STRATEGIE OR PROM

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 cen­ tury. A significant number of children will also be spared from blmdness or mcreased sever­ ity of common respiratory and diarrheal infections. Thus, the important question is how to ensure that these children receive sufficient vita­ mm A. This can be achieved through a number of complementary approaches including improvmg production, access, and utilization of vnamm A-rich foods; periodically supple­ menting 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 mar­ keting 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 pub­ lic 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 The Philippines United States Agency for International Development From the Vitamin A Expert Group (VAEG): Florentmo S. (USAID), Office of Health and Nutrmon, under the Solon, Gerardo Bayugo, Demetna Bongga, Rodolfo Nutrmon Communicat1on Project (Contract No. DAN- Florentino, and Rolf Klemm From the National 5ll3-Z-00-7031-00) and the Communication and Micronutrient Action Team (NMAT): Jaime Galvez-Tan, Marketmg for Child Survival Project (HEALTHCOM), Carmencita N. Reod1ca, and Elsa M BayanI From (Contract No. DPE-1018-C-00-5063-00). Both projects Cagayan de Oro City: Pablo P Magtajas, Ory Mayor, and were conducted by the Academy for Educational members of the Cny Council From the City Improvement Development. Publication was supported by the Office: Ernesto Alepdo, Peter AbejO, and Ledelmma Chua Opportunmes for MICronutnent Interventions (OMNI) From the Health Department: Rico Jacutm, M1ravel Project (Contract No. HRN-5122C-00-325-00), managed Tangcalagan, Nenita Rabe, and Esperanza Pimentel From by John Snow, Inc This publication was produced by the City Social Services and Development Office: Elsie Q Academy for Educational Development and does not neces­ Labuntog and Myrna Replagao From the Department of sanly represent the views ofUSAID It may be reproduced 1f Education, Culture, and Sports: Lourdes Pabayo, Virgilio credit 1s given. Jumamoy, Gil Constantino, Ysmael Pacana, Lita Munllo, SpeCial acknowledgments are due to Dr. Eunyong and Edith Lago. From the City Agriculture Productivity Chung and Dr. Melody Trott m the Office of Health and Office: Carlo Magno Raagas and Myrna Arrabaca From Nutnt10n for theu v1s1on m puttmg together a jOIIlt publi­ the Nutrition Center of the Philippines: Laura Tantoy cation summanzmg the expenence of two different USAID and Bernarda Ueno From the Academy for Educational projects m promotmg v1tamm A. Dr Frances Davidson, Development: Willard Shaw, Joseph D1edench, and Robert Chau of the M1cronutnent Workmg Group, assured its Letourneau. From USAID/Manila: Patricia Moser and production. Marichi de Sagun Thanks to USAID/Washington for The authors also wish to acknowledge the contnbut1ons fundmg these efforts and for their support of the many md1v1duals and organ1zat10ns who collaborat­ ed m conductmg the projects m Niger, the Ph1lippmes, and Indonesia. The work descnbed here 1s the result of theu Indonesia dedication, creativ1ry, and hard work m findmg ways to Among the several thousands of people who helped carry improve nutrmon-related behav10r In particular, the out the v1tamm A acnvmes m Indonesia as descnbed m this authors would like to acknowledge the followmg people document are from the Directorate of Nutrition: Benny who were mstrumental m the design, implementation and Kodyat, Dm1 Lanef, Asm1ra Soetarto, and Suherno From evaluation of the projects the Center for Health Education: Ida Bagus Mantra and Ruflma Rauf From Health Education/Central Java: Niger Victor Sartono From Community Health: W1dyastut1 W1b1sono and Tnhono. From Fatayat Nadhlatul Ulama: From the Ministry of Public Health: Atssa Sn Mulyat1 Asron and Lisa S1aiful From the Diponegoro Mamadoulta1bou, A1ssata Gmmba, Habou Kalla, University: Satoto. From Helen Keller International: Zemabou Mohamed, and Mounkeila Abdou From the Anne Palmer, Steve Wilbur, James Johnson, and Barbara Ministry of Agriculture: Ousmane Abdou From Tahoua Scholz From the Academy for Educational Development: Department: Xavier Crespm From Radio Tahoua: Tom Reis, Willard Shaw, Mark Rasmuson, Tjep Marku, Hach1m Mohamed. From the National Center for Health Indrawatl Josod1ppoero, and Dew1 Widanmgs1h Statistics: Moukeila Abou From Helen Keller International: Else Sanogo-Glenthoj, Issa Camara, and Cynthia Green and Ronald Parlato put together early Brah Ferdows From the Academy for Educational drafts of the case studies (Dr. Green for the Ph1hppmes and Development: Nancy Keith International Consultants: SOMATIVA, Mr Parlato for Niger) A note of apprec1anon Man-Mmg Hung, Hughes Kone, Rebecca Popenoe, also goes to Amanda Robbms (Academy for Educational Dandara Kame, Shawn Baker, and Stanley Yoder Thanks Development) for her admm1strauve assistance 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 INTRODUCTION

Margaret Parlato Renata Seidel

ADVANCES IN OUR UNDERSTANDING Of • supplementing the diet with high-dose cap- VITAMIN A sules and other pharmaceuticals; • fortifying commonly consumed foods; In the past decade our appreciation of the impor­ • promotmg changes in dietary practices; and tance of vitamin A has grown dramatically. Once vita­ valued prmcipally for its role in preventing blmd­ • improving product10n of and access to ness, vitamm A has been shown by recent scientific min A-rich foods. studies to increase the body's ability to fight infection and to contribute m critical ways to reducmg child Many factors determine what strategy or combina­ mortality. Vitamin A affects the course and outcome tion of strategies is most appropriate for a particu­ of infectious diseases. Without adequate levels of its lar country at a particular pomt m time. National protective effects, episodes of diarrhea last longer and programs often employ a mix of strategies depend­ childhood illnesses tend to be more severe. In com­ ing on the availability of foods in different regions, munities where vitamm A deficiency 1s common, 23 the status of the food industry, the possibility of percent of child deaths have been directly attributed increasing production of selected foods in a range to a lack of the nutrient.1 Furthermore, recent stud­ of horticultural zones, and the likelihood of ies suggest a strong assoc1at10n between the vitamin increasing consumption among those at greatest A status of HIV-infected women and reduced trans­ risk. Recognition is increasing, however, that food­ mission of the virus from mother to infant.2 based strategies are fundamental to long-term pre­ Despite advances m our knowledge about the vention of vitamm A deficiency. many stnkmg benefits of vitamin A, progress in elimmatmg its deficiency among affected popula­ tions has been disappointingly slow. Half a million APPROACHES TD CHANGING BASIC BEHAVIORS children become blmd each year and another 231 million are more vulnerable to infectious disease The four case studies mduded here illustrate how because of inadequate v1tamm A in their diets, communication programs can be designed to improve resulting in millions of preventable child deaths.3 vitamin A status m different contexts by applymg the To date, public health planners have focused on principles of behavioral science and social marketmg. four approaches to addressing the problem: These projects, which were funded by the U.S. I Agency for International Development, all used a sys­ generic messages was probably not feasible. No sin­ tematic methodology based upon audience/situation gle food could be found that was suitable across research and rigorous plannmg. The different mter­ provmces Instead, program planners developed a ventions aimed at promotmg carefully selected behav­ framework that enabled each province to select Its iors that would increase the VItamin A intake of at-risk own vitamm A "target food." populations. Type of program, cultural framework, Food-based approaches should only be designed and foods available in the target areas varied widely, as when research has shown that mcreasmg produc­ did the resources available for these interventions. tion and consumpt10n is feasible in the particular The Niger case study looks at a pilot proJect to test target area. In the Phrlrppmes and Indonesia, mex­ ways of diversifying food production and family diet pensrve plant sources of vrtamm A were available under difficult climatic and horticultural condmons. year round. In Niger, however, availability was an The Philippines study exammes how planners aimed issue. More costly animal sources of vitamin A had to promote both production and consumption of to be promoted during one season m order to cover green leafy vegetables m urban areas, as part of a new needs over a 12-month period. Researchers estab­ national emphasis on dietary solutions to vitamin A lished that families had disposable mcome during deficiency. Two case studies focus on Indonesia. The this critical penod following the harvest. ROVITA study looks at communication approaches A single food per se is challenging for a foods to improve capsule drstnbution. The SOMAVITA promotion program. The potential for "taste project-which followed ROVITA-was a bold fatigue" m the audience and vagaries of the seasons three-pronged national effort to test models to and the market create change vitamin A consumption patterns; to improve maJOr obstacles. Pro­ capsule drstnbution nationwide with an emphasis on Promoting several monng several foods high-risk provmces (in order to address the immedi­ toads is amore rs a more complex ate problem); and to develop NGO drstnbution and task, but raises the promotion systems in urban areas. complex task, hut likelihood of In­ The scale of these projects vaned from a small raises the likelihood at creased consumption expenmental effort m Niger reachmg 250,000 peo­ In the Phrlrppmes, ple, to a multi-level program in Indonesia covering increased consumption. the difficulty of a national population of 179 m1ll10n in the capsule focusing messages on distribut10n component and 2.2 million in the several foods was dietary change pilots. Lessons learned from these resolved by turnmg five vegetables mto one product projects are quite different. We hope they will be via "MACK-P"-the acronym for these different useful to policy makers and vitamin A program vitamm A-rich sources. Niger dealt with this dilem­ implementors, and can be applied to new contexts. ma by featuring different foods for each season. Selection of the "nght" foods calls for careful market and audience research. Pertment issues LESSONS FROM THE FOUR STUDIES include seasonal availability, vrtamm A content, cost, consumer acceptance, ease of preparat10n and Foods Promotion time required, and current consumpt10n level and the possibility of increasing it. Identifymg the nght Dietary change Interventions are most effective foods to promote necessitates invesngatmg a range when tailored to well defined geographic areas. of market, economic, social, and nutnt10nal issues. Distmct agricultural or cultural zones require To avoid getting lost m the sheer complexity of strategies geared to those local realities. SOMAVI­ these issues, program mangers should artrculate the TA research revealed that a national program with specific quest10ns they need to answer. I INTRODUCTION

Communication planners m the programs high­ helped focus and conserve promotion expenses. At lighted here were able to identify foods which satis­ the same time, decentralizing promotion efforts to fied these cnteria. However, one difficult "selection" the provmcial level (through traming and seed issue emerged. Parents hold firm beliefs about what grants) supported tailored commumcat10n activities. young children can digest, or what foods are appro­ A communicat10n program can only be as effec­ priate for the weanmg age child. In particular, green tive as the service delivery system it supports. The leafy vegetables (which are a prime source of vitamm ROVITA and SOMAVITA projects found that tak- A and usually among the best products in terms of mg a consumer per­ availability and cost) are often not fed to this critical spective when exam­ group. Messages must address mothers' specific Capsule programs lend mmg distnbut10n concerns about feedmg selected vitamin A-rich themselves ta large, issues (such as urning foods to their children. Planners must also adjust and location of cap­ their expectations, and not rule out alternatives, well-conceived national sule distribution) (such as animal sources of vitamm A or more expen­ promotion efforts. altered the way the s1Ve fruits) when resistance is strong. program should be Commg up with practical ways to improve vita­ organized. Studies mm A intake depends on good consumer pretesting showed that only 50 percent of villagers had local of each candidate food. Messages must also be health posts where they could obtam capsules. pretested once foods have been selected. For exam­ Although the government was committed to ple, the Niger program did not reqmre mothers to expandmg this system, officials also looked square­ eat more food m a context where this would seem ly at the current reality and began to mvolve NGOs unreasonable to them. They were rather encour­ in house-to-house sweeps and experimented with aged to feed children certain foods more frequently, other new ways to get the product to children thus achievmg the same result. Similarly, mothers Commitment by service providers is also cntical to were not asked to increase the amount of certam program success. Mid-project monitoring of the mgredients in given recipes, because this too would SOMAVITA capsule program revealed that govern­ have seemed unacceptable to them. ment health workers remained concerned about the Changes in food consumpt10n patterns require safety of various aspects of the new distribution sys­ shifts m deeply ingramed family habits and cultur­ tem, which they believed might lead to some children al norms. Programs lasting a smgle year or two may receiving extra doses. The project therefore developed be able to improve targeted behaviors over the short a booklet for providers on the "Safe Use of High-Dose term. Long-term shifts, however, require consistent Vitamm A" to assuage fears about toxic overdose. efforts and momtoring of impact over several years.

