Retinol as follows malunggay 980ug., alugbat 650ug.,

camote tops 453ug, kangkong 418ug, and pechay 234ug.

See Nutntion Center of the Ph1hppmes (NCP), A Report on

MOVING TO A LONG-TERM STRATEGY

the Pro;ect Social Marketing of Malunggay Atbp (Mamla and

Washmgton, DC NCP and Academy for Educational

Development, Apnl 1995)

5 Trends-MBL Inc Final Report on Pro;ect Leajj; (Quezon

City: Trends-MBL, November 29, 1994)

6 Consumer Pulse, Inc Final Report Knowledge,

Attitude, and Practice Survey (Pro;ect Laser Vision 2) (avail­

able from the Academy for Educational Development

Apnl 13, 1995)

Florentino Solon and Henry Briones are with the Nutrition

Center of the Phtlippines Jose Rafael Hernandez was with the

Academy for Educational Development in the Phtlippines

Lonna B Shafotz is with the Academy in Washington, DC

I

Case study

Blank

The Use of Integrated Media for Promotion ofVitatnin A C.apsule Consumption in Central Java, Indonesia

Thomas K Reis

Renata E. Seidel

Sartono, Sudaryono

Anne Palmer

The Use ol Integrated Media for Promotion ol Vitamin A Capsule Consumption in Central Java, lndonesia1

INTRODUCTION

In Indonesia, vitamm A deficiency remams a sen­ous threat to child survival. Nearly half of chil­dren under age six have madequate intake of vita­mm A, which increases their vulnerability to dead­ly childhood diseases. Blindness and corneal lesions (xerophthalmia) caused by vitamin A defi­ciency have become increasingly rare (affectmg one to two percent of children under age six, or approximately 50,000 to 60,000 preschool aged

' . ''

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'' I t . I r r r ~

' ''

Thomas K. Reis

Renata E. Seidel Sartono, Sudaryono Anne Palmer

children per year) However, the prevalence of milder eye diseases associated with this problem rs at least ten times higher. Many Indonesians con­tinue to associate the dangers of vitamin A defi­ciency with blindness. Convincing parents and health workers that vitamin A deficiency remains a threat to therr children is a challenge, now that the decline m blmdness has made the dangers less readily discernable.

In its fourth five-year plan (1984-1989), the Government of Indonesia (GOI) committed itself

INDONESIA Total Populanon = 179.3 m1ll1on

Intervention area= 1.5 m1lhon (Demak and Jepara d1stncts, Central Java)

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I'' ' ~ I \,

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to lowering morbid­ity and mortality of children under five from various causes, including vitamin A deficiency. At that time, the Indonesian Department of Health

In Indonesia, vitamin A deficiency remains a serious threat to child suruiua/.

had a national three-pronged strategy to decrease the prevalence of this problem among children between one and five years old. The plan called for:

• increasing target audience consumption of vitamin A-rich foods including dark green leafy vegetables, fruits, and fish;

• distributing megadose (200,000 IU) vitamin A capsules twice annually through village health posts;

• fortifying selected foodstuffs with vitamin A.

The Department of Health conducted various operations research projects regarding all three aspects of the strategy with the assistance of the World Health Organization, USAID, and other internat10nal and local nongovernmental organiza­tions. These projects became the basis for further development of the national strategy, expans10n of numbers of provinces receiving intensified assis­tance, and refinement of strategies for reducing vit­amin A deficiency. (See case study which follows.)

VITAMIN A WITHIN THE CHILD SURVIVAL CONTEXT

The Government of Indonesia requested assistance from USAID in carrying out one operations research project aimed at the second prong of the five-year strategy: namely distnbution of megadose vitamin A capsules to children on a semiannual basis. The three-year project, known as ROVITA, was inmated in late 1986 in the province of Central Java. One of ROVITA's goals was to apply social marketing techniques to increase the distribution and demand for megadose vitamin A capsules

THE USE OF INTEGRATED MEDIA IN INDONESIA

among mothers of children between one and five. The project originally aimed to achieve a coverage of 90 percent of those children in its target areas.

ROVITA also had two objectives related to diar­rheal disease: 1) to improve case management of diarrheal disease among children under five years old through oral rehydrat10n therapy and improve supply of oral rehydration salts (ORS), and 2) to

measure the change in incidence and severity of diarrhea before and after vitamin A supplementa­tion in a small cohort of children. This joining of themes was reflected in the project's name, ROVI­TA, which 1s an acronym for "Rehidras1 Oral" and "Vitamin A." This case study focuses on ROVITA's experiences in promoting vitamin A capsules.

Within the Indonesia Department of Health, ROVITA was a cooperative effort of the Dlfectorates of Diarrheal Disease Control, Family Nutrition Improvement, and the Dlfectorate of Community Health Educat10n. The project office was located in the Department of Health provincial headquarters in Semarang. With the Indonesian Department of Health as implementor, ROVITA drew addmonally upon the experuse of its collabo­rating organizations· Helen Keller International (HKI) as management facilitator and Diponegoro University as coordinator of evaluation activities. In the area of social marketing, ROVITA received tech­nical assistance from the HEALTHCOM Project.

SOCIAL MARKETING GOALS AND THE CONSUMER FOCUS

Social marketing focuses on the consumers-in this case the child and his or her caretakers-as the mea­sure of whether a product 1s deslfable, appropriate, affordable, and conveniently available. The initial step of social marketing activities is, therefore, usu­ally audience segmentation. Important groups include not only the primary target audience (gen­erally mothers in a child survival effort) but also secondary audiences such as husbands, health care workers, village leaders, community organizat10ns, and rehg10us groups. These people can have a strong influence upon what mothers value, what

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they know, and what they do. The goals of a commumcat10n program are defined in terms of the different target groups.

The ROVITA Project's target areas were the two distncts (or counties), of Demak and Jepara, located approxi­mately one hour and 2 5 hours respec­tively from the Central Java capital of Semarang. The total population mcluded approximately 1.5 million people. Among these were an estimat­ed 230,000 children under the age of five and an estimated 290,000 mothers of child bearing age. The project's pri­mary audience was caretakers (mostly mothers) of children between one and

The montho/ village posyandu rs held ma temporary location and p1ov1des a range of preventive health services

five years of age. Approximately 65 to 80 percent of this audience were from low mcome groups and lived m rural or semi-urban areas. Only about one-third of the mothers had completed six years of schooling.

The first tier secondary audience-those who deal most directly with mothers-mcluded kader, or community health volunteers (usually local mothers), and district health center staff, or puskesmas workers. Kader interact with mothers m two major ways. 2 They are responsible for holding posyandu, or temporary village health posts, once each month. Mothers come to have their babies registered and weighed, to have

Twice a year fin February and August/ kader disribute tree megadase vitamin A capsules ta children at the pasyandu.

their children's growth monitored on a monthly basis, to have their children vaccinated, to obtam ORS, and to receive health counselmg-mcludmg family plannmg mformation.

Twice a year (in February and August) kader also distribute free megadose vitamm A capsules to chil­dren at the posyandu. In addmon, these volunteers are responsible for going out mto the commumty to

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contact mothers who have not come to the month­ly posyandu sesswn. The Department of Health decided to rely upon the kader for distribution of vitamin A because mothers tend to view the posyandu as a place for healthy babies and for pre­vention and counseling, whereas they view the much more distant district health center, or puskesmas, as a treatment center and generally go there only when their children are sick.

The second tier secondary audience for the vlt­amm A capsule mtervention-those people who may influence mothers-mcluded husbands and community leaders such as the village chief, vil­lage elders, religious leaders, and teachers. The tertiary audience mcluded local government offi­cials and key decision makers withm the Department of Health.

Given these target audiences, the ROVITA Project determmed that its soC1al marketing program should concentrate on the followmg objectives:

• to develop a commumcat10n strategy aimed at mcreasmg mtake of vitamm A among children one to five;

• to improve kader skills m registering mem­bers of the target population;

• to mcrease kader skills in delivering vitamm A capsules and informat10n to the target group;

• to mcrease kader skills in recordmg and reportmg v1tamm A distribution;

• to strengthen the nutrition education compo­nent of posyandu sessions in relation to vitamin A.

The strategy for achieving the first of these goals focused on des1gnmg and conducting a series of integrated print and radio commumcation mter­ventwns to reach mothers and those who mfluence them on a daily basis. The strategy for achieving the remainder of these goals focused on effective face-to-face training of village health volunteers (targeted toward their dual roles as educators and distributors of v1tamm A capsules).3

The overall vitamin A capsule program therefore balanced promotion, or "demand creation" activi­ties, with distribution, or "supply side" activities.

MARKETING RESEARCH AND MESSAGE DEVELOPMENT

The collaborative nature of the ROVITA Project gave It strong resources to draw on m carrying out both the commumcation and trammg aspects of the program. Techmcal mput into message design came from experts m several sections of the Department of Health. The head of the Health Educatwn Section led the mass media communica­tion effort with assis­tance from the HEALTHCOM resi­dent adviser. The vit­amm A program manager (Nutrition Section) designed the

The ROVITA team carried out a series of studies to investigate the target audiences' perspectives, preferences, and practices.

face-to-face training strategy, and the traming mod­ules were elaborated with help from the Health Education Section head, HEALTH COM, and HKI.

This cooperative process began with the formula­tion of an mtegrated marketmg design. The two

THE USE OF INTEGRATED MEDIA IN INDONESIA

major goals of this design were: I) to develop sim­ple, memorable, and action-oriented messages that would be consistent from medmm to medium as well as integrated mto the face-to-face trainmg; and 2) to use the results of audience research to select media, develop materials, and distribute (or broad­cast) these to the target audience. The development of messages and the selection of media went hand m hand. Market research with the target audiences provided the foundation for both refining messages and planning commumcatwn activities.

The ROVITA team began by cons1dermg sever­al medical and logistical aspects of the vitamin A capsule mtervention as a basis for selecting a broad number of possible communication messages. The most important of these concerned attributes of the product (vitamm A capsules) mcluding the facts that they are free, for children, available twice a year (during February and August), and distrib­uted at the posyandu. Other messages concerned the importance of vitamin A for healthy eyes (the danger of corneal leswns, mght blmdness, and xerophthalmia) and the reasons for takmg capsules twice a year

In collaboration with a private Indonesian research firm, the ROVITA team then carried out a series of studies to investigate the target audiences' perspectives, preferences, and practices. The major studies were:

• a literature review of available mformation related to v1tamm A defioency;

• an ethnographic survey mcluding in-depth mterviews regardmg knowledge, attitudes, and practices of mothers (n=64), kader, (n= 16), formal and informal village leaders (n=16), retailers (n=8), tradmonal birth attendants (n=8), and puskesmas physicians and nurses (n=4);

• audience research to determine literacy, media usage, rad10 and telev1s10n ownership, popu­lar listening hours and stations, and so forth.

These studies revealed mterestmg mformatwn about the target audiences' understanding of the product and the advantages of different communica-

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I

In Indonesia, a "pill" per se ts valued as a painless key to good health Vitamin A has the added advantage of coming in an easily recognized shape

product. Local radio stations reached the maJority of even the most rural areas m Jepara and Demak. Studies mdicated approximately 40 percent of target mothers owned radios and 70 percent listened to the radio. The most popular programs were mm1dra­mas and mystery shows Print mate­nals appeared less prom1smg. Mothers Ill the target areas did not rounnely read newspapers or penodi­cals. On the other hand, cloth ban­ners are a very popular mass medmm Ill Central Java. On a given day, five to ten banners may be draped across streets or buildings m a town center advertising commercial products

uon channels. The team learned that mothers had little awareness of the prevalence of night blmdness or the value of vitamm A. Nevertheless, the product held certain mherently desirable qualities for them. A pill per se is valued by both mothers and health care providers because tt represents a tangible, pamless key to good health. Mothers put great faith m pills and are mterested in obtaining them for their chil­dren. Health care workers therefore find it reward­mg to distribute pills. Having something to give away affords the volunteers status. Pill-dispensmg held potential as a rallymg point for the posyandu.

Although those mothers surveyed had little understanding of the value of vitamm A, they were familiar with the capsule's distinctive look and had a local name for It (translatmg as "fish oil") Their familiarity with the product therefore had both positive and negative aspects The product could be easily identified by Its large tear drop shape, but one would not want to stress its common name.