Selecting Target Audiences Capsule Programs Every behavior change program must look careful­ Capsule programs lend themselves to large, well­ ly at who makes decisions relative to the actions conceived nat10nal promotion efforts. Message being promoted. If planners hope a woman will go consistency across broad geographic areas can to the local health post, research should look at who increase impact (quite unlike the case for dietary might mfluence her gomg (the husband? a neigh­ change programs). For example, standardization of bor?) In programs which address family food pur­ capsule distribution months-at six-month inter­ chase, consumption, and distribution patterns, the vals-allowed the SOMAVITA proJeCt to create an role of men can be key. The Niger ptoJect built "umbrella'' media program at the national level and messages upon the realmes of existmg gender roles I related to food provision, and encouraged small required special attent10n because-unlike in changes. Messages can be geared to alter family many other mterventions-this age group is often practices to a degree, but not to overhaul them. the hardest to reach. In Indonesia, the distribu­ Perceptions held by children themselves can also be tion site (posyandu, or village health post) is worth exammmg. In the Philippines, children were thought of as a center for younger children selected as a target audience because they make food because immumzat10n and growth monitoring decis10ns, because parents listen to their preferences, services are emphasized there. Messages needed to and because children's habits become life-long habits. be re-focused so that mothers remembered to bring their four- and five-year-old children to the health posts as well. Segmenting the Beneficiary Group

The programs studied here all remforced the fact Designing Effective Messages that the "under-five-year-old" is not a single group, but actually several distmct groups. Consistency of messages over time is fundamental Communication programs face different chal­ to the credibility of public health mtervennons. lenges m attempting to change the behaviors of Vitamin A programs therefore confront a difficult caretakers with regard to different ages. situation. Many countries (such as Indonesia) Most child survival intervent10ns find that the now find that theu messages are no longer credi­ under-two or the weaning age child is considered ble precisely because the deficiency has lessened­ vulnerable or special and blmdness is no longer an everyday remmder m certain ways, and of vitamm A's importance Our mcreased under­ caretaking practices Simplicity has its virtues. standing of the role vitamm A plays in strengthen­ surroundmg that Highly integrated plans ing the immune system also reqmres a new look at age are particularly message content. resistant to change. can "backfire" as When programs try to change the rationale for The food promotion the complexity of vitamm A supplementation and consumption, programs all found concerted effort must be put into pretestmg new this, and made spe­ interventions increase. messages among different audiences. Likewise, cial efforts to create intensive disseminat10n of the new messages 1s messages addressing essential. The SOMAVITA proJect found that weanmg age feedmg concerns. However, tradi­ health professionals were responsive to new mes­ tional beliefs about what is appropriate for the sages about v1tamm A's role m reducmg child mor­ young child often contradicted program messages. tality and in treatmg measles However, the same A second children's group to emerge with its messages will take much longer to become "mem­ own unique set of eatmg concerns was the older orable" and convmcmg among village leaders, vol­ child. In the Phdippmes, food preparation by unteers, and community members. mothers was affected by the difficulty they experi­ enced m getting children to eat vegetables. The media campaign helped raise the image of green Getting the Message Out leafy vegetables in the minds of children as well as theu parents. In Indonesia, contests were held to The effectiveness of mterpersonal communication test new recipes with children, m order to identify was illustrated by all of the proJects. These inter­ the tastiest ones. ventions reached outside the health system m order Capsule programs also found the older child to provide suitably comprehensive and intensive I INTRODUCTION

contact at the household and community levels. countries-especially related to beneficiary groups The key to outreach in Indonesia was harnessing and barriers-should provide useful insights for the energy of a women's relig10us group whose program planners launching new efforts. members are credible and trusted by the target Although much has been accomplished, many audience. In Niger and the Philippines, teachers challenges remain in the vitamin A communica­ and agricultural extension agents were trained to tion area. Every country must determine the prop­ conduct a wide range of activities. The Philippines er mix of strategies, given available resources, for effectively mobilized local elected officials. promoting vitamin A production, consumption, Choosing appropriate media is a complex and supplementat10n (as well as foruficat10n) so process and mid-project monitoring will reveal the that high-risk groups are reached effectively in the actual reach and impact of different channels. short term, and the vitamin A status of the general Each of these programs experienced some "sur­ population is raised over the long term. To achieve prises." ROVITA found that, although banners this long-term goal, focus must be put on finding are a popular medium in the target area, project ways to sustain behavior change so that new eating banners were largely unsuccessful in reaching patterns-med out for a few months during a women with messages. The Niger project discov­ commumcanon program-become routine, rein­ ered that effectiveness of village drama depended forced in myriad ways by the prevailing culture. upon the size of the village. Dramas were more This will require the efforts not only of communi­ effective in smaller villages. cat10n experts, but support for improvements in Simplicity has its virtues. Highly integrated the complex factors which influence "supply" for a plans can "backfire" as the complexity of interven­ given population. tions increase. Too many media, as well as too much reliance upon intensive local organization and planning, can complicate a program. No pro­ NOTES gram should be "bigger," or attempt more activities, than can be carefully planned on the basis of Beaton, G H., R Martorell, K.J. Aronson, B research, and can be monitored through simple, Edmonston, G McCabe, A C Ross and B Harvey systematized checks. The SOMAVITA project Effectiveness ofVttamm A Supplementation m the Control of experimented with direct mail questionnaires to Young Child Morbzdzty and Mortality zn Developing monitor various aspects of the provincial interven­ Countries ACC/SCN State-of-the-Art Senes: Nutrltlon tions. Although the system initially worked well, Policy D1scuss10n Paper No 13 (Geneva The Umted planners learned that respondents needed to be var­ Nations, 1993) ied over time as the novelty of filling out and returning paper work wore thin. 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) FUTURE DIRECTIONS 3. UNICEF The State of the World's Chzldren, 1995 Evaluation results from the four projects are encour­ (Oxford Oxford Umvers1ty Press, 1995) aging. 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 I Case study ; ~· NIGER Promoting Vitamin A in Rural Niger: Strategies for Adverse Conditions

Margaret Parlato Peter Gottert Promoting Vitamin Ain Rural Niger: Strategies for Adverse Conditions

Margaret Parlato Peter Gottert

THE SETTING can support only the most critical needs. Little more than a third of the nation's population has access to Niger is a poor, landlocked country in West Africa, basic health care. Transport is scarce, and funds for with large northern tracts in the Saharan desert. It is education are limited. Girls' education is almost home to 7.4 million people whose average annual per nonexistent. Scarcely 7 percent of young girls 7 to 1 capita income is equivalent to only about US $308. 12 years old attend pnmary school. 3 Although over 80 percent of the population live Health status in general is poor. Life expectancy directly off the land, a mere 3 percent of Niger's m 1992 was only 47 years. A high rate of mfant large surface is arable. This land is rapidly dedming m agricultural productivity NIGER because of mtense farmmg, Total Population= 7 4 million desertification, and the lack Population oflnterventton Areas Phase I = 26,000 E:2222ZI of mvestment m modern Phase II = 250,000 farmmg techmques. A rapid­ ly 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 Investment in basic social services is limned. The price of uramum, once a large rev­ enue and foreign exchange earner for the country, has fallen precipitously, and the largely agricultural economy I PROMOTING VITAMIN A IN RURAL NIGER

mortality, (134 per Serious levels of Withm this context, the Government of Niger 1000 live births) has made noteworthy efforts to establish a nutrmon results from acute and malnutrition in Niger program, but until recently, activities were limited chronic diarrheal and are largely due to to supplemental feeding and rehabilitat10n. respiratory infections, Following a senes of structural changes m 1988, the malaria, malnutrition, inadequate food Mmistry of Public Health expressed interest in and increasingly, HIV/ availability. expandmg from its traditional nutritional surveil­ AIDS.4 Serious levels lance/ rehabilitation focus to a more preventive of malnutntion in approach, centered around nutnt10n educat10n and Niger are largely due to inadequate food availabili­ communicat10n. ty. Not only are staple grams in short supply; low USAID subsequently encouraged application of mcome levels provide the population with little low-cost, community-based educational approaches purchasing power for a vaned diet. A poor balance in Niger. The Nutrmon Communicat10n Project of payments has also restricted food imports. (NCP) began m the country m January of 1991 Basrc nutnents are m short supply as are essential with a focus on the problem of vitamm A deficien­ micronutnents. In 1992, 53 percent of children 12 cy among those at highest risk: children six months to 23 months were underweight (based on weight­ to six years old, and pregnant and lactating women. for-age). Among mfants aged 6 to 11 months, the Implementation of the three-and-a-half-year rate of malnutrmon was 18.6 percent, and by the project was the responsibility of the Mm1stry of age of 24 to 36 months, 47.1 percent were already Public Health, Nutntion D1v1sion. The Academy stunted (based on low height-for-age). 5 Complex for Educational Development (AED) provided factors contribute to these rates. Among these are technical assistance-a total of 35 weeks for design low birth weights (due m part to mothers bemg mal­ and overall strategic planning as well as techmcal nourished), non-exclusive breastfeeding in the early superv1s10n (excludmg evaluat10n). Helen Keller months, diarrhea and other mfectious diseases, and International (HKI) provided day-to-day operational problematic weanmg practices. Vitamm A deficien­ and financial management. A Project Techmcal cy rs also nearly umversal. Estimates m 1991 indi­ Committee comprised of members of these core cated that those at highest nsk included 75 percent msmut1ons, along with the Ministry of Agriculture of all pregnant women, 66 percent of nursing and the Ministry of Education, provided a forum for women, 50 percent of children aged 13-36 months, debate about project decisions and actions. and 62 percent of children aged 37-72 months.6 Together with Helen Keller International, the Mm1stry had been active m distnbutmg vitamin A capsules in two of the country's six provmces since THE CHALLENGE 1989. However, as a result of increasmg mterna­ tlonal attention on vitamin A and its role in child In Niger, as in many other Afncan countries, strate­ mortality, the Mm1stry was mterested m re-examm­ gies for improvmg health status must deal with mg and expandmg its vitamin A program. This these basic realities: low public mvestment m the new collaborative effort was Niger's first effort to health sector, a poor and poorly-educated populace, test the feasibility of improving the vitamin A status declining personal mcome, and rapidly increasing of vulnerable groups by influencing the purchase population size. Furthermore, interventions to and consumpt10n of vitamin A-nch foods as well as encourage families or commumt1es to change their their commercial production. The unanswered food or health-related habits confront resistance to question was whether a food-based strategy mnovat1on that emerges naturally from the precari­ could-with existing water resources and market ousness of life. Any change from tradmonal pat­ mfrastructure-presendy be implemented m select­ terns can represent enormous risk. ed ecological zones of the country. I APHASED APPROACH

The overall project took place in two phases. The total project period of40 months was divided mto an experimental phase I conducted in 16 villages (a pop­ ulation 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 lillpor­ tant to have results quick- ly, objecuves were focused on certam fundamental Planners wanted ta issues. A carefully evaluat­ wark in an area where ed pilot mtervennon based upon research mto the eca/agy was mast local conditions and prac­ promising far a taad­ tices would determine if adequate, year-round vit­ based approach ta amin A sources were vitamin Apramatian. available at an affordable Presence ofsufficient water m the target area was important cost; help identify vitamm so that promotion ofincreased vegetable production would be feasible A-rich food sources; develop culturally acceptable strategies for meeting the sharp swings m seasonal avail­ • Proximity to the capital, Niamey (425 kilo­ ability of vitamm A food sources; and test approaches meters), and good road access. for delivering messages to the target population. Tahoua, one of Niger's six provmces, was selected • A smgle linguistic zone. as the project site for a number of important rea­ • Previous vitamm A program experience. HKI sons. Given the challenging environment and the had supported a Mmistry of Health vitamm A cap­ difficult goal of changmg tradmonal habits, plan­ sule distribution program m Tahoua since 1986. ners wanted to work m a pilot area where vitamin This meant that the population had a basic aware­ A was known to be a serious public health problem ness of the problem and an mstitutional base had and where the ecology was most promising for a been laid. As an established mternational agency, food-based approach to vitamin A promotion. HKI could serve as field representative for adminis­ They established a few basic criteria: trative assistance and financial disbursement.

• A year-round water supply and the practice of Birn1 N'Konm, the single district (or arrondzsse­ dry season gardening (so that vegetable production ment) selected within this province for phase I was already established and might be increased) activities, also claimed a diversity of village types in Tahoua Province had wells m most villages because terms of size, socto-economic development, water of an aggressive well-bmldmg program sponsored supply, existence of dry-season vegetable gardens, by the Government over the preceding five years presence or non-presence of a dispensary, and mar­ and numerous ramwater catchment sites that sup­ ket availability of vitamm A-rich foods, permitting ported dry-season gardens. a certain degree of comparative research. I PROMOTING VITAMIN A IN RURAL NIGER

INVESTIGATING PROBLEMS AND OPTIONS • Could vitamin A needs be met in each of the three distinct seasons or would supplements (cap­ sules) be needed to achieve full, year-round coverage Although phase I was limited in both size and for the population? scope, this mini-project followed a systematic social marketing process. Distinct stages of research, • What quantities of vitamin A-nch foods are strategic design, implementation, and evaluation being consumed by high-risk groups (children of different ages, pregnant and lactating women)? provided insights to set the proJect's behavioral tar­ gets, audience and communication channels, and • How large a gap exists between actual and laid the foundation for any expanded phase of optimal levels of vitamin A intake? activity. The first • What vitamin A-nch foods are available in task was to under­ Initial research led different seasons, and what are the richest dietary stand the context in sources of the micronutnent? which current food, planners to the • What constraints exist to increasing consump­ consumption, pro­ conclusion that the tion by the population of different vitamin A-nch duction, and pur­ foods (cost, taste, preparation time, image, etc.) and chase/gathering most promising whKh foods are the most appropnate from a con­ practices were car­ products would be sumer's perspective? ried out in the target • Are there penods of the year when families area, and to study liver and different have disposable cash and could afford higher-priced how these might be kinds of green leaves. animal sources of vitamin A? positively influenced. • How might commercial dry-season farmers be A four-month investigat10n examined soCial, eco­ encouraged to increase their production of vitamin nomic, and market factors affecting nutrltlonal sta­ A-nch foods? tus.7 Extensive desk research was combined with • What channels of communication reach the carefully focused studies. Technical consultants provided bnef but intensive training to a small target groups? 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. Re­ • I searchers set out to answer nine impor­ tant questions and to determine the proJect's specific behav10ral targets, audiences, and communication chan­ nels. In particular, the studies were