Radio appeared to be a prom1smg medi­um for promoting the

I

Obviously, the same amount at information cannot be conveyed through radio, an a banner, or through personal contact.

(such as cigarettes and foodstuffs) or events (such as films, sports, or music and drama events). The appearance of a new banner 1s wide­ly noticed in a village.

Choices of mass media centered on radio as a primary channel to announce and explam the mtervention and banners as a supportmg medium to be displayed at the posyandu, puskesmas, village halls, and other promment places. Print matenals such as posters were deemed inappropnate for a semiannual promotion since they would be too expensive for one-time use but not durable enough for multiple use. The banners, however, could be made durable enough to be reused and were valued enough by village chiefs that they would be stored during the mtervemng months and brought out for succeedmg interventions.

The choice of media m turn helped mfluence commun1Cat1on messages. Obviously, the same amount of information cannot be conveyed through radio, on a banner, or through personal contact. What mformation would bring mothers to the health center? Pretestmg of draft materials with the target audience showed which of the numerous commumcation messages mentioned in the beginnmg of this section were most essen­nal to the target audience and most appropriate to a radio script, to a banner, and to face-to-face communication.

THE CREATIVE STRATEGY AND MATERIALS DEVELOPMENT

Research convinced the ROVITA team that com­mumcation messages should be targeted to capital­ize on the product's inherent advantages and on the simple "where" and "when" of distribution. In­depth interviews revealed that mothers' attitudes towards pills were sufficiently positive that they would seek them out knowing merely that they were free and good for their children's health. Pretesting showed that extensive information about the importance of vitamin A, about mght blindness and xerophthalmia, was not appropriate for the rad10 spots and even less so for banners. However, such information was included in the health volun­teers' training so that mothers could learn more about the product when they made contact with the health care system. The message core, then, consisted of six points:

• The product is vitamin A capsules

• It is distributed every February and August;

• It is available at the posyandw,

• It is free;

• It is for children between the ages of one and five;

• Vitamin A is for healthy eyes.

Although project leaders were concerned about the negative connotation of the pill's popular name ("fish oil") they decided not to draw attention to the name or to complicate the message. The common name for the capsules was simply never to be used.

The ROVITA vitamin A capsule commumcat10n strategy was integrated in two important respects. Messages were to be consistent from medium to medium so that each channel would reinforce the other with essential, action-oriented information, and messages would be timed to reach mothers simultaneously ten days before, and then through­out each intervention month.

THE USE OF INTEGRATED MEDIA IN INDONESIA

RADIO SPOTS AND SCRIPTS

The ROVITA team contracted a pnvate sector FM radio station with production capabilmes to assist in creating three 60-second radio spots. These spots were targeted at mothers both to inform and create demand. Each consisted of a minidrama followed by the v01ce of an announcer bnefly sum­marizing the message and concluding with the national health slogan: "Let's go to the posyandu to

keep our children really healthy." The three spots emphasized slightly different

core messages The first was an amusing conversa­tion between a wife and her somewhat cost-con­scious husband. She wants to go to the posyandu to get her child the vitamin A capsule. The foolish husband tnes to discourage her because they don't have any money and besides, the child is healthy. The wise mother then informs him of the core messages: that vitamin A capsules are free, that they're also for healthy children, and that they're available every February and August-and now it's August (or February depending on the monthly promotion). The husband of course becomes sup­portive. The second rad10 spot features two moth­ers. The minidrama emphasizes that vitamin A is for healthy children as well as sick children and that someone can always tell you where the posyan­du is. The third spot is also a conversation between two women. One woman has just remembered that it's time to take her son for his vitamin A cap­sule. She runs out with her son to ask a neighbor where the posyandu is. (See box.)

The second and third spots were both designed to help mothers deal with the unavoidable lack of specificity in the message about where to get vita­min A Since the posyandu was still a relatively new institution, not all mothers could be expected to know where it is. The posyandu is located in a dif­ferent place in each village, so neither genenc rad10 messages nor banners could give mothers directions to the health post closest to them. "Just ask a neighbor" was therefore an important message in the strategy.

Audience research had revealed mothers' prefer­ences for dramas. And the rad10 station suggested

I

finishmg up each spot with a "voice of authority." Nmety percent of commercials end with an announcer summarizmg the message and audiences expect to hear this didactic appeal. Pretesting also helped select the background music. A tradmonal style known as dangdut was popular m the target areas and was used to catch mothers' attention at the mirndrama's outset.

The drama format provided an opporturnty to convey several non-core messages that the team felt would help mothers act As always, a commurnca­t1on program tnes to enlist the family and the neighborhood in support of Its goals. It uses char­acters and creates an atmosphere with which the target audience can identify. It also looks for poten­tial problems (e.g., that a sick child might not be given a pill) and potential obstacles (e g., that some­one might not know what a posyandu is) Given the nature of the vitamm A product, the team found such sacral and logistical cons1derat10ns more important than an elaboration of the techrncal aspects of vrtamm A deficiency.

Each spot was created m both the national lan­guage, Bahasa Indonesia, and the local language, Javanese. Budget as well as mmimum reach and frequency requrrements helped determme six local rad10 stations that would effectively reach mothers. Each station was contracted to broadcast the six spots ten times a day for 40 days dunng dramas and mystery shows-the most popular rad10 programs among mothers. Negotiat10ns with the pnvate radio stat10n helped keep the cost of production down to approximately U S $100 per rad10 spot. Broadcast costs averaged JUSt over U.S. $1 per mmute. Rad10 production and broadcast costs for the first vitamin A monthly promot10n thus came to less than U.S. $3,000 for a total of 2,400 one­mmute spots

!BANNERS

While radio spots could expand on the campaign messages, banners could convey only the mirnmum mformation They were designed to commurncate the basics: the product, the rec1p1ent, the timmg,

I

When the Neighbors Know Best

S ince the posyandu, or village health post, is a relatively new institution in Central Java, and since generic media could not

tell every woman where the posyandu in her own village was, radio messages encouraged women to seek this information from neigh­bors and others.

(Introduction ... music)

Wife: Ooh Pakne. I forgot .. .it's August, isn't it Pakne?

Husband: Yes, right! Go on to the posyandu. Although Parno is healthy, he still needs a vita­min A capsule for his health.

Wife: But .. .I forgot ... where is the posyandu again, Pak?

Husband: Bune, Bune. If you forget such a simple thmg, just go ask the neighbor next door.

Wife: Oh ... right, come on now Parno, we're going to the posyandu.

Husband: Ehhh ... Bune! Don't forget, it's free!

(music)

Announcer: Right! Get vitamin A cap­sules (echo) every August and February at the posyan­du. Let's go the to posyandu to keep our children really healthy!

(Smash .. fade out music.)

THE USE OF INTEGRATED MEDIA IN INDONESIA

FACE-TO-FACE

The banner emphasized the distinctive shape of the capsule and the fact that it ts free and for children

Face-to-face communica­tion between heath vol­unteers and mothers was vital to the mtervention. Volunteers played a dual role, first as distnbutors of the capsules and sec­ondly as educators and promoters of vitamm A. They also had the oppor­tunity to explam the campaign messages m more detail to mothers.

the place, and the pnce. In order to grab the atten­tion of both literate and nonhterate mothers, the banner was highly graphic. One side featured a large bottle of capsules labeled "vnamm A" and sur­rounded by a few distinctive megadose capsules. "Free" appeared m a promment red starburst. "Every February and August" appeared on the other side of the banner. Bold yellow letters on a green background read "Vitamm A Capsules-For Your Children. Get them at the Posyandu."

In order to create a banner that could be seen from a distance, the ROVITA team decided on a brightly silk-screened polyester banner four meters long and one meter high. Each one was fitted with grommets at the top and bottom and had wrap­around edges so it could be strung from a rope or hung on two posts. The banner went through numerous pretests with rural mothers. The draw­ings of the bottle and pills had to be revised several times to make them clearly recogmzable to moth­ers. The colors for different parts of the banner also were of great importance to mothers.

The ROVITA Project sent the 450 banners for the first monthly campaign to county health offices for distribution to village chiefs ten days before the first of the month. The head of the Central Java Department of Health sent a cover letter with the banners asking village chiefs to mount them m prominent places by August 1st. Additionally, 40 seven-meter banners were sent to all the puskesmas to be hung at theH entrances.

In preparation for the August intervention, the ROVITA team designed a traming program for health volunteers earned out dunng the months of May and June. The trainmg consisted of two days devoted to proper diarrhea case management and one day devoted to

vitamin A. The vita­min A trainmg emphasized the same core messages deliv­ered through the other media. In

Volunteers played a dual role, first as distri/Jutars at the capsules and secondly as educators and promoters at vitamin A.

addition, tramees were encouraged to conduct regis­tration of children and were mstructed m the logis­tical details of distnbutmg the vitamm A capsules. They also received basic mformation on how to diagnose eye problems.

A tiered system of training had been used suc­cessfully in Indonesia for other programs such as family planning and diarrheal disease case manage­ment and was also used by ROVITA. The first step consisted of traimng two groups of 40 puskesmas workers from throughout the project area. The fol­lowing month, small groups of trained puskesmas staff then trained groups of 20 kader each, reachmg a total of 2,200 kader with the vitamm A program. Ultimately, the volunteers were to train mothers mformally about vitamm A deficiency. The central

I

A manual for kader reinforced then role as distributors of vit­amin A capsules

trammg principle was that one learns by doing, and the central method was role-playmg. Each tramee played the role of a kader and a mother and had the opportumty to learn from the suggestions of the other tramees.

The proJeCt team also designed a manual for kader to use with mothers. The manual mcluded detailed illustrations and was carefully pretested with mothers. Trainees used the manual in their role-playing. Each kader received a certificate upon completion of trainmg.

After the training the volunteers were encouraged to conduct an intensive canvas of their respective areas to register all mothers with children between the ages of one and five m preparation for the next capsule distnbution.

MONITORING AND IMPACT EVALUATION

Momtormg after the first promotion consisted of a qualitative study of 78 mothers, 33 kader, and 15 puskesmas workers. Questions were simple and focused on whether the audience had heard or seen the messages and whether they had acted on them

I

In addmon, three large-scale quantitative surveys were earned out to measure the impact of the vita­mm A promotion activities and to determme, to the extent possible, what worked-and what didn't­and why." The first survey was earned out m October of 1988 and the subsequent surveys one and two years later The surveys measured vitamm A capsule consumption and other factors m Demak and m a control district, Rembang.

Despite a modest communICatlon budget, the provmce made sigmficant progress in expandmg coverage. After one year, consumption of capsules by eligible children mcreased from 24 to 41 percent m precincts with a posyandu. Capsule consumption m villages with a posyandu remained near 40 per­cent by 1990, although the number of posyandu (and therefore children reached) may have greatly increased dunng that time; this level was mam­tamed dunng the second year and then mcreased to over 50 percent m year three. No significant changes m awareness or capsule coverage were recorded m the control area. Awareness of capsules increased from 57 to 69 percent among all mothers within the mtervention area, with the largest increases among those livmg near a health post. Awareness among the latter increased beyond 80 percent durmg the second year.

Interpersonal channels (volunteers and health care workers) were the most effective means of reachmg mothers about vitamm A distnbution days. Coverage of eligible children was highest for those living close to a posyandu and for those chil­dren who were brought regularly (for immuniza­tion or weighmg). In 1989, about three quarters of women who attended the health post regularly had heard of the capsules, compared to 35 percent awareness among mothers who never attended. Reliance on the posyandu system limited the pro­Ject's reach because these volunteer health posts were only active in 50 percent of the precmcts in the mtervention area and were only open for three to four hours on the designated distnbunon days.

Exposure to radio and banner messages was sig­mficantly related to mothers' awareness of vitamm A capsules. About two-thirds of mothers with high radio exposure had heard of the capsules, compared

Vitamin A Coverage in Communities with a Health Post

• Intervention Control 40.6

30

~ '""' 242 25.1

20 1988 1989 1990 n=223 n=203 n=350 n=267 n=283 n=257

THE USE OF INTEGRATED MEDIA IN INDONESIA

they listened to the rad10 one day a week or less. Although momtoring mdicated that the banners were bemg displayed m all villages, It also found that many mothers never left home or went to the village center. Rad10 messages were designed to encourage mothers to seek help m findmg the posyandu, but spe­cific directions ultimately had to come from a face-to-face source. The special role of mter­personal networks was unusual m this cam­paign, and planners realized future interven­tions could be strengthened by g1vmg them greater support Providing mothers access to current sources of information, as well as adding new sources, would also be pnorities during the next phase of act1vmes.

Difference m intervention area between 1988 and 1989 zs szgmficant at p<.001. Changes in the control area were not significant and m 1990 may have been influenced by sule effects of the intervention

Bmldmg on the project results and lessons learned, the Indonesia Department of Health designed a nationwide program, mmally tar­geting the 13 provmces with the highest mci­dence of v1tamm A deficiency. Dunng this next phase, greater emphasis was to be placed on sooal mobilization through local leader-

Source Annen berg School for Commumcatzon, Unwerszty of Pennsylvania

to only one-third with no radio exposure. Of mothers who had seen a banner, 93 percent said they had heard of the term "vitamin A capsule," compared to 44 percent who had not seen a banner. However, exposure levels to both the radio messages and the banners were disappointing. By 1989, only 21 percent of mothers in the mtervent1on area said they had heard rad10 messages about vitamin A capsules and only 9 percent had ever seen a banner.

Both media access

Bespite a modest communication budget, the province made significant progress in expanding coverage.

and logistics limited the reach of messages. Although mcreased frequency of broadcasts (or careful t1mmg during heavy listening hours) might have helped reach more mothers, it would likely not have helped the 45 percent of mothers who said

ship structures and the nat10nal women's orgamzation, or PKK. Continued expans10n of the posyandu system would also contribute to greater coverage rates.

CONCLUSION

The ROVITA Project's expenences promoting v1t­amm A capsules demonstrated a number of simple but important lessons. First and foremost was that a communication campaign must be based upon careful audience research and materials pretestmg. Every product has unique aspects that must be fully mvest1gated from the target audiences' per­spectives. Second, if the basic communication program messages are concise, memorable, and action oriented, they can be conveyed through a number of different media. If these media are cul­turally appropriate, they can effectively remforce each other even if a single channel has a limited reach; however, no communication program can succeed if the aggregate reach of these media ts

I

inadequate. Third, different media can commum­cate core messages m umque ways. Radio can con­vey a more complicated message than a banner, and face-to-face commumcauon can convey yet more detailed information. Consistency of mes­sage and ummg of delivery are at the heart of an mtegrated social marketing activity.

Lastly, a commumcation effort can only be as successful as the capacity of the service delivery sys­tem to satisfy the created demand. An impact eval­uation that identifies who responded and what mfluenced them to act can provide powerful infor­mation not only for the design of subsequent com­mumcat10n activmes, but also for considerat10n by those who can affect the delivery of health services.

NOTES 1. This case study has been adapted slightly from a field note ongmally entitled "The Use of Integrated Media for Vitamm A Capsule Social Marketmg Activities m Central Java, Indonesia," wntten by the authors md1cated m 1990, and pubhshed m Notes from the Fzeld zn Communzcatzon for Child Survival, Renata E Seidel, ed (Washmgton, DC: Academy for Educational Development, Apnl 1993)

2 For a descnption of the kader system see "The Development of Counselmg Cards for Commumty Health Workers," by Sutisnaputra, OmaJ, M., et al, m Notes from the Fzeld zn Communication for Child Survival, Renata E Seidel, ed (Washington, DC· Academy for Educational Development, April 1993)

3 See also "An Exammation of the Performance and Motivation of Indonesian Village Health Volunteers," by Tom Reis, John Elder, Satoto, Benny Kodyat, and Anne Palmer, m International Quarterry of Community Health Education 11(1)· 19-27 (1990-91).

4 The results are summarized from Results & Realztzes A Decade of Experience zn Communzcatzon for Child Survival, by Renata Seidel (Academy for Educational Development, 1992) and from "Results From the Evaluation of the HEALTHCOM Project in Central Java, 1988-1989," by Judith A McDivm, Jeffrey McDowell, in collaboration with Satoto and Anne Palmer (CIHDC, Annenberg School for Commumcat1on, Umversity of Pennsylvania, March 1991). The 1988 and 1989 quantitative surveys were designed by

I

the CIHDC and ROVITA and carried out by Survey Research Indonesia For further mformanon on these, con­tact CIHDC, Annenberg School for Commumcation, Umvers1ty of Pennsylvama, 3620 Walnut Street, Philadelphia, PA 19104 The third survey (1990) was ear­ned out by ROVITA and Survey Research Indonesia The results are unpubhshed

Thomas Rezs was resident adviser for HEALTHCOMI

Indonesia and zs now wzth the Kellogg Foundation Renata

Seidel zs wzth the Academy for Educational Development m

Washington, DC Sartono ts wzth the Indonesian Department

of Health, Central Java. Sudaryono zs with the Indonesian

Department of Health, Central Java Anne Palmer was with

Helen Keller Internatzonal!Indonesza, and ts presently a con­

sultant based m Manz/a

Vitamin A Proniotion in Indonesia: Scaling up and Targeting Special Needs

Willard D. Shaw

Cynthia P. Green

Vitamin A Promotion in Indonesia: Scaling up and Targeting Special Needs

BUILDING ON PILOT Ef f ORTS

Indonesia's SOMAVITA Project was a bold appli­cation of social marketing principles to vitamin A promotion across the world's fourth most popu­lous nation, composed of 13,000 far-flung islands and populated by some 300 ethnic groups. The project demonstrated the ability of national leaders to study the results of well-organized and evaluat­ed pilot projects and immediately apply findings and successful elements to a national program. It

INDONESIA

I

Willard D. Shaw Cynthia P. Green

provides examples of "campaign" strategies smtable to the nature of different vitamin A interventions and contexts, sustainable with existing resource levels. SOMAVITA's multi-pronged approach sup­plied a framework for the entire program while promoting provincial and local capacity building, as well as creativity m planning appropriate local strategies for increasing consumption of capsules and foods.

Smee 1984, the Government of Indonesia has given high pnonty to promoting adequate intake of

Intervention areas: Nauonw1de capsule distribunon (total populauon = 179 3 million) [!] Intensive capsule promotion, 13 provmces (populauon = 70 million) m Foods pilots (4 d1smcts, 2 provmces) (population= 2 2 million) 9 Urban capsule pilot Oakarta, 7 subd1stncts)

population= 1,500,282

.,

' Papua' New

'' Guinea ,,. -- .........

VITAMIN A PROMOTION IN INDONESIA

vitamin A, mamly through megadose capsules or consumption of vitamm A-rich foods. In addmon to its ongomg nutnt10n education programs, the Department of Health conducted two pilot projects that developed many of the, strategies eventually used in the national program:

dren in two districts of Central Java dunng 1987-1991. (See previous case study.)

• SOMATA, or the Social Marketing of Vitamin A Project, promoted v1tamm A capsules and vitamm A-rich foods among 40,000 children m one district ofWest Sumatra during 1987-1989.1

• ROVITA, or the Oral Rehydration and Vitamin A Project, promoted vitamin A capsules and oral rehydration therapy among 230,000 chil-

In 1990-1991, the Indonesian Department of Health determined the broad outlines of its subse­quent Social Marketing of Vitamin A (or

Partners for a National Effort

OMAVITA "worked" because many different organizations were able to

work together-at the national level, across different levels of the health administrative sys­tem, and down to the extensive voluntary network which sup­ports village health services. Each of these different levels of collaboration required new partnerships and sometimes new ways of funding and administering activities.

The Department of Health served as the major implement­ing agency for SOMAVITA, with the active involvement of the Directorate of Nutrition, the Center for Health Education Center (PPKM), and the Directorate of Community Participation. Provincial and district officials responsible for health, nutri­tion, and community participa­tion were also heavily involved in promotional activities. The Department of Agriculture used its extension workers to promote home gardens and the

Department of Animal Husbandry encouraged poultry raising. The Department of Home Affairs helped mobilize the support of provincial gover­nors and village administrators, ensuring that village health posts (posyandu) staffed by vol­unteers were in place in as many areas as possible.

This broad net of govern­mental involvement was com­plemented by the work of non­governmental organizations which have deep contacts with­m the community. More than 30 nongovernmental NGOs participated in SOMAVITA promotional activities in the 13 priority provinces. Fatayat Nahdlatul Ulama, a young Muslim women's organization, received special assistance and actually conducted the urban demonstration project.

Universities and private sec­tor firms provided special exper­tise. MJM, a firm experienced in drug management studies, reviewed the DOH logistics sys­tem for capsule distribution;

Survey Research Indonesia con­ducted audience surveys in three of the target provinces and focus group research among mothers; the University of Indonesia and Atma Jaya University also assisted with research studies. Private sector firms produced radio and televi­sion spots, and radio and televi­sion stations contributed air time. Indonesia's news media covered the campaigns, helping to promote special activities throughout the nation.

Donor assistance was largely technical. Helen Keller International provided overall management of USAID sup­port and coordination with the DOH. USAID's HEALTH­COM Project provided techm­cal assistance and traimng in health communication, research, and community mobilization. UNICEF donat­ed vitamin A capsules for the DOH to distribute to the pub­lic free of charge, and also pro­vided supplementary funds for the campaigns.

I

SOMAVITA) program strategy. Counterparts from Helen Keller International and the Academy for Educational Development, who had assisted ROVITA through funding from USAID, initially advised the Department of Health to enlarge the pilot site in Central Java, which focused on twice­yearly capsule distnbunon, by expandmg from two districts to the entire province (28 million people).2

However, the government was faced with evi­dence of widespread vitamin A deficiency and stud­ies showing the positive impact of vitamin A sup­plementation upon morbidity and mortality of children; it was impatient to move qmckly to reach at-risk children. Decis10n makers were convmced that the new capsule promonon model was ready for national application, and they were not content with a gradual phase-m until all 27 provinces were covered.

AN INTEGRATED STRATEGY

The Department of Health (DOH) decided to

apply the framework used in the pilot projects to

SETIAP ANAK. -

USIA 1 SA,MPA,I 5 TAHlJN P lLR L U

The program focused mainly on capsule distribution because of its mandate to reduce vitamin A deficiency as rapidly as possible.

the existing but loose­ly-orgamzed nanonal effort to distribute vitamin A capsules. In addition, it decided to concentrate special resources on the 13 provmces with the highest incidence of vitamin A deficiency 3

SOMAVITA's prima­ry objective for its three-year duranon was to ensure that at least 40 percent of 18 million Indonesian children aged one to five received a megadose (200,000 IU) vitamm A capsule every six months at a local health post. This ambmous goal would dou­ble the percent of children who had received a cap­sule m the six-month distribution period precedmg the SOMAVITA launch. Strengthening of govern­mental and nongovernmental capacity m project design and implementat10n was an important, explicit part of the government's strategy to increase coverage nationwide.

The program focused mamly on capsule distnbu-tton because of its mandate to reduce vitamin A deficiency as rapidly as possi­ble. Megadose capsules provide ade­quate levels of vitamm A for three to six months. The DOH decided that distn­but10n at stx-month mtervals was suffi­oent because children would receive some vitamm A m their regular diets. Capsule distnbunon is also relanvely inexpensive-less than approximately US $.25 per child annually However, the recurrent distribution costs mount

KAPSUL VITAMIN A up over nme More importantly, cap­sules are not a long-term solut10n for the general populatton.