• Do available sources of vitamin­ A nch foods (markets, gardens, plants grown in the wild, and so forth) supply adequate quantities to meet the popu­ Men make many ofthe critical food purchasing dectstons in the family Here, lation's needs and how elastic is that a man purchases liver snacks at the market The program attempted to build supply? messages on such already-existing behaviors I Looking at Leaves and Liver

reliminary formative specific changes. Scaling/rank­ supplies, common units of research showed that two ing methods also helped ascer­ purchase and costs, seasonal Ptypes of food held the tain consumer preferences and availability, and flexibility to greatest potential for furnishing pick specific vitamin A-rich increase production and local increased vitamin A to the pop­ foods against a number of dif­ market supplies. ulation. These were a variety of ferent characteristics. • Focus group discussions green leaves and liver. A rapid • Each interview included a with men and women identified qualitative study then examined 24-hour food recall and food constraints that might emerge the market availability of these frequency lists. A researcher to recommended practices and foods and investigated what also measured all vitamin A­ revealed possible solutions. new purchase, preparation, pro­ rich foods prepared or pur­ •Key-informant interviews duction, and feeding practices chased and eaten by the with teachers, agricultural would be feasible to the target respondent and sample child. agents, nurses, and village groups. The highly focused • A researcher weighed all health workers provided further study was earned out in six vil­ the livers available from butch­ insights into local practices. lages by a team of four women ers in the sampled villages, to While many questions and two men, and mcluded a find out whether supplies looked at "leaves and liver" per mix of methods. would be sufficient in the tar­ se, others investigated commu­ • Individual in-depth mter­ get areas if demand actually nication channels in the popu­ views with 216 women and 60 rose to recommended levels. lation, as well as training needs men looked at current beliefs •In-depth interviews with for mfluential groups. as well purchase and feeding butchers, gardeners, leaf sellers, habits, and the practicality of and sauce sellers helped assess

RESEARCH RESULTS kinds of green leaves. In order to design speofic messages, however, they needed to understand the The research confirmed that vitamm A deficiency balance of costs, constraints, and changes that was widespread among women and children in might seem reasonable to the target audience and Tahoua Province and that awareness was lacking would lead to increased consumpt10n of these foods regarding the dietary needs of these vulnerable over the year. In May of 1991, researchers used a groups However, research also revealed that ade­ special mix of methods to look at these questions m quate vitamin-A rich sources existed; that sources of six villages. (See box) one kmd or another were available durmg each Because of the complexity of dietary practices, the season; that these foods were within the existing program looked at the knowledge, attitudes, and economic (and social) constramts faced by most behaviors of several categories of respondents. families; and that they were already eaten by the Whereas primary beneficiaries were young children general population at different times of the year, and pregnant and lactatmg women, other family although not in sufficient quantmes. and community groups play a major role m what Most importantly, mitial research led planners to foods are ultimately consumed m the household. the conclusion that the most promismg products This mdudes: men (who do most of the family food for an intervention would be liver and different purchasing mduding of vitamm A-nch snacks), I PROMOTING VITAMIN A IN RURAL NIGER

women (who prepare and serve the food and who approximately 32 types of edible wild leaves common have their own small, disposable mcomes), commer­ m the proJect area, at least eight are known to be nch cial gardeners (who produce vitamin A-nch foods m vitamm A: amaranth, senna, JUte, false sesame, for sale and home consumpt10n and who have the gynandro, purslane, and urena.8 Families harvest these potential to increase this supply) and health and or purchase them at a nominal cost from older women extens10n agents (who often mtroduce new ideas). who do the collection, and use them in hot salads or Research revealed that a combmat10n of prac­ sauces. The 24-hour food recall study found that 71 nces-takmg mto account the seasonality of foods percent of women and children had eaten green leaves and the availability of cash-would have to be pro­ the prev10us day-most m a sauce and the remamder moted m order to increase vitamm A intake through­ m yamoutse, a salad-like preparation made from out the year. (See box) greens, oil, spices, and often crushed peanuts. Green leaves grow wild dunng the rainy season and Generally it is made with fresh leaves available durmg in the month or so just after that Qune-October). Of the ramy season and is usually consumed as a snack. In other seasons the dish is sometimes prepared with Formative research helped construct thzs chart ofvitamin A-rich foods with their respective whole, dried leaves. months oflocal availability as well as cash flow ofhousehoUls m different seasons An addmonal 50g of green leaves daily would cost less Calendar of Vitamin A Sources in Niger than one percent of the aver­ Vitamin ASoul'le Cool Dry Hot Dry Rainy season COOIDFJ age weekly food expendi­ Season Season Season ture in the target group Consumption of green leaves JAN fEI MAR APR MAY JUJU JUIY AUG SEPT OCT Nill DEC could therefore be mcreased, but probably only dunng cer­ Amaranth ~ tam months. Baobab In the post-harvest months, Senna most families snll have some Jute lffllliillJ disposable income after they False Sesame have paid their debts. Com­ Gynandro l!l!fii!I> mumcation planners hypothe­ Red Sorrel illf!Jfifi!; sized that a pomon of this mcome could be spared to pur­ Drumstick Tree ~ chase liver. Liver is one of the Purslane most important vitamin A-nch Urena~ ~ foods consumed m the Cowpea f!llil!J!I provmce. While it is not eaten Sweet Potato as regularly as green leaves,9 it is Mango a highly-pnzed gnlled snack

Squash (pumpkin) ~ which men eat m the market Liver - and sometimes bring home for their wives and children. Spending Money Since liver is an ammal source of vltamm A, it con­ NOTE Heavy Imes represent the avatlabtlzry (for liver and spending money), or natural harvesting period (for vegetableslfiuzts) under rain-fed cultivation Shaded !mes represent tams a pre-formed and readily the addttzonal ha; vest period far vegetables ifwatered tn a garden during the dry season available form of the vitamm which is stored m the human I body; nutritional STRATEGIC DESIGN PROCESS requirements can be The overall campaign met through con­ strategy was based Behavioral Goals and Target Audiences sumption of small upon amounts at occa­ three principles: The overall campaign strategy was based upon three sional mtervals. seasonality, regularity, principles: seasonality, regularity, and frequency. One 25g serving of and frequency. Messages based upon these principles would in turn liver every two lead to greater quantity consumed. Planners weeks can provide selected practices that would, taken together, assure enough vitamin A to consumption of v1tamm A-rich foods throughout meet 75 percent of a pre-school child's needs dur­ the year with specific foods promoted m each sea­ ing that penod. 10 son. In add1t10n, the project promoted the regular Spendmg money 1s available primarily m the consumption of these foods when available. To post-harvest months of January-May, and in par­ establish easily memorable dietary patterns, moth­ ncular, January-March. Consumption of liver ers were advised to see to it that their children ate could therefore be affordably mcreased precisely greens every day and liver once a week when the during the months when other vitamin A-rich father goes to market. Lastly, children and preg­ foods are scarce. nant and lactatmg women need to consume or be In the hot season months (March-May), man­ fed enough vitamin A-rich foods. For women, total goes are plentiful, providmg an abundant source of satisfaction of vitamin A needs may be limned by vitamin A. Because of their popularity, planners economIC constraints, but messages could urge eat­ decided messages could be simple reminders to ing more-up to realistic limns. Children need to reinforce the habit and to make sure young chil­ be fed many times durmg the day m view of their small dren received small slices or mashed portions. stomach capacmes and immature digestive tracts. In the cool dry season (November-February) focus ProJeCt messages focused on promotion of snacks was put on increasmg production of greens in dry­ (liver, yamoutse, mangoes), rather than, for example, season commercial gardens. Squash is available in on eatmg greater quantities ma context where this this season but 1s not widely available and also is not would seem impossible, or changing tradmonal very popular. Planners therefore decided promo­ recipes to mclude "more greens" (which would also tional messages about squash should be secondary be unacceptable). In this way, greater frequency of In fact, the situation in this reg10n of Niger offered eating would lead to greater quanmy consumed. many opportunities: the foods that were to be pro­ These principles combined to help design spe­ moted were already commonly eaten, thus reducing cific behavioral objectives for designated target the extent and nsk of the proposed habit change. audiences: The foods were mexpensive, further facilitating the change. The foods promoted were diverse, appealing 1) To encourage husbands to ensure that their to both taste and seasonal availability. wives and children consume a varied diet and suf­ The task would be one of education and mfor­ ficient quantities of food to assure their good mat10n. Research showed clearly that people were health. unaware of the particular dietary needs of young This generic "family responsibility" theme of the children, pregnant and nursing mothers, and were communication campaign laid a foundation for unaware of the quannties/frequenc1es required to messages about the connection between food and meet essential needs. Women did not mcrease the health and about specific v1tamm-A related behav­ quantity of food they ate dunng critical phases of iors. The husband was m fact central to every aspect their reproductive lives, and their children's diets of the intervention. He 1s traditionally seen as the were generally madequate. provider of food for the family. However, this I PROMOTING VITAMIN A IN RURAL NIGER

responsibility is basically understood as In the ramy season, yamoutse, made from fresh synonymous with supplymg grams, or specifically leaves, is a popular snack and offers potential to millet-the staple food. The project wished to improve vitamm A intake of vulnerable groups. In expand this role so that the husband's attitudes and most other times of the year, green leaves, usually actions became part of better nutritional practices­ dned, are added to sauces in very small quantities to in particular, consumption of liver and green leafy flavor and thicken them. They contribute lmle vegetables. In this sense the project attempted to nutrmonal value. In keeping with the strategic ele­ begm a shift m cultural norms. ment of seasonality, special focus was given to eat­ ing fresh green leaves during the seasons when they 2) To increase the frequency with which fathers buy are plentiful. liver as a snack for their children and their wives. Planners considered trymg to improve the meth­ fu the pnmary purchasers of liver, fathers were ods used to dry leaves m order to preserve more vit­ selected as the target for this message. (Before the amin A. The sun drying process used m the reg10n intervention, only one percent of women reported degrades the vitamm A content. However, food buymg liver as snacks.) The husband/father is there­ experts consulted advised that, given the small fore the key provider of vitamin A for the family in the quantities m which dried leaves are consumed, this post-harvest period when cash flow is improved and would have little impact on overall vitamm A levels little else is available. in the diet lncreasmg the quantity of dned leaves used m sauces was also explored but rejected as a 3) To encourage mothers to assure that they and strategy. Their high cost would be an obstacle. their children eat CFA 5011 worth of liver per week. Also, from the villagers' perspective increasmg the Women were encouraged to ask their husbands to traditional propomon of leaves in sauces would brmg home liver snacks from the market; to buy some rum the taste and texture. themselves; and/or to share the liver of animals slaugh­ tered for feasts or other special occasions among them­ 5) To increase the amount of green leaves culti­ selves and their children. Messages explained the vated by dry season farmers. importance of liver for themselves and their children Commercial dry season production of green and suggested they share CFA 50 worth of liver with leaves was practiced only on a very limited basis in their children every week the project zone. Dry season farmers were therefore encouraged to grow greens on the borders of already 4) To encourage mothers to increase the fre­ cultivated land or as an interline crop (rather than to quency of including green leaves in the family take high-earning cash crops such as omons and diet, so that the quantity of greens eaten by their peppers out of culuvation). Discussions with agron­ six-month to six-year old children {as well as by omists on the possible problems of co-farming wild themselves, particularly if they were pregnant or greens with traditional garden vegetables mdicated lactating), would increase. the practices could co-exist. The key behav10ral messages focused on regu­ Messages stressed that green leaves can be sold lar consumpt10n: to eat green leaves daily and to (during the rainy season, women from the village assure that children begmnmg at six months of often harvest wild greens from millet fields and age eat them daily during the entire year The then sell them m the commumty) or can be eaten rationale was that green leaves-either fresh or by the gardeners' families. Although the sale pnce dried-are available during most of the year. of greens during the early part of the dry season Although the nutritional value of leaves is low (October) is low because of wild leaf harvesting, the durmg the penods of the year when they are price could go up substantially at the end of the dry consumed dry, emphasis on regularity was season. The profits would be good, smce the retained. investment would be low. 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 con­ sumption, therefore, messages stressed the connec­ A woman tn a Tahoua vzllage adds vitamin A-rich yellow squash to the family sauce tion between this food and protect10n of both the eyes and "the organism." Target groups did not have any appreciation for Planners also targeted a secondary message at gar­ the nutritional value or health benefits connected deners, although they felt that only certam of them with other vitamm A-nch foods. Messages therefore would be able to adopt it. The message was to introduced this relat10nship· that green leaves, liver, encourage the dry-season watering of drumstick squash, and mangoes are nutrmous, are beneficial to trees The tree produces copious and highly-pnzed the eyes, and also in protecting agamst disease. leaves during the rainy season, but dunng the dry season no leaves grow unless the tree is watered. Watenng, however, is an economic investment. CONSIDERING COMMUNICATION CHANNELS Furthermore, dried drumstick leaves imported from Nigena are already eaten in significant quantities, Disseminating information-and actually convinc­ suggesting that the pnce of the import is reasonable. mg target groups that they should change habitual Residents of Tahoua have gotten used to and now behav10rs-was a senous challenge. The selected prefer the taste of dried drumstick leaves, thus lower­ channel(s) needed to have the required reach and ing the economic value of fresh leaves to dry season credibility among the populat10n, needed to be gardeners. delivered with a certam level of frequency, and also had to be arranged at a cost which could be sus­ 6) To increase the frequency with which squash tained over time. and mangoes are eaten by children and pregnant Formative research among both men and women and lactating women. had included questions designed to gmde selection of Squash is also available but not grown in all vil­ channels that would reach the selected audiences. lages-apparently due more to tradmon than to Given the rural context and the complexity of behav­ any stnct agncultural or economic consideration. iors targeted, these questions had as much to do with While gardeners in Tahoua produce onions as their how people learn, as they did with "media'' per se. principle cash crop in both rainy and dry seasons, The study looked at some basic questions. How different villages diversify wnh peppers, cabbage, do women and men learn new practices and under tomatoes, or squash. Markets in villages that do what circumstances might they be convmced to produce squash offer the product in small quanti­ change their practices? Are women getting new ties, affordable to most. Although squash "keeps" health informat10n primanly from health profes­ for a long time it is hard to store (requmng a large sionals or from other women, for example? Are I PROMOTING VITAMIN A JN RURAL NIGER