PEBRUAlu DAN AGUSTUS DI PosYANDU

Semi-annual capsule distribution was aimed at one- to five-year old chtld1en, as illustrated m this poster/flyer distributed throughout the country

I

At the same time, the government therefore launched an effort to develop a long-term strategy of mcreasmg the production and consumption of vita-min A-rich foods. Previous studies had shown that vitamm A-nch foods are readily available in Indonesia but are

VITAMIN A PROMOTION IN INDONESIA

Kenyataan Yang Sudah Dibuktikan

Peneltt1an d1 Aceh

dan Jawa Barat

yang diperltuat oleh

penellt1an d1 India dan

Nepal, membuktl­

kan bahwa pembe­

nan V1tamm A dapat

mPrekan Argha

Kemat,an BalttF

antara JO''\ .. hmgg:;

54°'0

Hanya l1ma det1k

d1butuhkan untuk

rnembenkan kapsul

Vitamin A Tap1 manfaatnya sangat nya1a

meningkatkan daya tahan tubuh anak sekahgus

menurunkan resrko kesak1tan dan angka i..ematran

50

40

30

20

10

DAMP AK SUPLEMENTASI VITAMIN A PADA PENURUNAN ANGKA KEMATIAN BALITA

Aeeh Jab~r 1986 1988

60

50

40

30

20

10

Pengabdian Kita: Tumpuan Harapan 22 Juta Anak Indonesia Pengabd1an ktta amat menentukan keberhas1lan program Vitamin A mt Bila seluruh 1a1aran kesehatan dan sektor-sektor terka1t dapat men­Jalankan perannya mas1ng~masmg dengan bruk, maka 22 iuta anak Indonesia dapat tumbuh kembang sempurna

T1dak banyak yang harus d1keriakan " L1batkan Carnal, Kepala Desa, Kader Kesehat­

an, LKMD, PKK dan Tokoh Masyarakat lain dalam program Vitamin A

a Manfaatkan semua wadah dan keg1atan masyaraka1 untuk menga1ak 1bu membawa Anak Bahtanya ke Posyandu guna mendapat­kan Vitamin A

111 Pastikan reg1stras1 semua Anak Ballta d1 desa, dengan memanfaatkan Formuhr Reg1stras1 Kapsul VJ1am1n A dan UPGK d1 bawah koor­dmas1 Kepala Desa

• Bantulah Posyandu dalam membma kader, terutama dalam perannya memben kapsul V1tammA

" Untuk wilayah yang belum mem1hk1 Posyandu atau yang kun1ungan Posyandunya rendah, Puskesmas seba1knya membenkan perhat1an dan upaya khusus untuk membag1 kapsul pada Anak Bahia Tugas 1rn akan leb1h mudah b1la menggatang ke~asama d1 antara Kader, LKMD, PKK dan Tokoh Masyarakat

" Jagalah agar persed1aan kapsul selalu cukup d1 Posyandu sebetum bulan pembag1an kapsul

" Cata! dan laporkan persed1aan dan pembenan kapsul Vitamin A

A flyer for health professionals emphasized the new message, that vitamin A helps increase children's resistance to disease

dren aged 6 to 59 months with­m a one-year time frame.

Concern about health and nutrition problems m urban slums led to a third intervention under the SOMAVITA Project. Three out of ten Indonesians now live m urban areas, where vitamin A deficiency and other forms of malnutrition are more prevalent than m the country as a whole, and where poverty, multr­plimy of ethmc groups, and dif­ferent commumcatron patterns create challenges qmte distinct from those m rural areas. The HEALTHCOM Project there­fore focused some of its funds on mvestrgatmg constramts to cap­sule consumption m slum areas of Jakarta, providmg technical assistance to a nongovernmental organization which earned out a umque volunteer-based effort to expand capsule coverage among hard-to-reach groups.

not eaten by children m sufficient quantmes due to lack of information among caretakers, time constramts, or cultural beliefs. These foods can be cultivated m home gardens or obtained through fishmg or poultry-raismg by low-mcome families. Although promotmg dietary changes may be more difficult and costly than capsule distnbu­t10n in the short term, the Government of Indonesia considers it an essential part of a sus­tamable and cost-effective program to address micronutrient needs.

CAPSULES-COORDINATING LESSONS ANO RESEARCH

This second SOMAVITA imtranve was launched in 1992 on a pilot basis m a total of four districts m two provmces: Central Java and West Sumatra. The primary objective was to develop and test a strategy appropriate for replicat10n on a large scale. Each pilot was expected to produce an increase in con­sumption of selected vitamm A-nch food by chil-

Policies and Posyandu

Lessons from the pilot projects provided a basis for laying a firm policy foundation for the capsule dis­tribution program. The first of these lessons was the value of standard mtervent10n nmmg. In 1990, the Department of Health began setting the stage for a nat10nal campaign by announcing a new, country­wide policy of semi-annual capsule distribution. A semi-annual mtervennon would fix m the public mmd the assooation of vitamm A with these months and the local health post, or posyandu, where capsules are distributed. By concentrating commumcanon acnvmes on the February and August capsule distribution, the proJeCt could

I

Assuring Access - through Professionals and Volunteers

I ndonesia, a country of 13,000 islands, faces enor­mous logistical challenges in

delivering health services to its population. The Department of Health has created an infrastruc­ture that reaches down to the village level and relies upon both profess10nals and volunteers.

A network of community health centers (puskesmas) oper­ates at the subdistrict level. To provide basic health care in the nation's 200,000 villages, the DOH has also established vil­lage health posts (posyandu). Volunteers known as kader (primarily village mothers) who have received one to three days of training in one or more child survival interventions, gather at a central location m their villages and conduct monthly sessions to weigh chil­dren and provide advice on diarrheal disease treatment, nutrition, and family planning. Puskesmas staff periodically travel to the posyandus to pro-

vide immunizations. Posyandus are the main

delivery mechamsms for vita­min A capsules. In areas with no health posts, capsules are available from the local health center. Families who miss the capsule distribution cycle at the health post in their village can also obtain capsules at dis­trict health centers.

This delivery system works reasonably well, but it has many flaws that can affect a time-sen­sitive program. Fitst, the limited schedule of the posyandu (a few hours once a month) provides a narrow window of opportunity for mothers to attend. Second, the turnover rate among volun­teer kader is high. Some esti­mates place it at 50 percent a year although some kader do continue to work for many years. Third, once children have completed their immunizations at around age two, many moth­ers do not bring them to the posyandu. Also, families who set-

tle in urban areas without the required residence permits avoid going to the health post and officially registering their children.

Half of the villages in the ROVITA pilot areas did not have posyandu Even in areas with a posyandu, many mothers did not know the day of the month when theirs was active. Because there was no common day or date for posyandu to be held from village to VIllage, the mass media could not carry the important messages on time and place. Mothers who knew of their local posyandu saw it as a source of health services (e.g., growth monitoring, immuniza­tions, etc.) only for their youngest children.

Under SOMAVITA, the government continued its poli­cy of expanding the posyandu system, but also recognized that additional distnbunon channels for vitamin A cap­sules would be needed.

mobilize extra effort from village heads, commum­ty orgamzations, political leaders, and health providers. The new strategy lessened the possibility of donor and volunteer "fatigue." It also enabled the DOH to focus its modest commumcat10n budget on more intensive promotion during January/ February and July/August.

In addition, ROVITA had confirmed that access was a major obstacle to achieving high levels of vit­amin A capsule coverage. (See box.) The DOH con­tinued to mvest in the expansion of the posyandu

system for distnbutton of vitamin A capsules and other services; however, it also recogmzed that short-term goals could not be met without increas­mg access to capsules and mformat10n on foods. In a significant departure from previous policy, the DOH authonzed the distribution of capsules by approved groups (primarily NGOs) outside of the posyandu system.

I

In the past, volunteers had assisted with commu­nity nutrition education mmatives and with capsule distribution at the health post itsel( Now, however,

V1tammA mem.mg pentmg untuk ke,ehatan mdta dan mcncegah 1-..ebuta.m an.1k

Dan lebth pentmg !Jgt

Vitamin A

VITAMIN A PROMOTION IN INDONESIA

mamtain records of capsule distribunon and forward these to the provmcral health departments.

meningkatkan daya tahan tubuh

In a survey of logistics in three provinces, MJM found that rt took an average of 14 months for capsules to reach the health post, from mmal plan­mng through the process of procure­ment, shipping, and final drstribunon. The health posts generally received their capsules on trme or could obtain stocks from the commumty health centers. Although the survey revealed some areas for improvement, delivery of capsules per se was found not to be an obstacle to mcreased coverage. A manual on capsule logistics focusing on points recommend­ed by the study was developed dunng the proJect and sent to health centers.

schmgga peny•hll dldrc. h.1tuh ptlch .lldll .amp•h t1dak mud.1h mcnJ.id1 p.1r,1h d•n ttddk memh.1hJyakJ.n JIW<l .m.1h.

Jadt dengan Vlfdmm A anak meiuad1 lebih sebat rum Imai.

Yuamm A d.ip•t d1peroleh dalam bcntuk k•p,ul dan meldlm air '""" 1hu serta hcbcrap.1 hdh.m m.d.Jn.m

Karena 1tu &ebap anak 1 ·S tahun

b lnifab Rah:manya1

Vitamin A

pcrlu rnendapat salu kapsul Vitamin A, :! h.cth M;tdhun~

mbuat anak lebib '>Cbat dan lmat

-~- ~~~-~--~- -n -

l>ulan Pebruan dJn Agustus.

Selam kap,ul settap han anah perlu d1ben mdlanan &umber VJtdmm A ~cpert1

b.1yam daun smgkong, pCJ'<IY• telur atau hall

A flyer for community leaders outlined baste campaign messages and information, including the role of vztamm A in child survival.

NGOs could became involved in distribution out­side of the tradmonal system. Prev10us concerns (about the possibility of toxic overdose, or about the benefit of using capsule distribution as a means to strengthen the posyandu services) yielded to hard data from the pilot studies.

Reviewing Logistics

At project mcept10n, the government hrred Manggala Jiwa Muktr Consultants (MJM), a firm expenenced in drug management studies, to review the logistics of vitamin A capsule distribution and mvesngate whether the system was functionmg ade­quately. The DOH makes annual shipments of cap­sules to provincial health departments with supplies for all children under six m the provmce. From here, the capsules are sent to the commumty health centers for distribution to the health posts or paid health workers. In each village, community groups

Preliminary Audience Research

Research collected by the pilot efforts provided much of the background informanon needed to develop the SOMAVITA program Through surveys and qualitative techniques, the ROVITA and SOMATA proJects had collected considerable mformat10n on populat10n knowl­edge, dietary habits, consumer preferences, and media use m the pilot drstncts.

In October 1991, SOMAVITA conducted a sur­vey of more than 1,200 mothers to determme whether the information on consumer preferences and program constramts identified m earlier

lessons from the pilot projects provided a basis for laying a firm policy foundation for the capsule distribution program.

research was still valid on a larger scale. The survey also provided a baselme for a follow­up survey planned for October of 1993.4

Research was conduct­ed m West Sumatra, Central Java, and East Nusa Tenggara. These three provinces are

I

13. Jika seseorang mengkonsumsi vitamin A dosis tingg1 yang melebihi 200.000 SI, apa yang terjadi pada vitamin A yang berlebih tersebut dalam tubuh?

Sebagian besar dan v1tamm A yang berleb1b tersebut dalam bentuk yang t1dak berubah akan d1keluarkan melalm

This booklet on the "Safe Use o/Vttamm A Capsules" responded to questions asked most frequently by health professionals

culturally drstmct and provided an opportumty to examine cultural differences m attitudes and prac­tices. Smee the DOH also planned to carry out vit­amm A-rich food interventions in these provinces, focusmg research m those locations was efficrent. 5

The survey showed that most mothers already knew about vrtamm A capsules and had a positive attitude about obtammg capsules for their children. Accordmg to those mtervrewed, the maJor con­straint was their limited access to a health post at the reqmred ume. An addmonal problem for the capsule promouon program was that women large­ly tended to bring children under the age of two to the health post. The majority of services, such as growth momtoring and 1mmumzauon, are armed at these younger children, providing only partial over­lap with the target group for capsule coverage (one through five years old).

The survey also provided mformation on media usage. Most mothers, even those hvmg in rural

I

areas, were able to watch telev1s10n occasronally m their neighborhoods. Slightly less than half had lis­tened to the rad10 the day before the mtervrew. Rad10 lrstenershrp was greatly d1v1ded among a wide range of local rad10 stations. More than half the mothers had completed only pnmary school and thus had limited reading ability.

INTEGRATING NATIONAL AND PROVINCIAL HF ORTS

Planning and Training

To plan for the February 1992 launch of the nanonal capsule campaign, the DOH set up a five­member National Steering Committee, which also directed a National Implementation Team. The Committee included representatives of the DOH, HK.I, the Academy, and UNICEF, and was respon­sible for strategic planning, project planmng, and

All at the 13 priority provinces received small "seed grants" equivalent ta us 82,DDD tar their awn promotion activities.

mtegrat10n of activi­ties with DOH poli­cies. Within six months of Its forma­tion, the Committee developed a detailed implementat10n plan for nat10nal efforts. These focused on:

• launching an "umbrella" media

campaign throughout the country to promote cap­sules on a semi-annual basis; and

• providmg trammg, guidance, and momtonng to the provincial teams as both a support for theu ind1Vldual campaigns and m order to bmld long­term capacity.