men gettmg new ideas about gardenmg from the formances that convey local myth and history), and agricultural profess10nals or from other gardeners? also because they reach areas where radio and tele­ Are men at all aware of biomedical mformation vision have not yet penetrated Drama groups have about mother and child nutrition? Would they be the potential to reach women as well as men. wrllmg to make changes in household practices Drama rs an ideal vehicle for presentation of the because a health professional advised them to do so? family dynamics involved in decision makmg. 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 work­ ers 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 func­ tioning 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 per­ Drama is an ideal cent of women said Village dtamas provided an entertaznzng way to convey mes­ sages about family food deczstons they watched telev1- vehicle tor s1on. The usefulness presentation of the of pnnt materials was Actors convey specific mformanon (for example, severely limited by family dynamics about the importance of vitamin A-rich foods in a the low literacy rate; involved in decision child's diet); they can also reenact familiar encoun­ m Niger, 96 percent ters between husband and wife about scarce house­ of women aged 35 to making. hold finances and improved diet, child reanng and 49 have never been mtra-famrly authority, and suggest resolutron and to school. compromise. How, then, given a limited project budget, a lim­ ltmerant troupes, however, have certam disad­ ited time frame, and a limited health infrastructure, vantages. They are expensive, can be difficult to could mformation on an important but rather com­ manage and supervise, and may have a limited plex topic be presented widely and m some depth? range, given the socral, cultural, and ethnic diversi­ Communicatron planners decided to test the ty of the country. potential of a smgle communrcation channel-vil­ The project med out a new approach-village lage drama-which built upon a traditional medi­ drama-to take advantage of the strengths but um but incorporated changes that would allow for avoid some of the problems associated with Itiner­ local management/superv1s10n and a systematic ant groups. It focused on the motivation and means of conveymg project messages wrthm the trammg of local amateur actors to create and per­ designated population. form skits based upon the project's messages. Itinerant drama troupes m West Africa have been Village volunteers were organrzed into drama successful as message earners because therr perfor­ teams, trained m the use of dramatic techniques to mances are denved from long-standmg traditions convey informatron about vitamm A-rich foods (of story-tellers, or grzots, and song and dance per- (liver and green leafy vegetables m particular), and I How to Create aVillage Drama

n order to help train the volunteer the­ ater members, the village encadreurs were Igiven 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 mil­ let 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 Trazmng through role playing helped amateur actors learn you take a second wife. how to dramatize pro;ect messages Role B: Rabi: You are a nursing mother and provided supervision and techmcal support. The yesterday at the dispensary the nurse told goal was to build on traditional culture, to engage you that you must prepare 50 francs of liver local commumties m developmg theu own health for yourself and your children once a week education programs, and to create an mteractive and eat green leafy vegetables every day. vehicle for providing mformation and encourage­ This morning when your husband brings ment to adopt new practrces. you the millet, you ask him for money to purchase liver and greens. PHASE I IMPLEMENTATION In each village, government health workers, Training and Launching of Village Teams teachers, and agricultural extension agents were designated as encadreurs (tramers/ supervisors) Crucial to the success of this activity was a well­ responsible for forming and loosely managmg the designed training and supervision program and drama teams. Half of the villages had no an orientat10n/launch of efforts withm mdivid­ encadreurs, so health or agricultural workers from ual communrties. Planners also wanted to assure nearby villages were recruited. Members of the that local authorities had a sense of program proJect committee from Niamey assisted the local ownership. Their support was essential for gain­ leaders m the creation of drama teams and the ing village-level pamcipation. selection of actors. Participation was completely I PROMOTING VITAMIN A JN RURAL NIGER

voluntary. Actors were chosen on the basis of REVIEW AND STRATEGY REFINEMENT their interest and willingness to contnbute, not necessanly past experience or talent. An evaluation conducted after the end of phase The project technical committee trained the I indicated that the drama skits were popular encadreurs in a five-day workshop and supervised and well-attended: 61 percent of men and 34 them every other month. Training included: percent of women saw at least one play during the campaign.14 In all 16 villages, dramas were per­ • an orientat10n about the importance of vita­ formed regularly-an average of one performance min A to child survival and information about per week. vitamin A-rich foods; Most importantly, the percent of women who reported that they ate liver in the past week rose • maJOr messages to be included in individual dramas; from 52 percent to 69 percent; and the percent of women who indicated they gave liver to their • the overall communication strategy and the children in the past week rose from 51 percent to thematic context for different messages; 65 percent. Research also revealed some prob­ • repennon of model dramatic scenarios; lems, however. The evaluation showed that con­ sumpnon of both greens and liver was rising less • training principles for village drama teams among children than among adults, and that the (focusing on the amateur level of participants, their youngest children were not being fed more. inexpenence with health or other development themes, Consumption of greens was shown to be particu­ but also their spontaneity and innovativeness); larly lagging. The project technical committee • supervisory/administrative requirements: how concluded that special focus needed to be placed many times to visit the troupe; what to observe; how on the weaning infant. to provide construcnve advice; how to keep good Other changes were suggested m the manage­ records, and so forth. ment and institutional support of the village drama activities. The system of non-resident encadreurs worked poorly. Health encadreurs, in Encadreurs received a parncular, made infrequent visits to project vil­ The project technical Role Play Guide to lages other than theu own, ostensibly due to their assist in their train­ already heavy workload and the lack of transport. committee concluded ing sessions and Village drama teams expressed the need for more that special focus supervisory visits. regular supervision and for some kind of stipend. needed to he placed on (See box.) They then Planners decided it was essential that encadreurs be trained village teams identified within each village; that more teachers the weaning infant. over a penod of five and agncultural agents be recruited; and that a days, including both district-based training and supervision framework "classroom" instruc­ be established. tion and practical training. At the end of train­ Only a few of the original 16 village drama ing, each village drama team was to have teams recruited women actors. Male actors played developed a complete skit. Teams were then asked roles created for women. Although this added a to carry out at least one performance (three ten­ certain local flavor and humor in some cases, pro­ minute skits) per week over a period of four months. ject personnel decided it also detracted from the Encadreurs received a small per diem to cover potential impact of some household interactions, food and transport while on supervisory missions. and inclusion of women was crmcal. They pro­ The volunteer teams received non-cash incentives posed that women should be involved in all village such as T-shirts and diplomas. drama teams in the future. I PHASE II The results confirmed that additional emphasis should be put on the weanmg child, and also on the New Villages, New Design importance of feeding green leaves and mangoes A new message emphasized that a child could digest A second phase of proJeCt fundmg provided the mangoes if well mashed and fed in small quantities opportumty to apply lessons from phase I to a (Fibrous mangoes m large quantities will, m fact, larger area (80 villages in four distncts) and to cause diarrhea in infants as well as older children, refine project messages, improve local supervis10n, but small slices will provide minimum daily and test a more extensive media mix. Phase II reqmrements of vitamin A without side effects.) began with a two-week qualitative study to exam­ The ethnographic study found that liver ts mashed me the vitamm A context and explore some issues between the fingers to make it edible for weamng related to infant feedmg 15 m the new areas. A age children baselme study1 6 was also conducted m two of the In addition, the technical committee decided to four arrondzssements mduded m the expanded give more emphasis to the message about dry season area. The mformanon was also used for planning watering of drumstick trees. During phase I, tt purposes. The baseline survey consisted of 474 seemed to be the message most easily accepted by mterviews (375 women and 99 men) earned out gardeners. in 15 villages. 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 man­ agement 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 oper­ ational 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 gov­ ernment personnel-health workers, agricultural extension agents, teachers-as encadreurs and supervised their activltles. Of the 80 villages selected for the phase II mter­ vention, only 40 of the larger ones were chosen to have village drama teams. In adopting this expen­ mental design, planners hoped to be able to exam­ me the effecnveness of the medium m light of overall differences in knowledge and behavioral

Counseling cards displayed 16 baste pro;ect messages Pzctu1ed change in the villages with and without drama, and here are cards showing a father who has purchased liver to assess 1f village-drama could be managed effi­ snacks and a mothe1 who ts gathering wild greens ciently m a larger-scale project I 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 chan­ nels 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 pro­ grammmg and was therefore wdlmg to pro­ duce and air vitamm A spots and programs at produced dramas low cost. By the start of phase II, the station Radio Tahoua visited each village and taped the locally for weekly broadcasts had already gamed popularity through its broadcastmg of the local news. Both drama and non-drama villages organized messages with written remmders on the back to interpersonal education on vitamm A and related gmde the person delivering the counselmg session food issues. Dunng phase II, the terms of reference Postcard-size counseling cards, reproductions of for encadreurs were expanded to mclude counselmg the larger originals, were supplied as reference guides and group discuss10ns about vitamm A. The vol­ for the village drama teams. In addition, the project unteers received special trainmg m these areas and reproduced 80,000 postcards and distnbuted these were asked to conduct a minimum of one commu­ to the population of the target area to encourage an mty group discussion per week, as well as individ­ "each one, teach one" dissemmation of messages. ual counselmg. Radio dramas were recorded m the villages with Flipchart-size counseling cards supported the drama teams. A recordmg team from Rad10 Tahoua face-to-face counseling The two-sided cards fea­ went to about 30 villages and taped at least one per­ tured large illustrations of the six basic vitamin A formance m each. They broadcast a total of 42 different ten-mmute skits, one per week for ten­ ::.::.- and-a-half months. In addition, the team went to non-drama villages and recorded mterpersonal edu­ cation 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 vol­ unteers, 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. Women members oftheater teams proudly display their Dunng phase II, village drama ran for four to six cewficates ofpartmpatzon, which they received at theater months m 40 villages; mterpersonal educat10n Jestwals activmes were earned out for six to eight months I dependmg on the village; and radio broadcasts ran Overall Knowledge and Reported for ten months. This provided about 12 months of Behavioral Change promotional activmes. Together, the media offered complementary Knowledge of the importance of vrtamm A-nch strengths (entertamment and inter-community foods mcreased significantly The percentage of discuss10n, depth of issue development and expla­ women who cited vitamm A-rich foods as impor­ nanon, frequency and reach of "remmder" mes­ tant for the health of children one to two years sages). The hope was that this media mix would mcreased from 32 to 57 percent. encourage diffus10n of messages throughout the The evaluanon showed important increases m community, thus creatmg a general awareness and both purchasing and consumption behav10r for acceptance of new ideas as well as adopnon of liver. Prior to the phase II campaign, 43 percent of behav10rs by individuals. 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 indi­ EVALUATION AND CONCLUSIONS cated that their children ate liver mcreased from 37 percent to 49 percent. The project conducted a detailed evaluanon for the The number of men who said they brought home phase II mtervention in an equal number of villages liver m the week previous more than doubled, from 6 and m the same arrondissements as the baseline sur­ percent to 15 percent. The percentage of women who vey.17 (Respondents mcluded 406 women and 311 reported that their husbands brought home liver men.) The post-survey measured the changes in increased from 6 percent to 26 percent; and the per­ knowledge, attitudes, and reported pracnces among centage of women who indicated they themselves the population m general and compared changes in 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 hus­ bands 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 lim­ ited success. The survey found that only 59 percent of women reported introducing greens at the correct age, compared to 52 per­ Both men and women reported brzngzng liver snacks more cent at baseline. This often from the market place to share at home overall, BO percent of seems to mdICate that men and 40 percent of the message was not effectively communi­ the two categones of villages (drama villages and women heard or saw cated or that resistance non-drama villages). A qualitative component con­ same element of the to it remamed strong sisted of interviews with encadreurs, village drama Changes m reported team actors, and Ministry supervisors from the educational program. consumption of squash provmcial and distnct level. and fuut were insigmf- I PROMOTING VITAMIN A IN RURAL NIGER