Given the scale of acnvmes planned, trammg was key. Beginnmg m 1991, the Duectorate of Nutnnon sponsored trainmg courses for two nutri­tion officers from each of the 27 provmces to pro­vide basic mformatron and skills m social market­ing. A health educat10n specialist and an NGO rep-

resentative from each of the 13 priority provmces also attended. The goal was to create a small, core social marketing team in each province. In addi­tion, a trammg-of-trainers course on social market­mg was held m April of 1992 for DOH nutrition educators and leaders from national NGOs so that traming could be disseminated down to lower lev­els. The DOH is workmg toward the goal of having one person m each district of the country trained in social marketmg.

Following the national trainmg course, the National Implementation Team visited each of the 13 priority provmces to explam the SOMAVITA program Each province established a SOMAVITA lmplementat10n Team consistmg of the three peo­ple who attended the soClal marketmg traming course and representatives of government depart­ments such as agriculture, village development, and

FORMULIR REGISTRASI KAPSUL VITAMIN A UNTUK ANAK UMUR 1-5 TA HUN (12 • 60 BULAN)

RT/RW I {l'VA/!T/1991) Duson Posyandu

NamaAnak LIP (!) (2)

Ketua Kader Posyandu

" Tahun 1991 Desa

Tg1 Lahtr Orang Tua Tgl Peinbenan Kapsul (3) (4) Februan (S) Agustus

Ketua RT /RW

Kere:rangan (6)

A 38-page manual for health officials covered all aspects of vitamin A capsule pwmotion, and included explanations of various campaign forms-such as this one for recording cap­sule distribution at the vzllage health posts

VITAMIN A PROMOTION IN INDONESIA

religion. The 13 provinces were mobilized m phas­es between February 1992 and August 1993.

All of the 13 pnonty provmces received small "seed grants" eqmvalent to US $2,000 for theu own promotion activmes. Receipt of these grants was contingent upon preparation of written proposals for communication activities before each six-month capsule distribution cycle. The grants were success­ful in motivating creative responses from the differ­ent plannmg groups; however, provmces also added funds from their own sectoral budgets.

Before each campaign cycle, the National Implementation Team held workshops to review program progress and plan upcoming national pro­motional activities. SOMAVITA also encouraged NGOs to participate m program planning and implementat10n in order to investigate additional distribution channels and expand the scope of mterpersonal communicat10ns. As the SOMAVI­TA program progressed, the benefits of widening the distribution pomts and mvolvmg NGOs became clear.

Messages and Audiences

Gmdance from the national level mcluded elements of the overarching vltamm A capsule-promotion strategy. Most important among these was the mes­sage strategy. The ROVITA ProJeCt messages pro­vided the starting pomt:

• The product is vitamin A capsules;

• It is distributed every February and August;

• It is available at the posyandu;

• It is free;

• It is for children between the ages of one and five;

• Vitamin A is for healthy eyes.

However, research had shown that the credibility of "Vitamm A is for healthy eyes" was being under­mined (among both parents and health providers)

I

l -i

'

PEMBINMN KESEJARTERAAN KELUARGA

PKK TIM PENGGERAK PUSAT

HIMBAUAN KEl'UA UMUMTIMPENGGERAKPKKPUSAT

KEPADAPARAKADERPOSYANDU

~ ' Denu ke.~ehatan dan kc.lang.rungan ludup anak~anaJ... lata, kepada para kader PKK : .r }angakltf dt Poq.andu, st;; a mengl11111bau ~upaja r • !:.etwp bu/au Februan dan Agustus secura akhf Anda melahanakai;:

' -'

pembagwn kapvul vttamm A pada :i.emua Halt/a d1 Posyandu 1H1a~ah Anda-

• Meng_a1ak para tbu a!J4f membawa anak Balua merer.a tw.p bulart ke Posyandu untuk men.1agal..esehatan anaknya, dan mr.ndapatkankapsul v11amm A ttap bu/an Fi:.brunrt dan Aguslus.

Amal baktl Andat1dakakansm-s1a SemuapiliakamJ.tbertenmakasth dru.lsangat rnenghargm Jenh payah Anda semua

Semoga Tultan mehmpahkan karunta dan raJunatNya atns ketuJusan amal Anda.

Promotional posters such as these encouraged volunteer kader and reminded them to participate zn the new semi-annual capsule distribution cycles

because of the gradual drop m cases of vitamm A­related blindness This situat10n required an impor­tant thematic shift. In order to emphasize the role vitamin A plays in strengthening the immune sys­tem and reducing childhood mortality from several causes, another message was added:

• Vitamin A keeps children healthy and strong.

In a commumcat10n program, any shift m basic messages is nsky and reqmres careful pretestmg and persistent remforcement among target groups. Broadcast media directed at families, as well as extensive print materials directed at health care providers, promoted this new rationale for vitamm A consumption

The core messages emphasized that even a child who appears healthy needs vitamm A Mothers who

I

were uncertam where to go for capsules were advised to ask their neighbors Messages also remmded mothers that children between the ages of two and five should be brought to the health post for capsules. This age group contmued to have lower coverage rates than younger children.

The pnmary audience for SOMAVITA mterven­tions was mothers of children aged one through five. The national and provmcial campaigns mamly targeted rural mothers. Secondary audiences were:

• health care providers at the provmcial, district, and subd1stnct levels;

• village health volunteers (kader);

• village leaders;

Im leaders of community orgamzations; and

II public health program managers m the DOH offices at all levels.

Bue to cost, logistical difficulties, and literacy limitations, print mate­rials were targeted mainly to the secondary audiences.

Health care providers and village health vol­unteers are the maJor sources of vitamin A capsules and advICe on child nutrmon The project had to convmce them of the importance of vita­min A and motivate them to make an

extra effort dunng the intensive campaign months Village leaders and commumty organizations pro­vide essential support m mobilizmg local popula­tions. SOMAVITA encouraged NGOs and com­mumty orgamzations to take an active role in plan­ning the local campaigns, m providing face-to-face communication with mothers, and m actually dis­tnbutmg capsules.

NATIONAL MEDIA PLANS

One year before the national vitamm A capsule campaign was officially launched, the DOH pro-

mated the new semi-annual distribution system to the national media. The Minister of Health appeared on television promoting capsules and the DOH held a press briefing for journalists.

The national communication program, with a potential countrywide audience of 179 .3 million people, aimed at achieving the greatest possible reach with simple but significant messages. It relied heavily on radio and television public service announcements (PSAs) to disseminate basic infor­mation to mothers and snr up interest and support for the vitamm A program. Broadcast messages were also designed to remind health workers, vol­unteers, and influential villagers of their own roles in capsule distribution. SOMAVITA staff worked with the Indonesian Ad Council to produce one of the television spots and to mcrease the amount of free time provided for its PSAs. The rad10 spots were produced in Jakarta based on data from the field and sent to all 660 radio stat10ns with the request to give them air time. Print materials helped motivate health workers and also provided stan­dardized mformanon about both campaign activi­ties and vitamm A itsel£

Due to cost, logistical difficulties, and literacy limitations, print materials were targeted mamly to the secondary audiences. All materials were designed to encourage face-to-face promotion by village volunteers, health workers, doctors, and community organizat10ns.

The Center for Health Educanon in Jakarta and the Directorate of Nutrit10n, with assistance from HEALTHCOM and HKI, developed a range of materials for national dissemination.6 These included:

• Television Spots- One television spot pro­moted the message that vitamin A is good for healthy eyes; a second spot emphasized the role of vitamin A in strengthening children's resistance to disease. The spots were aired as public service announcements on 12 stations.

• Radio Spots- SOMAVITA produced three radio spots. The project conducted a nationwide competinon for the third script m 1993, m order to

stimulate the interest of provincial and district health

VITAMIN A PROMOTION IN INDONESIA

personnel. (The team received 153 entrees from 24 provinces.) Durmg each campaign month, the radio spots were broadcast an average of 90 times.

• Leaflets for Health Workers- Each com­munity health center received copies of a leaflet for health workers m time for the August 1992 cam­paign. More than 47,000 copies were printed. The leaflet stressed the child survival benefits of vitamin A and suggested activities that staff could undertake to mcrease capsule distribution. These ranged from involving local groups in the program, to helpmg establish alternate distnbunon methods where needed, to making sure that all children are regis­tered, and monitoring the supply of capsules. The leaflets also aimed to motivate health workers, remmding them that, "A drop of our dedICation lowers the death rate of children under five."

• Leaflets for Community Leaders­Community leaders around the nation received a leaflet entitled "Secret for Keeping Children More Healthy and Strong." It was designed for village heads and their wives, who are usually members of the volunteer-based Family Welfare Movement (PKK) that helps to organrze village health posts. The leaflets stressed the new message that vitamm A increases children's resistance to disease. About 124,000 copies were distnbuted.

• Management Guidelines- More than 20,000 copies of "Guidelines for Capsule Distribution" were sent to provincial and district health offices and all community health centers. The gmdelmes were developed to standardize pro­gram management and the method of calculatmg capsule coverage. They encouraged health workers to go door-to-door after the distribution cycle was over m order to give capsules to children who had not received them. The gmdelmes also gave permis­sion for local NGOs to help in capsule distnbut10n and promotion.

• Resource Packets- To provide health staff with background information on the mortality effects of vitamin A and other new developments in vitamm A research and policy, SOMAVITA distrib­uted 440 Resource Packets Each packet consrsted

I

of a folding file box with vanous nationally- and internationally-produced documents about vitamin A translated into Bahasa Indonesia.

• Informational Booklets- Nearly 20,000 booklets entitled "Safe Use of Vitamin A Capsules" were distributed to health institutions throughout the country. The booklet answered the most fre­quently asked questions about the safety of capsules.

• Newspaper Articles- Staff prepared articles about the health benefits of vitamin A for newspa­pers and specialized health publications.

• Other Print Materials- These included a poster for community health centers and village health posts, a health education monograph, and a one-page traming module on nutrmon counseling for the village health volunteers' basic trammg book.

PROVINCIAL MEDIA PLANS

During the three years of SOMAVITA, the 13 pn­onty provmces developed theu own implementa­tion plans for each six-month capsule distnbut10n cycle. Before receivmg every subsequent grant, the provmces had to submit campaign reports and receipts for the previous cycle, as well as plans for the upcoming cycle. Although strategies were approved and monitored by the National Team, decentrahzat10n of planning effectively encouraged local mnovat10n and sustamability.

Channels and creative approaches varied by provmce

1111 In South Sumatra, Boy Scouts assisted with capsule distribution. A new ment badge was designed for those who met distribution targets m selected isolated areas.

• In Aceh, speoal semmars mobilized officials and health profess10nals to distribute capsules and "sweep" areas house to house.

• In Maluku, the provincial team developed vitamin A episodes for a television senes on the "family doctor" and also for a comedy program.

I

• The lnan Jaya team designed materials suit­able for its particular ethnic group (posters and radio scnpts) and mobilized village leaders.

• The West Sumatra team mobilized traditional medicme sellers in urban areas to promote vitamm A capsules The team produced radio spots, posters, and slides for cinema. The military also contributed by parucipating m "sweepmg" activmes.

• The West Kalimantan team orgamzed panel discussions about vitamm A m every distnct.

• In Southeast Sulawesi, the team designed a brochure for relig10us leaders and special materials for the local market.

(' 1·

(,lfHJ1Ri"<lfll KEPAIA OAERAIJ TINC.KAT I

JAW'\ TENGAH

Saudara Petugas Pamong, dan Kader,

Saya bentahukan bahwa Kapsul Vitamin A sangat pentmg unluk Kesehatan anak balita

Bulan Februari dan Agustus ialah bulan prunbag1an kapsul Vttamm A melalui Posyandu tanpa membayar

Tugas saudara 1alah men1amm agar SEMUA anak bali!a dt w1layah keria saudara d1daltar dalam Formuhr Reg1strasi Kapsul Vitamin A, dan mendapat Kapsul Vitamin A langsung dart Kader

The Governor of Central Java appeared with his wife on this poster promoting capsule distribution, and "signed" this letter encouraging kader

• The North Sumatra team held capsule distri­bution competitions for health centers.

• The Central Java team produced guide­lines for distributing capsules through local kmdergartens.