Women's Reported Vitamin A-Related Exposure to Media Practices During the Previous Week Overall, 60 percent of men and 40 per­ cent of women heard or saw some ele­ 100% ment of the educational program. Exposure to radio among women was • Pre Intervention 80% encouragmg. A total of 21 percent of .... Post lntervenli1n women mterviewed heard skits on the ~ 'E radio and 20 percent said they heard ~ 60% radio spots. This represents a very large ... number of those women who reported ...E ; that they had listened to radio in the 'li:i 40% -... week prior to the evaluation (29 per­ ...""~ cent). Of those mterviewed, 26 percent a. 20% stated that they saw counselmg cards. This is a relatively low figure, however, smce 1t comcides with the 27 percent 0% who said they saw a skit m the drama-vil­ Served children Ate liver V1tamm A-nch Bought V1tamm lages. The evaluation mdicated that vol­ fresh greens snacks bought A-nch snacks wnh by husband own money unteers generally used the counselmg cards most often after a skit performance, n= 375 pre-intervention; n= 406 post-intervention suggesting that at least in the drama vil­ Changes in these practices are significant at p< .01. lages, mterpersonal education was not carried out in the intensive way planned Source P Stanley Yoder, 1995 The percent of women who saw skits was lower than expected, given the fre­ icant. The null effect for squash was perhaps due to quency of performance (once a week), their novel­ the fact that the vegetable is not grown in all villages. ty, and the fact that they were performed free and The lack of impact on frmt consumption was affect­ with local actors. ed by the season of the year when the survey was con­ Villages that had pamcipated m phase I showed ducted (December). Mangoes, for example, the sigmficantly higher levels of knowledge and behav­ prmcipal fruit, were not available then. ior change. However, whereas m phase I the village Dry season cultivation of greens remamed drama teams had a low. Similarly, gardeners reporting cultivation of measurable effect on squash remamed low. Mare precise and knowledge and behav- As part of a larger program in Tahoua, Helen refined media planning 10rs, phase II revealed Keller International and the Ministry of Health con­ a different picture. ducted a linked household food consumption survey could significantly New villages without in January 1995 usmg the HKI food frequency increase the reach drama teams did sig­ method.18 The survey documents improvement in mfican tl y better on consumption of vitamm A-nch foods by preschool and effectiveness at both measurements of 19 children. At the baseline m January 1994, popula­ communication knowledge and report­ tions in only three of the 15 commumties studied ed behavioral change were not at risk of vitamm A deficiency. One year programs in rural than new villages with 20 later, five additional communities had increased their areas at West Africa. these teams. This is consumption to adequate levels. mitially surpnsmg I because the drama-villages were of higher socio­ information collected fed directly mto crucial deci­ economic levels, and they also had the benefit of sion makmg. exposure through more media. This project did not hire any research or adver­ Several explanations are possible. Perhaps most tising firms. Internat10nal specialists were able to important, villages selected for drama teams were design necessary research studies and tram local generally larger than those m the non-drama group, interviewers, many of whom were Mm1stry of and also larger than those selected m phase I. Health personnel. Diffusion of messages-and especially of messages • Village drama can be an energizing force for through drama-was probably not as effective in commumty involvement and a powerful way to those villages. The evaluation showed that drama build interest m a nutrition issue. Adequate super­ teams tended to perform m their own neighbor­ vision-probably on a monthly basis-is required hoods. The smaller size of the non-drama villages to keep up motivat10n of volunteer actors and may have resulted m an active word-of-mouth shar­ assure that the content of performances is on track. ing of ideas: messages about vitamin A received by Program managers must devote funding and per­ some members of the commumty may have been sonnel for this critical function and must also shared and discussed with others, creatmg an ener­ momtor implementation closely. gized commumcations environment, whereas in the • Careful planning at the village level can s1g­ larger drama villages the concepts were less fully nifican dy extend the reach and effecnveness of shared and discussed. commumcation activities. For example, rural groups appear to respond favorably to activity goals that are challengmg yet reahsnc. When LESSONS LEARNED allowed to set their own acnv1ty goals, drama groups performed more frequently than when Although the mtervention m Niger was designed goals were set for them by the national team. Smee for a difficult and umque environment, and both the dynamics of larger villages (over 2,500 people) messages and media were tailored for a distinct differ significantly from smaller villages, reachmg a population, a number of lessons emerged whtch high percentage of the populat10n requires an are applicable to other vitamm A social marketing implementation plan whtch specifically mcludes programs. act1v1t1es m each village neighborhood. • Mass media can provide important motiva­ • A food-based approach to improvmg the vita­ tional support to community-led activities and also mm A status of a populat10n ts feasible m certain extend the number of people reached by village zones of the country with adequate water and an level events. When a radio announcer mtroduces a ex1stmg base of commercial dry-season vegetable drama performance m a remote village, for exam­ production. ple, credibility of the event mcreases enormously, as • Obtainmg the nght kind of mformation on does enthusiasm among those who contribute to which to base a commumcat1on strategy does not the field activities. have to be a time consuming, costly, and compli­ • More precise and refined media planning cated undertaking. Use of a short list of highly spe­ could mcrease the reach and effectiveness of com­ cific questions to gmde formative research can keep mumcation programs m rural areas of West researchers focused on essential issues-that ts, only Africa. Village size, for example, appears to be a those required to identify realistic and concrete key factor in how mformat10n flows and the kind behavioral targets, the right target groups, and ways of media mix that is most effective. (The lesson of reaching them. The project found surpnsmgly from this mtervention was that the impact of lmle "wastage" in its research efforts. Most of the drama groups will drop substantially wtth the size I PROMOTING VITAMIN A IN RURAL NIGER

of a village rf local plannmg does not ensure wide 7 The results of two maJor studies conducted as part of the coverage. Rad10 coverage also vaned with village project provided the basis for program plannmg: size, with more listeners m larger villages.) Overall Hung, Ibid access and exposure to mass media and commum­ Keith, Nancy, Field Research in Birm N'Konnz Vitamin A ty events also varied extraordmanly by gender. Communication Pro;ect (Washmgton, DC Academy for Careful audience segmentatron by village unit and Educational Development, March-June 1991) by gender could be expected to improve the also 8. Wilson, A., Gathered FoodJ m West Africa A Neglected impact of commumcanon efforts. Component of Village Food Economy (M Sc TheSJS, • A pilot project that rt rs limited in scope and Cal1forma Polytechmc State Umvers1ty, 1989) earned out over a short penod can be a powerful 9 Hung, op cit (Only 8 9 percent of a combmed total of on-the-job trammg arena for agencies havmg little pregnant and lactatmg women and children 6 to 72 prevrous expenence designmg communication pro­ months old reported consumption of liver m the previous grams. A pilot project allows staff to go through all 24-hour penod ) essential steps-from plannmg to evaluanon-in 10 Hung, op cit rapid succession. The format provides feedback on what works and doesn't work. Unseasoned staff 11 At the nme of this study US $1 was eqmvalent to can gam confidence and experience. about 250 CFA. 12 Keith, op cit Although the Niger program was m many ways a lesson in how to design strategies for adverse con­ 13 Baker, Shawn et al , Enquete de Base Sur !es Connazssances, dn10ns, this challenge also helped keep the pro­ !es Attitudes et !es Pratzques en Matiere de Vttamine A, Arrondzssements de Birnt N'Konnz et Ille/a (Washmgton, DC gram focused on essential principles: that research Academy for Educational Development, January 1994) must be carefully targeted; that programs must be "commumty owned"; that costs must be sustain­ 14 Kone, Hughes, Evaluation du Pro;et de Communication able; and that insmutionalrzatron of systematic Sociale en Vttamme A (Washmgton, DC Academy for approaches among local professronals rs key to Educational Development, December 1992) long-term success. 15 Popenoe, Rebecca, Republic ofMger· Formative Research Vitamin A Social Marketing P1o;ect (Washmgton, DC Academy for Educational Development, January 1993)

NOTES 16 Baker, op cit Umted Nations Development Programme and The 17 Yoder, P Stanley, Fmal Evaluation Report, Vitamin A World Bank, African Development Indicators (New York Promotion Pro;ect, Niger, Phase II (Washmgton, DC: and Washmgton, DC 1992) Academy for Educational Development, January 1995) 2 Mm1stere des Fmances et du Plan, Enquete 18 The HKI/Food Frequency Method uses cutoff scores for Demographique et de Sante, Niger, 1992 (Columbia, MD frequency of consumption of vitamm A-nch foods that have Macro International, Inc, 1993) been validated agamst WHO cntena for the prevalence oflow­ 3. Ibid serum retmol (a b1olog1cal mdJCator of v1tamm A deficiency)

4 Ibid 19. Berger, Susan E, Preliminary Results of Study Conducted m Tahoua District, January 1994 and January 5 Ibid 1995 (New York Helen Keller International, 1995)

6 Hung, Man-Mmg, Report on the Availabzlity and 20 Yoder, op cit Consumption ofVttaminA-Rich Foods in Mger(Washmgton, DC: Academy for Educational Development, 1991) ------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

Florentino Solon Henry Briones Jose Rafael Hernandez Lonna B. Shafritz

INTRODUCTION

Each day 17 Filipino children become blind due to vitamm A deficiency, even though foods rich m v1ta­ mm 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 pro­ mot10n 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 PHILIPPINES nutrmon educat10n/commumcation. By promot­ Total Population= 60.7 million mg consumption of v1tamm A-nch foods supple­ Intervention (Cagayan de Oro) = 399,000 Comparison Site (General Santos) = 250,000 mented by fortified margarme, the government I MOVING TO A LONG-TERM STRATEGY

plans to gradually essential. To keep costs down and enhance the pro­ phase out capsule The government's long­ ject's prospects for both impact and sustainability, distribution. These term strategy is to proJect planners wanted to integrate the campaign efforts are aimed at into the programs of various local government eliminating vitamin change dietary patterns agencies. From the outset, the proJeCt was con­ A deficiency by the through comprehensive ceived of as a significant community mobilization year 2000. The plan program, paired with a multi-media campaign. is to initially develop nutrition education/ The cities selected, Cagayan de Oro (for inter­ social marketmg communication. vention) and General Santos City (for comparison), strategies in growing have populat10ns of 399,000 and 250,000, respec­ urban areas. An tively. In such densely settled areas, many low­ inter-agency National Micronutnent Action Team income residents are malnourished. The Cagayan (consisting of major domestic and international de Oro City Nutrition Governing Board assumed NGOs active in the field) is charged with imple­ responsibility for actually implementing the pro­ menting nutrition education/communication to ject. Several city agencies undertook to organize support the National Micronutrient Program. special activities, including the City Health Office, As part of this longer-term approach, the Schools DivlSlon, Agriculture Office, Social Nutrmon Center of the Philippines carried out an Services and Development Office, and City intervention to test the feasibility of promoting Improvement Office. The Association of Barangay both consumpt10n and product10n of green leafy (or ward) Captains also played an active role. vegetables in a rapidly growing urban area of the Philippines. The Vitamin A Expert Group (a sub­ committee of the National Micronutrient Action AUDIENCE RESEARCH Team) and the Center designed the proJect in a series of consultative meetings and a three-day Prev10us surveys had identified various causes of workshop during November and December 1993. inadequate intake of vitamin A-rich foods. Parents The HEALTHCOM project, funded by the U.S. explained that they seldom serve green leafy and Agency for lnternat10nal Development and con­ yellow vegetables because their preschool children ducted by the Academy for Educat10nal refuse to eat them. Mothers were not well informed Development, provided technical assistance in about the health problems associated with vitamin social marketing, administrative management, and A deficiency and the importance of consuming a full-time resident adviser assisted by two field foods rich in this vitamin. Pnor to the campaign, coordinators. (Local costs of the proJeCt totalled the amount of green leafy and yellow vegetables about US $450,000.) grown for home consumpt10n had been low. Project leaders selected two cities on the southern Specific information about knowledge, attitudes, island of Mindanao to serve as intervention and and practices related to vitamm A and dietary control sites. They wanted to test their approach in patterns in the intervention city was needed, and comparable medmm-sized cities that were growing the proJeCt commissioned a baseline survey rapidly. The intervention city needed to have ade­ m August/September 1994. Consumer Pulse quate local broadcast media and cinemas; the con­ Research, Inc., a marketing research firm, designed trol would be in a different administrative health and earned out the formative research. 3 In both the region and would be isolated from the other's radio experimental and control areas, stratified, random and televis10n signals. These cities, located on the samples of 300 women were selected. Respondents "garden island," normally receive sufficient average were all from the lower-middle and low-income annual rainfall to support a gardening component. groups, and were all mothers of children aged one Support from local government officials was also to six. The survey included a 24-hour dietary recall I and collection of information on consumption of STRATEGIC DESIGN PROCESS green leafy vegetables m the previous week. The quest10nnaire also focused on knowledge of vitamm Defining the "Product" and the Objectives A and specific green leafy vegetables, attitudes toward these vegetables, their different sources and An effective communication strategy requires sim­ supplies, mothers' experience with vitamin A cap­ ple, act10n-oriented messages concerning an easily sules, and their sources of information and media remembered "product." The program implemen­ use. The researchers also examined gardens in tors actually identified several products that could homes, communities, and schools to determme the be promoted together in order to increase vitamm amount of the green leafy vegetables bemg pro­ A consumption. These vegetables included duced (based on the number of plants and size of Malunggay leaves, Alugbati, Camote tops, Kangkong, areas planted). and Pechay. These vegetables were selected because The baselme find­ they are widely acceptable, readily available ings indicated that About 28 percent at the throughout Mmdanao (and most other reg10ns of most households ate children aged one ta six the country), and affordable to people of all income green leafy vegeta­ levels. Only pechay reqmres much labor to culti­ bles regularly but had inadequate intake vate. All five are very nch m vitamin A.• that children aged at vitamin A~rich toads. In order to transform these five products mto one one to six and preg­ simple and memorable one, the team decided to nant and lactatmg coin a new acronym, MACK-P, from then mitial women consumed less than other household mem­ letters. In the campaign, the first vegetable­ bers. About 28 percent of the children aged one to malunggay--received special attention. six had inadequate intake of vitamm A-rich foods, Malunggay (drumstick or horse-radish tree) leaves based on their mothers' reports of food eaten m the are nch in vitamm A and calcium and are easy to grow previous 24 hours. Because the plant is lnterestmgly, a high percentage of households found m most back mterviewed said they had some kmd of vegetable yards, malunggay is An effective garden. Only 27 percent of those in outlymg rural one of the more pop­ areas and 20 percent of those m the city proper said ular vegetables. It can communication strategy they had no vegetable garden. be prepared in many requires simple, actian­ The survey also provided mformat10n about the different ways-as a prevalence of different media in the intervention base for stews or ariented messages area. Of households interviewed, 73 percent mixed with other veg­ about an easily owned rad10s and 41 percent owned televisions. etables. However, it remembered "product." Exposure to these media was higher than owner­ can turn bitter if 1t is ship, however. Only 17 percent said they never lis­ not fresh, is over- tened to the radio. In outlying rural areas, 58 per­ cooked, or is past its cent said they never watched television whereas prime. One potential barrier to general consumption only 15 percent m the city proper said they never of malunggay is a somewhat poor image: many people watched. Exposure to movies was low. In outlymg think of it as a food for the poor. rural areas, 82 percent of households said they had Alugbatz (malabar mghtshade) and camote (sweet not seen a movie in the last six months; 60 percent potato) tops are excellent sources of vitamin A and of urban dwellers said they had not watched are common m the central part of the country. Exposure to pnnt materials was also somewhat low, Kangkong (swamp cabbage) is also a good source of with 58 percent of those interviewed saymg they vitamin A, but suffers from a different kmd of poor never read newspapers. image. It is often thought of as food for hogs. I MOVING TO A LONG-TERM STRATEGY

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

Audience Segmentation

Given the complexity of changing food consump­ tion 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; Program staffcheck the price ofa bundle of malunggay-the • pregnant and lactating women; and ''M" in ''MACK-P"-as part ofa market survey • school children.

Many people mistakenly believe that the type of kangkong that is grown in swampy areas causes Parents are obv10usly the key decis10n-makers schistosomiasis (a parasitic infectton of the blood regarding food purchased, produced m a garden, vessels and organs) and carries other worms as well. and served at home. Pregnant and lactatmg Pechay (Chinese cabbage) contains vitamins A women nounsh their children m the womb or and C as well as calcmm and iron. It is well-liked through breastmilk and are the primary and is considered a prestig10us food. Because it is source of vitamin A for infants. School children labor-intensive to grow and commands a high pnce were another signifi­ in the market, people mostly grow it to sell rather cant target group than for home consumption. Improving the image at m the intervent10n. The MACK-P acronym also reflected the rank­ green leafy vegetables Lifelong eating habits ing of the five vegetables in regard to thetr vitamin are shaped early. A content. For example, malunggay has twice the among children Children are exposed Vitamin A content as camote and four times more themselves would also to advertismg and than pechay. store displays pro­ Project planners set three major behavioral goals help "empower" the moting junk food, for the intervention: toad provider. but may lack infor­ mation on healthy • increase the frequency of consumption of foods. They can be the five green leafy vegetables by 25 percent among effective voices in carrying messages to adults, children aged one to six and among pregnant and are the parents of the future and the trend and/or lactating women, setters for the next generation. Formative research showed that mothers thought their chil­ • increase the production of the five MACK-P dren disliked vegetables, and found this a barri­ vegetables in household and institutional gardens er to servmg them. Improvmg the image of by 25 percent; green leafy vegetables among children them­ • increase the frequency of purchasing selves would therefore also help "empower" the MACK-P vegetables by 25 percent. food provider. I The proJeCt also focused mtens1ve efforts on a mumty-level channels were more detailed. For number of secondary audiences: example, they provided mstructtons on procedures for gardeners who wished to plant green leafy veg­ • local government officials, who provided etables, and recipes for mothers who wished to logistical support to the campaign and were mstru­ serve a balanced diet with MACK-P. mental m commumty mobilization; Vanous thematic messages supported the actton­ onented recommendat10ns by focusmg on the ben­ IB government frontline workers and commum­ efits of MACK-P. Campaign matenals stressed that ty volunteers who are the main sources of knowl­ malunggay and the other green leafy vegetables con­ edge on nutrmon and served as active promoters tam v1tamm A and that v1tamm A 1s good for the wtthm the commumty; eyes and helps children to grow tall and strong. Prevent10n of mghtblmdness and promot10n of IB vegetable growers and vendors, m order to greater height were linked to MACK-P throughout encourage them to produce and sell the MACK-P the campaign "Mighty Malunggay," a super hero, vegetables; and mcarnated these protecttve qualities, and became the star of TV spots and also booklets for parents. • owners of small eatenes ( carenderta) and food Some materials refuted the belief that kangkong vendors, since poor families and workers often pur­ causes sch1stosomias1s. chase cooked food.

Media Mix and Promotional Plans Messages ProJect planners selected a media "mix" based upon Tactical messages m the intervention focused on the prevalence of different channels and a strong eating, plantmg, and purchasing MACK-P vegeta­ emphasis on commumty mobilization. Broadcast bles. The most simple, direct message designed for media therefore served broadcast media, which served as the taglme for all not only to dissemi­ rad10 and television spots, was "Eat malunggay and Various thematic nate basic messages, other vegetables nch m vitamm A every day!" messages supported but also to support Messages for print, mterpersonal, and various com- local vitamin A the action-oriented promotional events recommendations by through live coverage of events, special focusing on the benefits mterv1ews, and enter­ at MACK·P. tainmen ti mformatton approaches. Rad10 was selected as the primary broadcast medmm due to its high owner­ ship 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 Children were an important target audience m the interven­ demand for the intervent10n's goals, however, fell tion Televmon commercials were pretested with them as well on the shoulders of mynad local government agen­ as adults cies and commumty organizations. The City I MOVING TO A LONG-TERM STRATEGY

Government of Cagayan De Oro signed a own plans for their agencies to conduct events Memorandum of Agreement with the Nutrition geared to their particular target audiences. (For Center of the Philippines in August of 1994, defin­ example, the City Division Office of Schools pro­ ing the role of the city government and the various posed "MACK-P Corners" in school rooms and technical agencies in implementing the social mar­ visual aids to be used by both teachers and pupils.) keting activities. In effect, the city government, The partiopants also finalized plans for "echo" personified by the Office of the Mayor, took on the trainmg of their respective field workers. social marketing ofMACK-P as its own project and In the followmg two months, each agency con­ mobilized its resources to support the actual design of ducted a senes of traming sessions for their own local project activities. Lme agencies m health, frontline workers and community-based volunteers education, social wel- in order to orient them to the project and train fare, agriculture, and them m outreach techmques. Training for these nu trmon subsequently Radio was selected as workers was extensive: mobilized their own the primary broadcast staffs to conduct these medium due • The City Division of Schools conducted ses­ events and to carry to its high sions in nine district schools, reaching 1,419 teachers, out energetic mterper­ ownership and 56 school administrators, and nine district super­ sonal outreach in the visors. communities. listenership. One of the unique aspects of this project lmong Basahon was the extraordmary decentralizat10n of plannmg Pagdasig sa mga Each of the agencies developed its own implemen­ Pamilya sa Pagkaon ug tation and momtonng plans, which were reviewed Pagtanom ug Malunggay at the central project level. Atbp. 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 plan­ ning/traming exercise in order to ensure unified messages and approaches at the community level. Thts booklet for ctty workers provided ideas about how to During the workshop, participants developed their plan creative MACK-P "events" zn their dzjferent departments I II The City Health Office trained 147 staff By mobilizing these different agencies to come members, including medical officers, public health up with their own events, the project assured mter­ nurses, nutntiomsts, rural health midwives, and personal commumcatlon (whether one-on-one or samtary mspectors. In addition, the Health Office one-to-group) to the full range of target audiences. trained 85 commumty-based health volunteers The health workers would reach pregnant and lac­ (who cover about 25 families each), and 71 Avon tatmg women, preschoolers and their mothers and ladies (cosmetic salespersons). fathers; social welfare workers would reach three­ to six-year-olds and their mothers; educators would Ill The City Improvement Office trained 106 reach seven- to fourteen-year-olds in the public commumty-based volunteer workers for nutrition. schools and in turn their families; and agricultural workers would reach mdividual farmers, farmers' II The City Agriculture Office tramed 38 agn­ associations, and women's orgamzations in the dif­ cultural specialists. In turn, this group trained about ferent barangays (wards). 700 members of the Farmers' Association and 485 members of the Rural Improvement Club (com­ IMPLEMENTATION posed of women farmers).

Ill The Department of Social Services and Special Activities Development tramed 21 social workers and field Community activities brought the basic campaign supervisors as well as 79 day care workers. message, "Plant and eat MACK-P" vividly mto the minds of cltlzens. MACK-P was present through­ out the city: In Schools. Teachers, pupils, and parents partic­ ipated in classroom and school garden activmes. Teachers and their students organized displays about the five green leafy vegetables m 1,386 class­ rooms m the city's 47 public elementary schools. Grades five and six students created ongmal MACK-P recipes and held cook.mg demonstra­ tions. 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 and planted these with MACK-P. Some "MACK-P Corners" dzsplaymg the five vegetables and explam­ used the produce to mg thezr benefits appeared m school rooms across the czty Community activities feed malnourished brought the basic pupils or sold it to the All of these workers learned what roles they could community. School personally take to bring MACK-P "alive" in a range campaign message, actlvltles reached about of creative ways. For example, the City Health "Plant and eat MACK-P" 55,000 school chil­ Office gave sess10ns on vitamin A health issues, tips dren. Seventy kinder­ on health center displays and gardens, recipes vividly into the minds garten classes with which could be used in innovative "food stalls," and at citizens. nearly 1,800 pupils methods for distnbutmg a proposed parent's guide. also participated. I 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 (T­ shirts, cash and certificates) to the best displays and wmners of competitions.

Broadcast Media

Broadcast matenals prepared for the campaign tar­ Students m grades three and four partzczpated zn MACK-P geted multiple audiences. Four televis10n spots on pngle-szngzng contests the benefits of vitamin A were designed to appeal to parents and children. Two of these spots were also Via health centers. Health workers set up shown m cinemas as "infomercials." The popular eight displays and 18 gardens containing the animated Mighty Malunggay spot featured the super MACK-P vegetables m the city's 47 health cen­ hero saving a little boy who, trippmg over a trash ters. Some centers participated in rad10 quiz can, falls in the way of an oncoming truck. After shows and recipe contests. Health workers also understanding that the boy has nightblindness due persuaded 20 small eatenes (carenderia) in the to a deficiency of vitamm A, Mighty Malunggay public market to sell dishes containing the convmces him to eat MACK-P. Fence ofLife used a MACK-P vegetables. background of nursery rhymes and a stylized Through farmers' groups. Agricultural workers panorama of children to emphasize the key benefits encouraged communities to establish communal (good eyesight and good health) of eating and gardens on vacant public and pnvate lands. In planting MACK-P. rural districts where land was available, volunteers Two radio spots adapted the storylines of Mighty and citizens planted 21 communal gardens. The Mulunggay and Fence ofLife. In addition, the pro­ farmers' association and women's groups assisted ject promoted rad10 coverage of campaign activities families m eight rural districts to establish home throughout the city. Coverage mcluded live reporting gardens. Agricultural of special events, on-the­ workers provided seeds spot interviews, question­ and cuttings of the and-answer programs, qmz MACK-P vegetables. shows, recipe contests, At day care centers. and announcements about With the help of parents, local activities. day care workers set up A national research displays and gardens con­ company, Trends-MBL, tammg the MACK-P veg­ Inc., pretested both radio etables. They also orga­ and television spots mzed "family fun quiz through four focus group shows" with parent-child discussions of local moth­ teams m 95 day care cen­ ers aged 18 to 45 and ters. These activities children aged seven to reached about 2,000 chil­ Health centers sponsored radzo quzz shows and recipe contests nine. Pamcipants were all dren and their parents. "MACK-P wzth coconut oil" shown here, won a top prize from lower-middle and I Pretesting-Understanding the Mother's Perspective

retesting of radio and children to see the spots in Malunggay and wanted to be televis10n spots revealed order to offset junk food strong and smart like him. points needing refine­ commercials. They liked the Pretesting identified prob­ ment, and also provided message that providing lems with the translation valuable new insights into nutritious food does not into the local dialect, the mothers' views on food have to cost a lot of money, accent of the speakers, and preparation and eating and felt vindicated for serv­ the density of 15-second habits. ing malunggay, which is usu­ spots. Although the transla­ In the target households, ally the cheapest vegetable tor was a native Cebuano food purchases consume available. speaker, he was from a more than half the family Neither mothers nor chil­ slightly different region than income. Mothers wished dren in the pretest groups the target area. Even such they could afford to serve understood the concept of fundamental phrases as more meat, which they nightblindness well. How­ "clear eyesight" (which in regarded as essential to a ever, mothers were willing to one dialect can be interpret­ healthy diet, and associated accept the message that ed as "dagger looks"), "full eating lots of vegetables with increased intake of vitamin of vitamin A," and "night­ being poor. However, they A "makes the eyesight clear," blindness" needed to be were aware that vegetables whereas children were more refined for the target audi­ contain vitamins and other interested in "makes one ence. Some participants nutrients, and made an tall." In the original Mighty said that the messages in the effort to serve them to their Mulunggay spot, children 15-second spots were too children-sometimes offer­ thought that the boy stum­ complicated to be under­ ing bribes or camouflaging bled on a stone because he stood in such a brief time. the vegetables. was weak. The storyline was Key concepts were therefore Mothers were grateful that changed (to have him run re-cast so that meaning was the project's television and into a trash can) in order to unmistakable in the dialect radio spots remforced the make it more dear that his of that geographic locale, idea of servmg vegetables to eyesight was poor. Children and the short spots were children. They wanted their liked the super-hero Mighty simplified.

low-income groups November 1994. The resultmg publicity included 22 Radio·hroadcasters because these popu­ live reports on rad10 and television and three feature lations were at great­ articles m local newspapers about the special events devoted nearly IB hours est risk of vitamm A A delayed start of implementation (resultmg from a of tree air time to deficiency. 5 Results lengthy contractmg process for the media produc­ led to a number of tion) limited the media campaign to only 13 weeks interviews and live refinements in the mstead of the six months origmally planned. Still, coverage of MACK·P spots. media coverage dunng this penod was mtensive. The project held a Nine radio stations aired campaign spots more than events. media launch and 5,000 times; three televis10n stations aired spots 445 press conference in times; and six cmemas showed spots 1,600 times. I MOVING TO A LONG-TER!d STRATEGY

In addition, radio broadcasters devoted nearly 19 hours of free air time to mterviews and live cover­ age 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 mfor­ mation 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 commumty­ based health and nutrition volunteers, teachers, and workers in day care and health centers. Frontline Thts colorful "food prescrzptzon slip" helped parents visua­ workers and volunteers also received a special gmde. lize the appropriate quantities offoods for different ages "Your Gmde m Motivatmg the Family to Eat and 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 support­ ing background informauon.