• In East Timor, additional capsule distribution posts were opened and identified for the public with signboards.

• In West Nusa Tenggara, materials ranged from cinema slides, to radio spots, to mobilization meetings at the district level.

• In South Kahmantan the Governor and an important religious leader appeared on posters. Volunteers from a women's relig10us organizat10n promoted capsules through kmdergartens, home vISits, and Koramc readmg groups.

These programs were aimed at province-wide populations varying from 747,557 (in East Timor) to 28,555,737 (in Central Java). Together, the 13 provinces had a potential audience of more than 70 million people.

PRETESTING AND MONITORING

All materials used in the nat10nal campaign were pretested at the provincial level with intended audiences and revised as indicated. The National Team developed specific guidelines for pretesting each item, including tips on how to set up a focus group, what quest10ns to ask, and how to record what the pretesters had learned. Pretestmg was expedited by sending materials through the mail to pretest sites. Health education staff and/or members of NGOs who were tramed in social marketmg conducted the pretests at the village level. The project provided funds for travel to vil­lages and for reporting.

Pretests of the leaflet designed for commumty leaders led to substantial changes. Focus group par­ticipants found that the leaflet was overloaded with mformation and techmcal jargon. Women object­ed to a proposed reference to vitamm A deficiency

VITAMIN A PROMOTION IN INDONESIA

Pretesting was expedited by sending materials through the mail to pretest sites.

as "increasing child mortality." They explained that, "Only God is responsible for decidmg who will die." The reference was changed to "Vitamm A increases

your child's resistance to disease."7

Midway through the project, the team wanted to assess mothers' reactions to new messages highhght­mg the impact of vitamin A upon morbidity and mortality. A special vitamin A "posmonmg study" was therefore conducted in 1993.8 Focus group dis­cussions with mothers (rural/urban; nch/poor) m three provmces explored possible themes for radio and television spots and the leaflet for caregivers.

The study found that mothers were well informed about vitamins in general but felt that vit­amm A had no special claim to improvmg or pro­tecting a child's health. Mothers found three of the five promotional messages pamcularly compellmg. These emphasized themes of "the good caring mother," "preventing blindness," and a child's eyes as being "the wmdow of God." The project ulti­mately reJected the last of these as inappropriate for non-Islamic audiences. Consequently, a radio spot developed for the subsequent campaign stated: "Good, canng mothers bring their children to the health post for capsules."

Regular monitoring of program implementat10n occurred through both periodic site visits and also an innovative process of direct-mail surveys. Durmg each campaign cycle, a two- to three-person team from the national level visited provmcial and district health offices as well as village health posts and observed ongoing field activmes. The team used a "momtonng checklist" to prepare a stan­dardized report on program management, IEC materials and distribution, involvement of NGOs, capsule supply, and follow-up of participants trained m social marketing. During one of these visits, teams learned that health care workers had questions about the safety of high dose vitamin A capsules. This led to the booklet described above on "The Safe Use ofVitamm A Capsules," which was

I

distributed before the February 1994 campaign. Direct-mail surveys helped assess the reach and

impact of communicat10ns. In September 1992, the team designed a one-page, self-addressed ques­tionnaire to provincial and district health offices, community health centers, village leaders, and vil­lage members of the Family Welfare Movement (women who usually manage the health post cap­sule distribution). The questionnaire was then mailed out after each campaign. It was designed to

monitor exposure to television and rad10 spots, understanding of the main messages in spots, recep­tion and use of printed materials, presence of an active posyandu, local program activities, capsule supplies, and possible constraints. The surveys found that materials were reaching their intended audiences. They documented a large increase in

Figure 1: Vitamin A Capsule Distribution in All Indonesia (27 provinces)

80

70

... BO ... = ... =-... .... =i 50 = :E ... .... ... ... 2 40 = ... ... ::e -= 30 .... = = ... ....

20 ... ... a.

10

0

Aug 91 Feb 92 Aug 92 Feb 93 Aug 93

Note Data for August 1991 includes capsules distributed in the previous six months Subsequent data are for capsules distrib­uted during the semiannual distribution cycles Denominator (NJ = 23,319,270 chzldren 1-5 (according to 1990 census)

I

knowledge of capsule distribution months, vitamin A benefits for child survival, and the DOH policy of giving extra vitamin A to children with measles.

Over 1, 100 quest10nnaires were returned after the first mailing, yielding a response rate of 59 percent. Over time, the response rate fell to nearly half that. Respondents who received a questionnaire after every campaign cycle were less likely to send it back, suggesting the need to vary the respondent sample.

CAPSULE PROGRAM RESULTS

The SOMAVITA capsule campaigns clearly had a dramatic impact, according to DOH national sta­tistics. Children's consumption of vitamin A cap­sules tripled in less than three years. In 1991 at the

Figure 2: Vitamin A Capsule Distribution in the 13 High Risk SOMAVITA Provinces

80

70

... BO ... = ... =-... .... =i 50 = :e: ... .... ... ... 2 40 = ... ... ::e = 30 .... = -= ... ....

20 ... ... a.

10

0 Aug 91 Feb 92 Aug 92 Feb 93 Aug 93

Note- Data for August 1991 includes capsules distributed zn the previous six months Subsequent data are for capsules distrib­uted during the semiannual distribution cycles Denominator ts

number of children 1-5 according to 1990 census

start of SOMAVITA, only 20.7 percent of all Indonesian children aged one through five had received a capsule m the previous six-month peri­od. With the first national campaign in February 1992, this proportion jumped to 43.4 percent. SOMAVITA's goal of 40 percent coverage was thus achieved m the very first campaign. By August of 1993, overall coverage m the last distnbution peri­od reached 56.2 percent according to DOH statis­tics. (See figure I.)

In the 13 high-risk provmces, capsule distribu­tion Jumped even more impressively. With an mi­tial coverage rate of 24.4 percent, coverage rose after the first campaign to 46.6 percent, and by the August 1993 distnbution cycle to 65.5 percent according to DOH statistics. (See figure 2)

An endlme survey of two of the three provinces surveyed as a baseline measure in 1991 (Central Java and West Sumatra) was conducted m October 1993.9 Evaluation results showed that capsule cov­erage had increased but that the proportion of chil­dren aged three through five receiving capsules had not changed. About 70 percent of the children receiving capsules were aged one to three. Program managers realized that the messages about older children had not penetrated. A radio spot empha­sizmg children's age was made for the February 1994 campaign, and a poster featuring an older child was sent to village health posts for the August 1994 campaign.

Results from direct-mail surveys provided addi­tional insights. More than 90 percent of respon­dents (village leaders and health workers) knew the capsule distnbution months. Approximately half had seen or heard radio or televis10n spots and 81 percent had received a leaflet on vitamin A One­thlfd of respondents (from provmcial to village lev­els) had learned the new campaign message that vit­amin A promotes resistance to childhood disease and reduced mortality. In addition, 24 percent reported that measles should be treated with vita­mm A. Neither of these facts had been disseminat­ed to these audiences before the SOMAVITA effort. The ma1ority of volunteers (87 percent) still responded that the ma1or benefit of vitamm A was to prevent blindness. This reflects the challenge of

VITAMIN A PROMOTION IN INDONESIA

attempting to shift important health messages, and mdicates that focus needs to remam on getting this new idea across to various audiences.

DIVELOPING A MODEL FOR DllTARY CHANGI

SOMAVITA's pilot projects for promoting dietary change were conducted to develop a model that could be used on a national scale. Dietary change interventions often focus on mvestigatmg what is feasible in relatively small geographic areas. Although the SOMAVITA pilot areas were well defined (two districts each m Central Java and West Sumatra, totallmg 2.2 million people) project plan­ners hoped to select foods and design strategies which would have nationwide applicability.

The study also concluded that no single food could be selected that was appropriate tor all three provinces.

Later known as SUVI­TAL (Promoting Natural Sources of Vitamin A), the mitia­tive set out to develop approaches that would also mamtain low costs and management efficiency.

The first step was a Nat10nal Food Strategy Workshop organized in June of 1992 and

attended by representatives from the National Planmng Board, Departments of Health and Agriculture, research mstitutes, and umversmes. Based on information from the 1991 baseline survey of mothers m Central Java and West Sumatra, work­shop participants selected ten foods that were rich m vitamin A and were available m sufficient quannnes that consumption could be mcreased. These mcluded amaranth, cassava leaves, carrots, swamp cabbage, papaya leaves, papaya, a type of banana, mangoes, eggs, and liver. The origmal goal was to identify a sm­gle food from this IISt for promotion throughout the pilot reg10ns.

SOMAVITA then conducted a qualitative study in a subsample of six villages m each of the sur­veyed provmces Using observation, focus group

I

d1scuss10ns, and in-depth interviews, the study assessed the ten vitamm A-nch foods in terms of their nutnt10nal value, availability, pnce, accept­ability, and current level of consumption. The study narrowed the select10n to five foods (ama­ranth, cassava leaves, papaya, eggs, and liver) but also concluded that no smgle food could be select­ed that was appropriate for all three provinces. Local conditions, amtudes, and behaviors were too diverse. As a result, SOMAVITA's strategy shifted to a provmce-by-provmce food selection and pro­motion approach.

In May 1993, each province held a plannmg workshop. Participants mduded key DOH staff, rep­resentatives from other mtersectoral agencies, local universities, and village health volunteers Usmg social marketing plannmg worksheets developed by the HEALTHCOM Project, pamc1pants selected a food to promote. Cntena for select10n included availability, consumer acceptance, current consump­tion and the possibility of increasing this level, vita­min A content, current practices, pnce, and ease/time of preparat10n. In Central Java, planners selected eggs. In West Sumatra, planners selected amaranth-a green leafy vegetable. Participants also identified target groups and test sites, and developed major components of the communication strategy.

The next step was to select specific program objectives based upon current practices regarding selected foods. A rapid baseline study in the target distncts provided mformat10n from over 800 moth­ers regardmg their consumption patterns and basic knowledge, attitudes, and practices relevant to the selected foods. 10 Based on the survey results, district planners set goals for the pilot programs:

• In Central Java- to mcrease the proportion of children who ate eggs three or more days m the prev10us week from 40 percent to 60 percent w1th­m one year.

• In West Sumatra- to mcrease the propor­tion of children who ate amaranth three or more days In the previous week from 27 percent to 50 percent withm one year.

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Messages emphasized the benefits of the recom­mended foods and the importance of eating them every day. Central Java's chief slogan, "Never a day without eggs," appeared m all campaign matenals. West Sumatra's materials stressed that ''Amaranth 1s a good source of Vitamin A that's cheap and easy to get." Target beneficianes for the pilots mcluded those younger than those for the capsule programs, children begmning at six months of age (through five years) were emphasized, given the importance of the weanmg period.

Implementation

Provincial nutrition offices in Central Java and West Sumatra prepared one-year implementation plans for their mtervennons. The DOH provided about US $10,000 to assist in carrymg out the

On specified days,

children brought eggs to sc/1001 and ate them together.

plans. Each provmce launched its pilot effort with distnct onentat10n meetings; West Sumatra also conducted trammg at the sub-d1stnct level.

Although mass media played a part

m both pilots, community events and Interperson­al communication were stressed. Collaboration among different government agencies and with local NGOs helped "get the word out" through multiple channels. In Central Java, the provincial health office developed a range of matenals including:

• six ind1v1dual radio spots, which were broad­cast about 60 times m each district as public service announcements, plus a radio spot for a family series, broadcast 12 times;

• a poster for subdistnct health centers;

• leaflets about eggs and other vitamin A-nch foods for agricultural extens10n workers.

The Potential Problem of Taste Fatigue

P rograms that promote increased consump­tion and product10n of specific foods need to be conscious of the potential for "taste

fatigue" in the target audience. Indonesia's pilot foods promotion project (SOMATA) found that women might serve greater quantities of a particular food but would not cook it more fre­quently unless the recipes could be varied. When the SOMAVITA program in West Sumatra developed a radio spot to promote vitamin A-rich amaranth, planners included hints about how to avoid "boring'' the family with too much of a good thing.

Radio Spot: Conversation between two Housewives at the Market

Ida: Oh my! You are buying amaranth at the market every day1

Heri: I certainly am! Amaranth is a great source of vitamin A and it's easy to get.

Ida: But don't you get bored with eating amaranth every day?

Heri: Why should it be boring? That depends on how I cook it.

Ida: How do you cook it?

Heri: Well, you need to vary how you prepare it. For example, I serve it simply as a vegetable, or within kripik, or perkedel, or bakwan. I can put amaranth in all these dishes.

Ida: Oh, so 1t depends on how you cook it.

Heri: Yes, amaranth can be in all these dishes, but it tastes different.

Ida: Well, if that's the case ...

Heri: Sure! Try it yourself later!

Announcer: Amaranth is a good source of vit­amm A that's cheap and easy to get. Eat ama­ranth every day served in all kinds of dishes!

VITAMIN A PROMOTION IN INDONESIA

Extension workers from the Central Java Department of Animal Husbandry encouraged poultry farmers to mcrease egg producnon and the Department of Trade monitored the pnce and mar­ket supply of eggs dunng the mtervennon. The Education Department orgamzed monthly mstruc­t10n for elementary school and kindergarten teach­ers about vitamm A. On specified days, children brought eggs to school and ate them together. The Family Welfare Movement held egg recipe demon­strations and contests; village volunteers gave out cooked eggs to children brought to the posyandu for weighing and immumzauons Fatayat Nahdlatul Ulama, an Islamic young women's orgamzat10n, dissemmated vitamm A mformauon dunng its reli­g10us teachings.

The public health offices m West Sumatra were also prolific. They produced:

Ill a rad10 spot encouraging vaned ways to use amaranth m local dishes;

Ill banners for subdistrict health centers;

II a poster for health centers featunng amaranth and vanous vitamm A food sources,

Ill leaflets for rehg10us leaders, encouragmg them to ment10n vitamin A messages m their teachmg;

• a cassette recordmg of such a sermon;

Ill a cassette contammg traditional muslC and songs about v1tamm A m a local language, for health centers and village health posts.

Extension workers from the Department of Agriculture encouraged families to plant amaranth and other vitamm A-nch vegetables. Volunteers from the Family Welfare Movement orgamzed recipe contests and cookmg demonstrations m the villages. Previous pilots had held recipe contests that were successful in drawmg attention to the food promonon effort but often resulted m com­plex "wmnmg" recipes not readily adopted by the general populanon. The project team sent a nutn­uomst and anthropologist to visit several villages and develop and pretest recipes based upon local

I

dishes commonly given to children. Volunteers organized recipe contests m these villages, and chil­dren participated m selecting the winnmg dishes.

Monitoring

The national team monitored the promotion of vit­amin A-rich foods in Central Java and West Sumatra through visits to provmcial and district health departments. Using a standardized monitor­mg checklist, the team checked the status of pro­motional materials and assessed the impact of mes­sages disseminated through the provincial mass media campaigns.

District health department supervisors also visit­ed community and village health centers to observe local promot10nal activmes. The supervisors found that the pnce of amaranth m West Sumatra had doubled and even tnpled in the course of the year. Prices for eggs did not increase in Central Java, pos­sibly because the agricultural extens10n workers had been promoting mcreased egg production.

FOOD PROMOTION RESULTS

In June of 1994, rapid endline surveys in the pilot districts provided mformat10n on changes in the tar­geted behaviors. 11 Both provinces saw substantial increases in desired practices since the baseline a year earlier In West Sumatra, the percent of surveyed women who reported that their children had eaten amaranth three or more days m the prev10us week rose from 27 to 48 percent, almost meetmg the tar­geted goal of 50 percent. Central Java exceeded its objectives. The percent of women who reported giv­ing their children eggs three or more days in the pre­vious week Jumped from 40 to 77 percent.

The survey did not show mcreases in consump­tion of any other vitamin A-nch foods in the target reg10ns. However, some other important behav10rs did improve. In Solak district of West Sumatra, for example, research showed a great reduction in the number of mothers supplementing breastmilk before the desired age of four months.

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THE URBAN PILOT STUDY

Planning and Preparing for the Urban Experiment

SOMAVITA's third initiative was a pilot intervent10n to experiment with innovative techniques for pro­moting vitamin A capsule consumption in urban slum areas. Capsule and food promotion programs had so far focused on delivery and promononal mech­anisms for rural populat10ns. However, a high urban­izat10n rate in Indonesia, with an accompanying

Capsule and food promotion programs had so far focused on delivery and promotional mechanisms for rural populations.

rapid growth of slums, requires design of appropriate new strategies for these high-risk populations. Besides the different logistic problems of health delivery m urban slum areas, populations face chal­lenging social and economic situations whICh differentiate

them from rural populations as a target audience for health messages. Among these are a larger propor­tion of households with wage-earnmg and smgle mothers ( translatmg into less time to take children to health posts); greater time constraints affecting meal preparation and breastfeedmg; high mobility; high population density combmed with a multiplic­ity of ethnic groups; and large cultural diversity m health attitudes and feeding practices. Furthermore, many mothers are simply afraid to take their chil­dren to the local health post, or posyandu, because the family has not been granted permission to regis­ter legally in the city. This is a problem for many urban slum dwellers who have migrated from other provinces. (See box)

In 1992, the HEALTHCOM Project conducted background research for the urban pilot through mterviews with representatives of 16 organizations carrymg out health programs m the city. The study highlighted the difficulty of reaching the poorest urban dwellers m any systematic way Ethnic

VITAMIN A PROMOTION IN INDONESIA

its volunteers to public health programs (mcludmg immu­nization, oral rehydrat10n, and prenatal care) and was mterest­ed m explonng how It could help the vitamm A program. SOMAVITA's mandate to encourage the parnopation of local orgamzanons, and also improve their capacity to both promote and deliver services, made FNU a good match for the urban program.

Promotional activities included song competitions among traditional singing groups which were required to compose songs on a vitamin A "theme "

In February 1993, SOMAVI­TA began a iomt project with Fatayat Nahdlatul Ulama to pro­mote capsules and support the work of the local posyandus in three subdistricts of East Jakarta.

groups tend to cluster together in one neighbor­hood, with more than 30 different groups livmg w1thm a few blocks' radms. Residents often avoid government services that have registranon require­ments. On the other hand, religious figures have been successful m influencing these disparate and otherwise ISolated groups.

The study also aimed to identify potennal part­ners for an expenment in improving vnamm A cap­sule coverage m poor areas. Fatayat Nahdlatul Ulama (FNU), an Islamic young women's orgamza­tion with six million members nationwide, emerged as an important collaborator. Within Jakarta as a whole, 382 FNU motivators and 40 supervisors provide a regular network of face-to-face, neighbor­hood-based communication. Their ongoing act1v1-ties mclude Koramc study groups, Ansan (women's credit and loan assoc1at10ns) and other relig10us assemblies in homes. Gatherings often provide the opportumty to convey social messages.

FNU offers an effective and sustainable channel for reachmg the poorest segment of urban dwellers. Its members are trusted because they live within the communities they serve, and denve high cred1-b1lity from their religious functions and ded1ca­non. FNU had previously provided support from

Target areas were selected based upon low vitamm A capsule coverage rates, high prevalence of communicable diseases, and the avail­ability of Fatayat motivators at the community level. Officially, 161,930 families lived in these subdis­tncts. An addinonal four subdistncts were selected for the second phase of acnvines.

Together with the DOH national and local offi­cials and HKI, HEALTHCOM and Fatayat devel­oped a plan with three important goals:

• to increase capsule coverage in the target areas by 50 percent after three distribunon penods;

• to develop a model distribution strategy to reach the hard-to-reach, complementmg the gov­ernment's standard delivery mechamsms;

• to assist FNU to build their institutional capacity through trammg and through plannmg and implementing a pilot intervention.

A collaborative foundation was essential to the success of this unusual effort The Fatayat project team met with DOH offioals at each admm1stra­t1ve level, with local government officials, and with leaders of the Family Welfare Movement (or PKK, which assists m running the posyandus) to secure their approval and support for the project.

I

Training was the next important step. Many of the FNU volunteers had already participated m SOMAVITA's national-level training in social marketmg methodology. The HEALTHCOM Project organized two additional workshops for the urban pilot. The first of these focused on Rapid Assessment Procedures in order to give FNU a simple method for gathenng information useful to the design of their program. Dunng the second day of trammg, Fatayat supervisors and motivators went mto the commumties to inter­view 270 mothers and observe theu hvmg envi­ronments. Results were tabulated and discussed before trammg ended.

A second workshop was designed to enhance the volunteers' interpersonal communication skills to help them motivate mothers and to supervise or provide feedback to their team members. Tramees also learned about the health implications of vita­min A and, together with observers from the DOH, developed capsule distribution forms to be used in their mtervent10n.

IMPLEMENTATION

The pilot implementation plan includ­ed three ambitious phases of activities for FNU volunteers: 1) dissemmat10n of messages to mothers promoting attendance at the posyandu for capsule distribution; 2) collect10n of data on children who did not receive capsules m the semi-annual campaign; and 3) house-to-house "sweeps" to distnbute capsules to those who had not been reached

• Weekly Koranic study groups- Volunteers wove messages about the importance of preventmg disease and the benefits of vitamm A mto their reg­ular Koramc d1scuss10n meetings (Pengajzan, or readings at the mosque, as well as Yasznan, or group readmgs in homes). Even new migrants who belong to virtually no other soCial groups often attend such meetings.

• Sermons at the local mosques- Rehg10us leaders who were informed about the importance of v1tamm A became enthusiastic about includmg information and motivat10n m theu sermons.

B Music and song events- Traditional music competitions were held combming Independence Day celebrations with promotion of v1tamm A cap­sules. FNU motivators, PKK volunteers, and ado­lescent girls performed. Some smgers wore green and yellow costumes representmg v1tamm A "col­ors." Other events mcluded children's song festivals at elementary schools and performances of local bands. Cassettes were also produced with vitamm A songs and speeches.

Before each capsule campaign, Fatayat motivators developed wntten plans out­lmmg theu proposed promotional activ­ltles. SOMAVITA reviewed the plans and provided necessary fundmg. During July and August of 1993, volunteers used multiple channels to reach their audiences. These channels mcluded.

FNU volunteers went house to house after semi-annual capsule distribution periods to find children who had not yet received capsules

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VITAMIN A PROMOTION IN INDONESIA

Getting to Know An Urban Population-or Populations

akarta's urban capsule pilot program began in three subdistricts and expanded

to another four. The popula­tions of these subdistricts faced some common problems, but were also tremendously varied. For example:

• In Pulogadung subdismct, more than 55,000 families from 20 different provinces have settled in an area of just 15.6 square kms. A central bus depot makes it the "gateway'' to Jakarta for migrants. Pulogadung is one of the pri­mary termmals for waste dis­posal in Jakarta. Many of the residents therefore work as waste collectors.

• Matraman subdistrict has a population density of more than 37,000 people per square km. Residents live in 62 dif­ferent "hamlets" in an area of just 4.85 square kms. They

work as daily laborers, petty traders, pedicab/bus drivers. Social conflicts and crime are high, as are various forms of gambling and prostitution.

• Cakung has an average of 5,000 people per square km. It has the highest concentration of industry in Jakarta, with 702 industries registered in 1991. Residents work as daily laborers, or collect waste. Women work as food traders, seamstresses, or servants.

Most of the children in these areas do not attend school either because of family poverty or because their fami­lies do not have legal residence. The children often work in petty trade or small scale industry. When FNU volun­teers conducted their rapid assessment of the target subdis­tricts, they found that health cards revealed immunization

rates much lower than other areas of Indonesia. About 43 percent had received their third dose of DPT; about 56 percent had received their third dose of OPV by age two; and 42 percent were immu­nized against measles. Although urban areas are in theory easier to reach through mass communication than rural audiences, the multiple languages and varied customs and cultures of slum areas make it difficult to design use­ful messages. Very low literacy levels undermine the usefulness of print materials as well. High intensity interpersonal commu­nication is the most promising medium. SOMAVITA's urban pilot therefore focused on developmg the outreach capac­ity of a credible volunteer net­work to support its capsule­distribution goals.

• Community media- Banners remindmg mothers to come to the posyandu for capsules, loud­speakers mounted on cars announcmg the day and time of capsule distribution, puppet shows, drum bells, parades of volunteers wearing vitamin A T-shms, and a simple flyer promoted capsule-dis­tnbution days.

local posyandus and compared the lists of children who had received capsules with rosters provided by heads of the individual hamlets. Names of children and parents were then compiled as the basis for home visits m September. Each volunteer took cap­sules for the children m her parncular area and went to ind1v1dual homes to distribute them and also to provide counselmg about the vitamin A promotion effort. In addition, motivators kept their own lists of families who attended their regular religious meetings but had not established legal residence. Volunteers were able to visit these homes as well during the "sweep."