MONITORING

Each local government agency periodically mom­ tored its own campaign activmes and compared results to the plans they had developed In addi­ tion, 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 A simple booklet for parents featured Mighty Malunggay explaining the benefits ofvitamin A and how to increase studens and kept charts at the local schools. both consumption and home production I Learning to Garden via the Radio

o encourage broad cover­ compost about six inches thick. tin cans, or pots, or in a age of vitamin A activities garden plot. Tand issues, the project gave 2. Stick three to four stems of radio broadcasters a manual malunggay about three inches For planting m plastic containers, with sample "scripts" of inter­ deep into the soil. tin cans or pots, JUSt follow the views. In the one that follows, same steps as in planting alug­ a mother calls in to ask advice 3. Water regularly. bati, camote tops, and kangkong. on how to grow vegetables when she has very little space. The method of planting pechay 1. Fill container with soil "Mrs. Pineda" has four active is slightly different from the other mixed with dry manure of children and finds the rising vegetables but it's still easy to do: compost about six inches thick. cost of vegetables a worry. 1. Prepare a container or 2. Stick three to four stems Radio Expert Response: seedbed that can hold soil two about three inches deep into Mrs. Pineda, Believe it or not, inches thick. the soil. you can still have your own veg­ etable garden even in a small, 2. Pulverize the soil and sprin­ 3. Water regularly. limited space. You can plan kle thinly with seeds. them m pots, plastic bags, or tin You see, it's really easy to cans. Here are three very easy 3. Cover the seeds thinly with plan and maintain a vegetable steps you can follow: soil. garden. Start one today and enjoy a great harvest of fresh, 1. Fill container with soil 4. After three weeks, transfer budget-saving vegetables the mixed with dry manure or seedlings in plastic containers, soonest!

RESULTS area; consumpt10n of the other two vegetables increased slightly. The control area saw less than 10 A post-campaign survey consisted of interviews percent increases for two vegetables and no change with 300 women-mothers of children aged one to or declines for the other three. six-each m Cagayan de Oro and the control site, The proportion of intervent10n children aged General Santos City, during February/March one to six who had eaten green leafy vegetables 1995.6 The survey found that the project had m the 24 hours before the survey rose from 35 achieved most of its obJectives. percent to 42 percent after the campaign-a 20 Consumption of all five MACK-P vegetables m percent increase after three months of media pro­ the week prior to the survey increased markedly motion and five months of mterpersonal and among children aged one to six and among preg­ special events. Most mothers reported that they nant and lactatmg women m the experimental increased children's consumption of the MACK-P area. Household consumption m the previous vegetables by serving dishes made from their week of three of the five MACK-P vegetables usual recipes more frequently, rather than trymg rose by more than 25 percent m the experimental new recipes. I MOVING TO A LONG-TERM STRATEGY

Intervention households revealed more favorable amtudes toward vegetables after the campaign. A higher propomon of mothers agreed that daily serv­ mgs 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 veg­ etables was sull the mam reason cited for not serv­ ing 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- Home production ofMACK-P vegetables increased substan­ cent in the control tially through promotion ofszmple methods, such as growing area. Both areas were The proportion at ofpeachay zn sand bags, as shown here affected by a drought during the interven­ intervention children tion period, which aged one ta six who had m schools, day care centers, and health centers m unfortunately makes Cagayan de Oro City, which increased the overall it difficult to draw eaten green leafy availability of MACK-P. However, the drought useful compansons vegetables in the 24 during this period inhibited planting and reduced between the causes of crop yields in both areas. food consumption hours before the survey The campaign achieved excellent coverage, reach­ patterns m these rose tram 35 percent mg many survey respondents through multiple chan­ areas. This could nels. The propomon of mothers who said they had explam the fact that to 42 percent. seen or heard information about green leafy vegeta­ children's consump- bles rose from 36 percent before the campaign to 95 tion of MACK-P remained lower than that of other percent following the campaign. More than half the household members. respondents had heard or seen the rad10 and televi­ The campaign did not generate as much behav- sion spots. Although few volunteered that print 10ral change among mothers regarding feeding of 6- materials were a source of their information about to 11-month-olds. Although the sample size was MACK-P, more than one-third recalled receivmg small and conclusions must be tentative, the data such matenals when asked directly. Nearly one m mdicated that few of these very young children were four heard about the MACK-P vegetables from gov­ fed MACK-P despite mothers' own declarations that ernment workers, especially midwives and commu­ mfants need vitamm A more than other family mem­ nity health volunteers. Interpersonal sources reached bers. The chief barrier remains a widespread belief more of the rural audiences, while mass media (radio among parents that green leafy vegetables cause diar­ and television) reached more urban residents. rhea at this age. The project also brought financial benefits to par­ After the campaign, more households in the ticipating agencies and families. One elementary experimental area were growing each of the five school prmcipal reported that fewer children needed MACK-P vegetables, whereas an mcrease in house­ supplementary food at school and that school atten­ hold gardening was found for only one vegetable in dance improved. Her school earned money from the control area. Increases in the experimental area selling extra produce in the market and used it to ranged from 37 percent to 700 percent. The eval­ buy more seedlmgs and planting materials and to uation noted an increase in production of MACK-P defray costs of parties for each class. I LESSONS LEARNED translations Only the target audience can confirm that mtended meanings have been conveyed. If The project demonstrated that an intense, albeit 15-second radio or television spots are to be used, brief campaign can mfluence food ch01ces-indud­ messages should be simple and dear mg both consumption and production practices­ when all elements of a social marketing approach • Targeting messages to elementary school chil­ are set in motion. In particular, this mtervention dren can influence their own attitudes and behav­ illustrated the importance of local government and iors, as well as influence or support those of their community support mechanisms. Clear advocacy parents. Children m Cagayan de Oro City liked and leadership from the top, support through the the super-hero character and nursery-rhyme pngles various agencies, and collaborative implementat10n created for the campaign. Mothers said that the of the project gave it visibility throughout the com­ campaign made it easier for them to convince their mumty, and also meant that "success" was widely children to eat green leafy vegetables. owned by all of those • The mvolved. Such par­ very young child (6 to 11 months old) was a difficult target ticipation is essential group in the MACK-P project, The project and has been m many to sustammg gains projects around the world. The belief that green and applymg lessons demonstrated that an leafy vegetables are hard to digest or cause diarrhea to future goals. among the very young is a intense, albeit brief serious barrier. Message Moreover, because strategies need to focus strongly upon this key age the pilot was a campaign can influence group when feeding of solids starts, and on jomt effort with the particular barriers to food choices. healthful the National Micro­ dietary practices. nutrient Act10n Team • Nutrit10n-related programs can have spillover ( consistmg of the effects which increase the likelihood of sustainabil­ Undersecretary of Health for Health Education and ity; for example, income generation from the sale of major domestic and mternational nutrition vitamin A-rich vegetables m this project helped buy NGOs), it is receivmg attent10n from national deci­ new materials and provided a reward for those sion makers and the results will be applied toward working on the project. The major long-term ben­ larger efforts. efit of this project may have been to convmce Other key insights can be applied to programs mothers that inexpensive, home-grown foods can throughout the world: provide a well-balanced, healthy diet. In addmon, • A multi-media, multi-channel program can the prospect of earning mcome from MACK-P veg­ bring about changes m deeply ingramed behav10rs etable sales mcreased the likelihood that schools, when messages are consistent and reinforcing. households, and other groups will continue grow­ This project demonstrated once more the impact ing these vegetables. that community volunteers and health workers can have in complementing media coverage and help­ • The number of objectives, audiences, behav­ mg to clarify complicated messages In this case, iors, and products mduded in the campaign added mterpersonal channels had greater reach m outly­ to the complexity of the research process m ing rural areas, whereas mass media had greater this mtervention. Research results were delayed reach in the city proper. partly due to this complexity. Seemmgly carefully integrated plans can "backfire" as the complexity of • Experience m this project confirmed the an mtervention mcreases Simplicity has its own importance of pretesting all materials-including virtues, which should be factored mto plannmg. I MOVING TO A LONG-TERM STRATEGY

• The process of obtaming contract approvals, the Pro;ect Social Marketing ofMalunggay Atbp (Mamla and and also the time required to learn the results of Washmgton, DC NCP and Academy for Educational research, can always be expected to take longer than Development, Apnl 1995) ongmally planned. Project planners need to bmld 5 Trends-MBL Inc Final Report on Pro;ect Leajj; (Quezon in extra time to allow City: Trends-MBL, November 29, 1994) for possible delays m The very young child both these areas. At 6 Consumer Pulse, Inc Final Report Knowledge, [B ta 11 months aid} the same time, mobi­ Attitude, and Practice Survey (Pro;ect Laser Vision 2) (avail­ hzmg support for able from the Academy for Educational Development was a difficult target streamlining these Apnl 13, 1995) group in the MACK-P processes is important for increasing effi­ Florentino Solon and Henry Briones are with the Nutrition project, and has /Jeen ciency of social mar­ Center ofthe Phtlippines Jose Rafael Hernandez was with the in many projects keting efforts over Academy for Educational Development in the Phtlippines time. In general, Lonna B Shafotz is with the Academy in Washington, DC around the world. 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 ofthe Effect ofMargarine 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 ofMalunggay 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 I Case study

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

Blank The Use ol Integrated Media for Promotion ol Vitamin ACapsule Consumption in Central Java, lndonesia1

Thomas K. Reis Renata E. Seidel Sartono, Sudaryono Anne Palmer

INTRODUCTION children per year) However, the prevalence of milder eye diseases associated with this problem rs In Indonesia, vitamm A deficiency remams a sen­ at least ten times higher. Many Indonesians con­ ous threat to child survival. Nearly half of chil­ tinue to associate the dangers of vitamin A defi­ dren under age six have madequate intake of vita­ ciency with blindness. Convincing parents and mm A, which increases their vulnerability to dead­ health workers that vitamin A deficiency remains ly childhood diseases. Blindness and corneal a threat to therr children is a challenge, now that lesions (xerophthalmia) caused by vitamin A defi­ the decline m blmdness has made the dangers less ciency have become increasingly rare (affectmg readily discernable. one to two percent of children under age six, or In its fourth five-year plan (1984-1989), the approximately 50,000 to 60,000 preschool aged Government of Indonesia (GOI) committed itself

INDONESIA Total Populanon = 179.3 m1ll1on Intervention area= 1.5 m1lhon (Demak and Jepara d1stncts, Central Java)

I'' ' ~ I \, ''I :

' . '' I t . I r ' 'I '' r r ~ '' I THE USE OF INTEGRATED MEDIA IN INDONESIA

to lowering morbid­ In Indonesia, vitamin A among mothers of children between one and five. ity and mortality of The project originally aimed to achieve a coverage children under five deficiency remains a of 90 percent of those children in its target areas. from various causes, serious threat to child ROVITA also had two objectives related to diar­ including vitamin A rheal disease: 1) to improve case management of deficiency. At that suruiua/. diarrheal disease among children under five years time, the Indonesian old through oral rehydrat10n therapy and improve Department of Health supply of oral rehydration salts (ORS), and 2) to had a national three-pronged strategy to decrease measure the change in incidence and severity of the prevalence of this problem among children diarrhea before and after vitamin A supplementa­ between one and five years old. The plan called tion in a small cohort of children. This joining of for: themes was reflected in the project's name, ROVI­ TA, which 1s an acronym for "Rehidras1 Oral" and • increasing target audience consumption of "Vitamin A." This case study focuses on ROVITA's vitamin A-rich foods including dark green leafy experiences in promoting vitamin A capsules. vegetables, fruits, and fish; Within the Indonesia Department of Health, ROVITA was a cooperative effort of the • distributing megadose (200,000 IU) vitamin Dlfectorates of Diarrheal Disease Control, Family A capsules twice annually through village health Nutrition Improvement, and the Dlfectorate of posts; Community Health Educat10n. The project office • fortifying selected foodstuffs with vitamin A. was located in the Department of Health provincial headquarters in Semarang. With the Indonesian The Department of Health conducted various Department of Health as implementor, ROVITA operations research projects regarding all three drew addmonally upon the experuse of its collabo­ aspects of the strategy with the assistance of the rating organizations· Helen Keller International World Health Organization, USAID, and other (HKI) as management facilitator and Diponegoro internat10nal and local nongovernmental organiza­ University as coordinator of evaluation activities. In tions. These projects became the basis for further the area of social marketing, ROVITA received tech­ development of the national strategy, expans10n of nical assistance from the HEALTHCOM Project. numbers of provinces receiving intensified assis­ tance, and refinement of strategies for reducing vit­ amin A deficiency. (See case study which follows.) SOCIAL MARKETING GOALS AND THE CONSUMER FOCUS VITAMIN AWITHIN THE CHILD SURVIVAL CONTEXT Social marketing focuses on the consumers-in this case the child and his or her caretakers-as the mea­ The Government of Indonesia requested assistance sure of whether a product 1s deslfable, appropriate, from USAID in carrying out one operations affordable, and conveniently available. The initial research project aimed at the second prong of the step of social marketing activities is, therefore, usu­ five-year strategy: namely distnbution of megadose ally audience segmentation. Important groups vitamin A capsules to children on a semiannual include not only the primary target audience (gen­ basis. The three-year project, known as ROVITA, erally mothers in a child survival effort) but also was inmated in late 1986 in the province of Central secondary audiences such as husbands, health care Java. One of ROVITA's goals was to apply social workers, village leaders, community organizat10ns, marketing techniques to increase the distribution and rehg10us groups. These people can have a and demand for megadose vitamin A capsules strong influence upon what mothers value, what I 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 approxi­ mately one hour and 2 5 hours respec­ tively from the Central Java capital of Semarang. The total population mcluded approximately 1.5 million people. Among these were an estimat­ ed 230,000 children under the age of five and an estimated 290,000 mothers of child bearing age. The project's pri­ The montho/ village posyandu rs held ma temporary location and p1ov1des a mary audience was caretakers (mostly range ofpreventive health services mothers) of children between one and five years of age. Approximately 65 to 80 percent contact mothers who have not come to the month­ of this audience were from low mcome groups and ly posyandu sesswn. The Department of Health lived m rural or semi-urban areas. Only about decided to rely upon the kader for distribution of one-third of the mothers had completed six years vitamin A because mothers tend to view the of schooling. posyandu as a place for healthy babies and for pre­ The first tier secondary audience-those vention and counseling, whereas they view the who deal most directly with mothers-mcluded much more distant district health center, or kader, or community health volunteers (usually puskesmas, as a treatment center and generally go local mothers), and district health center staff, or there only when their children are sick. puskesmas workers. The second tier secondary audience for the vlt­ Kader interact with amm A capsule mtervention-those people who mothers m two Twice ayear fin may influence mothers-mcluded husbands and major ways. 2 They February and August/ community leaders such as the village chief, vil­ are responsible for lage elders, religious leaders, and teachers. The holding posyandu, kader disribute tree tertiary audience mcluded local government offi­ or temporary village megadase vitamin A cials and key decision makers withm the health posts, once Department of Health. each month. Mothers capsules ta children at Given these target audiences, the ROVITA Project come to have their the pasyandu. determmed that its soC1al marketing program should babies registered and concentrate on the followmg objectives: weighed, to have their children's growth monitored on a monthly • to develop a commumcat10n strategy aimed basis, to have their children vaccinated, to obtam at mcreasmg mtake of vitamm A among children ORS, and to receive health counselmg-mcludmg one to five; family plannmg mformation. • to improve kader skills m registering mem­ Twice a year (in February and August) kader also bers of the target population; distribute free megadose vitamm A capsules to chil­ dren at the posyandu. In addmon, these volunteers • to mcrease kader skills in delivering vitamm are responsible for going out mto the commumty to A capsules and informat10n to the target group; I THE USE OF INTEGRATED MEDIA IN INDONESIA