• Home visits- Person-to-person commum­cation dunng home visits, especially with families whose children had missed the posyandu distnbu­tion cycle, gave volunteers an opportumty to pro­vide mformation and also help establish trust.

Followmg the end of the August dIStribution penod, the Fatayat volunteers returned to their

Volunteers recorded all the capsules they dismb­uted m the children's health cards and also reported

I

this mformat10n to their supervisors who relayed it to the local posyandus In this way, distribution by the FNU volunteers became a complementary and integrated activity withm that of the regular posyan­du effort.

Based on early successes during this first distrib­ution cycle, the proJect expanded its target audi­ence to an additional four subdistricts (in North Jakarta) for the February cycle, raising the number of eligible children to over 16,000. HEALTH­COM repeated the two workshops on Rapid Assessment Procedures and mterpersonal commu­nication for volunteers workmg in the new areas. Dunng this round of trainmg, greater responsibili­ty was given to the lead trainers of Fatayat's nation­al office. FNU volunteers from other provmces also attended these workshops. The goal was to bmld greater capacity withm the organization to carry out such interventions with little outside donor assistance. HEALTHCOM also carried out a cost study of the Fatayat intervention to help them develop a cost efficient model that could be repli­cated with local funding levels.

MONITORING AND RESULTS

Fatayat supervisors held weekly meetmgs with their motivators and also met monthly with the commu­mty health post coordmators and FNU headquar­ters staff. After each "sweep," each FNU motivator completed a checklist indicatmg:

• number of children m the neighborhood;

• number of children brought to the posyandu for capsules;

• number of homes visited;

• number of materials dissemmated;

• activities conducted and those involved;

• number of Koramc readmg groups where vitamin A was discussed.

This detailed mformation provided a simple but appropriate method for gathering proJect data.

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Results showed that total coverage in the mterven­tion areas increased from 15 percent to 60.1 per­cent of children one to five after three semi-annual distribution cycles. 12 After the fourth cycle in August 1994, coverage increased to 70.2 percent of eligible children. 13

Four in five of the children receivmg capsules in this cycle obtamed them from FNU, mdicatmg that most of the increased coverage resulted from FNU's home visits. This fact reflects the challenges to the posyandu system in an environment where mothers may not have the time or the necessary sense of security to take a child to a government-run service; it also reflects the dedication of the FNU motiva­tors and the effectiveness of their person-to-person contact in the urban slums.

FNU supervisors m some other provinces are begmnmg to replicate the pilot program on their own. Some of the volunteers from other provinces who attended the second round of training also sent m reports that they had mobilized their networks to begm support of the vitamm A program and had already reached several thousand children without any external assistance.

LESSONS LEARNED

The SOMAVITA program demonstrated that gov­ernments can bring vitamm A capsule promotion programs to national scale quickly if national and provincial decision makers make a maJor commit­ment of staff and resources. In this program, dele­gatmg responsibility for program planning and implementation to provincial and district levels helped create a feeling of ownership. It also encour­aged local activism and led to mnovative promo­tional activmes. A decentralized approach has bet­ter likelihood for sustainability because local agen­cies gam the skills and confidence to contmue on their own. Training of core groups is essential to the success of this process.

SOMAVITA's explicit objective of bringmg NGOs into the planning and implementat10n processes-for the capsule, foods promotion, and urban pilot activmes-clearly added to program

impact. It demon­strated that non­governmental and local groups can contribute substan­tially not only to

promotion efforts (their usual role in public health pro­grams) but also to

program design and

Seed grants were a particularly useful device tar motivating local creativity and encouraging a search tar matching funds.

to the mechamsms of health service delivery itself. The necessary investment m traimng and momtor­ing of these groups saves costs in the long run, con­tributes to capacity building, and provides a tangi­ble benefit to participating organizations through skills development and motivat10n.

A number of addmonal key lessons can be drawn from the SOMAVITA experiences:

• SOMAVITA's nat10nal capsule program effort had a dual role: 1) to provide an "umbrella'' mass media campaign which dissemmated uniform messages in all provinces; and 2) to provide trainmg and monitoring for provincial staff and activities. This approach, combmed with SOMAVITA's phased assistance to high-risk provmces, focused limited resources effectively. Seed grants were a par­ticularly useful device for motivatmg local creativi­ty and encouragmg a search for matching funds.

• Policy decisions based upon the lessons from pilot proJeCts were central to the success of the nat10nal program. Standardizat10n of the six-month distribut10n cycle allowed for broadcastmg of mes­sages nationally, and helped avoid volunteer and donor "fatigue" at the commumty level. The gov­ernment also looked squarely at evidence that the posyandu system was not yet strong enough to serve as the sole system for capsule distribution, and responded with effective changes m policy. Th(l Jakarta pilot proJect demonstrated that an NGO can provide an effective complementary mecha­nism for distribution.

• SOMAVITA found that the DOH's funda­mental message about the benefits of vitamin A

VITAMIN A PROMOTION IN INDONESIA

needed to be revised, due to the reduced mcidence of blmdness associated with vitamin A deficiency. Although such shifts m messages are risky, forma­tive research and mtensive commumcanon efforts to both primary and secondary audiences can assure the credibility of new messages over time.

• The "under five year old" or the "one to five year old" is not a single audience segment, but m reality many segments. Child survival programs often reveal that the youngest child is a speoal challenge. (Immunization programs often have difficulty raismg rates among the under-ones. Dietary change programs often find that mothers will serve recommended dishes to older children but not to those who are weanmg ) In contrast, SOMAVITA's capsule campaigns had most trouble reachmg older children who otherwise do not receive services at the posyandu New messages were targeted accordmgly.

• SOMAVITA planners originally hoped to design a vitamm A food promotion model similar in some ways to that of the national capsule pro­gram. With a uniform message strategy, an "umbrella" national campaign mdudmg mass media could be supported by mtensive promot10n activmes at the local level. However, experience showed that the foods promoted must be selected at least as far down as the provincial level. Although both provmces involved m the vitamm A-rich food promotion programs saw improvements m desired practices, one year is not sufficient for achievmg long-term dietary change m a populat10n. Furthermore, promotion of a single food is less like­ly to have an impact on vitamin A mtake than pro­motion of several foods. The need for variety m a family's diet, as well as challenges of the market, cre­ate difficulties for a single-food approach.

• The SOMAVITA experience confirmed the necessity for special strategies geared to the realities of urban populations, especially the urban poor. Working with groups who have a presence m the target communities, who are trusted, and who are motivated and trained to provide effective face-to­face counseling is vital.

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• Monitoring of mtervenuon activities on a continumg basis (through site visits and question­naires) revealed problems that could be responded to quickly. For example, visits with health workers convinced the national team that guidelines were necessary on vttamm A capsule protocols. The team was able to print these during the mtervention and dissemmate them on a nationwide basis.

• SOMAVITA's capsule-promotion messages were broadcast over more than 600 televis10n and radio stations throughout the country. The proJeCt attempted to develop monitonng systems for the broadcasts but ran into both technical and cost dif­ficulties. Devising a simple momtonng system uti­lizing project staff personnel to collect data will be a pnority in subsequent efforts.

• Direct mail proved initially to be a successful way of monitoring program process and results m dis­tant areas. The pilot proJeCt (ROVITA in particular) had already expenmented with this channel, and found the mail system adequate and recipients responsive. Over time (after two surveys), however, those who received quest10nnaires on a repeat basis began to lose mterest and no longer responded. Future programs will vary the list of those they survey.

Indonesia has promoted vitamm A capsules among the population for nearly 20 years. Even given the fact that "pills" and "vitamins" are both valued "products" in the public's mind, coverage throughout the country was low at the begmnmg of the SOMAVITA ProJeCt. The need for a major examination of the distnbution system, as well as systems for proVIdmg informat10n and promotmg demand in commurnties, was clear. At the same time, the government knew it had to look beyond capsules to the longer-term goal of dietary change. SOMAVITA's three-thronged program was a bold effort, m a short time-frame, to test and apply new models to meet these challenges. Each of these mitiatives brought about impressive changes in health practices through cost-effective and sustainable means. The lessons from SOMAVITA will be invaluable in helping build a strong national program that meets the needs oflndonesia's diverse population.

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NOTES 1 Pollard, Richard, Social Marketing ofVztamzn A, SOJ\.1A­TA Pro;ect, West Sumatra Province, Indonesia Qakarta The Manoff Group, with the Department of Health, Duectorate General of Commumty Health, Republic of Indonesia, and Helen Keller International/Indonesia, 1989)

2. SOMAVITA I was a one-year "bridge" between ROVITA and the nat10nw1de project, implemented m Central Java m 1990 In this document, "SOMAVITA" is used to descnbe the nauonw1de, three-year project launched m 1991 and techmcally named SOMAVITA II

3. The 13 provmces were Aceh, North Sumatra, West Sumatra, South Sumatra, Central Java, Southeast Sulawesi, South Kal1mantan, West Kal1mantan, West Nusa Tenggara, East Nusa Tenggara, East T1mor, Maluku, and Inan Jaya

4 Information mcluded in this case study on the baselme and endlme surveys, and regardmg data gathered by the DOH on the SOMAVITA activities, are reported m· SOJ\.1AVITA Pro;ect Final Report 1 August 1991 - 30 September 1994 Qakarta Mm1stry of Health and Helen Keller International, September 1994).

5 East Nusa Tenggara was ongmally to be part of the vlta­mm A-nch foods mtervention; however a natural disaster in Flores m 1992 damaged villages, commumcation net­works, and mfrastructure A foods mtervention was later launched, but not as part of the program descnbed here.

6. For further mformation about the campaign matenals see the SOMAVITA project document, Taking the Message Nationwide Soczal Marketing of Vztamzn A in Indonesia Qakarta M1mstry of Health, Republic of Indonesia, and Helen Keller International; draft, May 1994)

7 Additional mformation about pretestmg is provided m "Gettmg the Word out on V1tamm A and Mortality: Developmg Pnnted Material for Commumty Leaders," Qakarta: Mm1stry of Health of the Republic of Indonesia, and Helen Keller International, February 1993)

8 Survey Research Indonesia (SRI), Vztamzn A Positzonzng Research-A Qualitative Report Qakarta· SRI, September 1993)

9 The endlme showed changes m mothers' reports of cap­sule coverage between 1991 and August of 1993 of 20 3 percent to 30.6 percent m West Sumatra and 45 7 percent to 58 percent m Central Java (p< 001) The West Sumatra

baselme data were s1m1lar to that collected by the DOH. However, the Central Java baseline was s1gmficantly higher than the DOH statlsncs. The evaluators suggest that smce Central Java was the ROVITA province, sampling differ­ences (survey areas close to ROVITA areas vs. DOH entire provmce figures) may have played a role

10 The Rapid Assessment Procedure (RAP) adapted here was developed by the Johns Hopkms Umvers1ty for use by pnvate voluntary orgamzanons.

11 The rapid assessment method was mtended as a pro­gram management tool. Use of a simple, low-cost samplmg system hmltS the mterpretatlon of the results Results are discussed m SOMAVITA Pro;ect Final Report 1 August 1991 - 30September1994 (Jakarta: Mm1stry of Health and Helen Keller International, September 1994)

12. Academy for Educational Development and Helen Keller International (HKI), "Urban V1tamm A Promotion m Jakarta A Collaborative Pro1ect among Fatayat NU, the Department of Health, Academy for Educational Development, and Helen Keller International," (Paper pre­sented at the XVI International V1tamm A Consultative Group Meetmg, Chiang Mai, Thailand, October 24-28, 1994)

13 The Urban Health Study Group of the Umvers1ty of Atma Jaya also earned out a study m four subd1stncts (with over 700 mothers) to examme socio-econom1c factors that determme v1tamm A capsule d1stnbut10n and to provide another measure of the impact of the capsule promotion campaigns Results are reported m the SOJl.1AVlTA Pro;ect Final Report

Willard Shaw is with the Academy fo1 Educational Development and Cynthia Green is an international consul­tant based in Washington, DC

VITAMIN A PROMOTION IN INDONESIA

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