• to mcrease kader skills in recordmg and major goals of this design were: I) to develop sim­ reportmg v1tamm A distribution; ple, memorable, and action-oriented messages that would be consistent from medmm to medium as • to strengthen the nutrition education compo­ well as integrated mto the face-to-face trainmg; and nent of posyandu sessions in relation to vitamin A. 2) to use the results of audience research to select media, develop materials, and distribute (or broad­ The strategy for achieving the first of these goals cast) these to the target audience. The development focused on des1gnmg and conducting a series of of messages and the selection of media went hand integrated print and radio commumcation mter­ m hand. Market research with the target audiences ventwns to reach mothers and those who mfluence provided the foundation for both refining messages them on a daily basis. The strategy for achieving and planning commumcatwn activities. the remainder of these goals focused on effective The ROVITA team began by cons1dermg sever­ face-to-face training of village health volunteers al medical and logistical aspects of the vitamin A (targeted toward their dual roles as educators and capsule mtervention as a basis for selecting a broad 3 distributors of v1tamm A capsules). number of possible communication messages. The The overall vitamin A capsule program therefore most important of these concerned attributes of balanced promotion, or "demand creation" activi­ the product (vitamm A capsules) mcluding the ties, with distribution, or "supply side" activities. facts that they are free, for children, available twice a year (during February and August), and distrib­ uted at the posyandu. Other messages concerned MARKETING RESEARCH AND MESSAGE the importance of vitamin A for healthy eyes (the DEVELOPMENT danger of corneal leswns, mght blmdness, and xerophthalmia) and the reasons for takmg capsules The collaborative nature of the ROVITA Project twice a year gave It strong resources to draw on m carrying out In collaboration with a private Indonesian both the commumcation and trammg aspects of the research firm, the ROVITA team then carried out a program. Techmcal mput into message design came series of studies to investigate the target audiences' from experts m several perspectives, preferences, and practices. The major sections of the studies were: Department of The ROVITA team • a literature review of available mformation Health. The head of related to v1tamm A defioency; the Health Educatwn carried out a series of Section led the mass studies to investigate • an ethnographic survey mcluding in-depth media communica­ mterviews regardmg knowledge, attitudes, and tion effort with assis­ the target audiences' practices of mothers (n=64), kader, (n= 16), formal tance from the perspectives, and informal village leaders (n=16), retailers (n=8), HEALTHCOM resi­ tradmonal birth attendants (n=8), and puskesmas dent adviser. The vit­ preferences, and physicians and nurses (n=4); amm A program practices. • audience research to determine literacy, manager (Nutrition media usage, rad10 and telev1s10n ownership, popu­ Section) designed the lar listening hours and stations, and so forth. face-to-face training strategy, and the traming mod­ ules were elaborated with help from the Health Education Section head, HEALTH COM, and HKI. These studies revealed mterestmg mformatwn This cooperative process began with the formula­ about the target audiences' understanding of the tion of an mtegrated marketmg design. The two product and the advantages of different communica- I 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 I percent listened to the radio. The most popular programs were mm1dra­ mas and mystery shows Print mate­ nals appeared less prom1smg. Mothers Ill the target areas did not rounnely read newspapers or penodi­ cals. On the other hand, cloth ban­ ners are a very popular mass medmm Ill Central Java. On a given day, five to ten banners may be draped across In Indonesia, a "pill" per se ts valued as a painless key to good health Vitamin streets or buildings m a town center A has the added advantage ofcoming in an easily recognized shape advertising commercial products (such as cigarettes and foodstuffs) or uon channels. The team learned that mothers had events (such as films, sports, or music and drama little awareness of the prevalence of night blmdness events). The appearance of a new banner 1s wide­ or the value of vitamm A. Nevertheless, the product ly noticed in a village. held certain mherently desirable qualities for them. Choices of mass media centered on radio as a A pill per se is valued by both mothers and health care primary channel to announce and explam the providers because tt represents a tangible, pamless mtervention and banners as a supportmg medium key to good health. Mothers put great faith m pills to be displayed at the posyandu, puskesmas, village and are mterested in obtaining them for their chil­ halls, and other promment places. Print matenals dren. Health care workers therefore find it reward­ such as posters were deemed inappropnate for a mg to distribute pills. Having something to give semiannual promotion since they would be too away affords the volunteers status. Pill-dispensmg expensive for one-time use but not durable held potential as a rallymg point for the posyandu. enough for multiple use. The banners, however, Although those mothers surveyed had little could be made durable enough to be reused and understanding of the value of vitamm A, they were valued enough by village chiefs that they were familiar with the capsule's distinctive look would be stored during the mtervemng months and had a local name for It (translatmg as "fish and brought out for succeedmg interventions. oil") Their familiarity with the product therefore The choice of media m turn helped mfluence had both positive commun1Cat1on messages. Obviously, the same and negative aspects amount of information cannot be conveyed The product could Obviously, the same through radio, on a banner, or through personal be easily identified contact. What mformation would bring mothers by Its large tear drop amount at information to the health center? Pretestmg of draft materials shape, but one would cannot be conveyed with the target audience showed which of the not want to stress its through radio, an a numerous commumcation messages mentioned common name. in the beginnmg of this section were most essen­ Radio appeared to banner, or through nal to the target audience and most appropriate be a prom1smg medi­ personal contact. to a radio script, to a banner, and to face-to-face um for promoting the communication. I THE USE OF INTEGRATED MEDIA IN INDONESIA

THE CREATIVE STRATEGY AND MATERIALS RADIO SPOTS AND SCRIPTS DEVELOPMENT The ROVITA team contracted a pnvate sector FM Research convinced the ROVITA team that com­ radio station with production capabilmes to assist mumcation messages should be targeted to capital­ in creating three 60-second radio spots. These ize on the product's inherent advantages and on the spots were targeted at mothers both to inform and simple "where" and "when" of distribution. In­ create demand. Each consisted of a minidrama depth interviews revealed that mothers' attitudes followed by the v01ce of an announcer bnefly sum­ towards pills were sufficiently positive that they marizing the message and concluding with the would seek them out knowing merely that they national health slogan: "Let's go to the posyandu to were free and good for their children's health. keep our children really healthy." Pretesting showed that extensive information about The three spots emphasized slightly different the importance of vitamin A, about mght blindness core messages The first was an amusing conversa­ and xerophthalmia, was not appropriate for the tion between a wife and her somewhat cost-con­ rad10 spots and even less so for banners. However, scious husband. She wants to go to the posyandu such information was included in the health volun­ to get her child the vitamin A capsule. The foolish teers' training so that mothers could learn more husband tnes to discourage her because they don't about the product when they made contact with have any money and besides, the child is healthy. the health care system. The message core, then, The wise mother then informs him of the core consisted of six points: messages: that vitamin A capsules are free, that they're also for healthy children, and that they're • The product is vitamin A capsules available every February and August-and now it's August (or February depending on the monthly • It is distributed every February and promotion). The husband of course becomes sup­ August; portive. The second rad10 spot features two moth­ • It is available at the posyandw, ers. The minidrama emphasizes that vitamin A is for healthy children as well as sick children and • It is free; that someone can always tell you where the posyan­ • It is for children between the ages of one du is. The third spot is also a conversation between and five; two women. One woman has just remembered that it's time to take her son for his vitamin A cap­ • Vitamin A is for healthy eyes. sule. She runs out with her son to ask a neighbor where the posyandu is. (See box.) Although project leaders were concerned about The second and third spots were both designed the negative connotation of the pill's popular name to help mothers deal with the unavoidable lack of ("fish oil") they decided not to draw attention to the specificity in the message about where to get vita­ name or to complicate the message. The common min A Since the posyandu was still a relatively new name for the capsules was simply never to be used. institution, not all mothers could be expected to The ROVITA vitamin A capsule commumcat10n know where it is. The posyandu is located in a dif­ strategy was integrated in two important respects. ferent place in each village, so neither genenc rad10 Messages were to be consistent from medium to messages nor banners could give mothers directions medium so that each channel would reinforce the to the health post closest to them. "Just ask a other with essential, action-oriented information, neighbor" was therefore an important message in and messages would be timed to reach mothers the strategy. simultaneously ten days before, and then through­ Audience research had revealed mothers' prefer­ out each intervention month. ences for dramas. And the rad10 station suggested I finishmg up each spot with a "voice of authority." When the Neighbors Know Best Nmety percent of commercials end with an announcer summarizmg the message and audiences expect to hear this didactic appeal. Pretesting also ince the posyandu, or village health post, helped select the background music. A tradmonal is a relatively new institution in Central style known as dangdut was popular m the target SJava, and since generic media could not areas and was used to catch mothers' attention at tell every woman where the posyandu in her the mirndrama's outset. own village was, radio messages encouraged The drama format provided an opporturnty to women to seek this information from neigh­ convey several non-core messages that the team felt bors and others. would help mothers act As always, a commurnca­ t1on program tnes to enlist the family and the (Introduction ... music) neighborhood in support of Its goals. It uses char­ acters and creates an atmosphere with which the Wife: Ooh Pakne. I forgot .. .it's target audience can identify. It also looks for poten­ August, isn't it Pakne? tial problems (e.g., that a sick child might not be given a pill) and potential obstacles (e g., that some­ Husband: Yes, right! Go on to the one might not know what a posyandu is) Given the posyandu. Although Parno nature of the vitamm A product, the team found is healthy, he still needs a vita­ such sacral and logistical cons1derat10ns more min A capsule for his health. important than an elaboration of the techrncal aspects of vrtamm A deficiency. Wife: But .. .I forgot ... where is the Each spot was created m both the national lan­ posyandu again, Pak? guage, Bahasa Indonesia, and the local language, Husband: Bune, Bune. If you forget Javanese. Budget as well as mmimum reach and such a simple thmg, just go frequency requrrements helped determme six local ask the neighbor next door. rad10 stations that would effectively reach mothers. Each station was to contracted broadcast the six Wife: Oh ... right, come on now spots ten times a day for 40 days dunng dramas and Parno, we're going to the mystery shows-the most popular rad10 programs posyandu. among mothers. Negotiat10ns with the pnvate radio stat10n helped keep the cost of production Husband: Ehhh... Bune! Don't forget, down to approximately U S $100 per rad10 spot. it's free! Broadcast costs averaged JUSt over U.S. $1 per mmute. Rad10 production and broadcast costs for (music) the first vitamin A monthly promot10n thus came to less than U.S. $3,000 for a total of 2,400 one­ Announcer: Right! Get vitamin A cap­ mmute spots sules (echo) every August and February at the posyan­ du. Let's go the to posyandu !BANNERS to keep our children really healthy! While radio spots could expand on the campaign messages, banners could convey only the mirnmum (Smash .. fade out music.) mformation They were designed to commurncate the basics: the product, the rec1p1ent, the timmg, I THE USE OF INTEGRATED MEDIA IN INDONESIA

FACE-TO-FACE

Face-to-face communica­ tion between heath vol­ unteers and mothers was vital to the mtervention. Volunteers played a dual role, first as distnbutors of the capsules and sec­ ondly as educators and promoters of vitamm A. They also had the oppor­ The banner emphasized the distinctive shape of the capsule and the fact that it ts free and tunity to explam the for children campaign messages m more detail to mothers. the place, and the pnce. In order to grab the atten­ In preparation for the August intervention, the tion of both literate and nonhterate mothers, the ROVITA team designed a traming program for banner was highly graphic. One side featured a health volunteers earned out dunng the months of large bottle of capsules labeled "vnamm A" and sur­ May and June. The rounded by a few distinctive megadose capsules. trainmg consisted of "Free" appeared m a promment red starburst. two days devoted to Volunteers played a "Every February and August" appeared on the other proper diarrhea case dual role, first as side of the banner. Bold yellow letters on a green management and distri/Jutars at the background read "Vitamm A Capsules-For Your one day devoted to Children. Get them at the Posyandu." vitamin A. The vita­ capsules and secondly In order to create a banner that could be seen min A trainmg as educators and from a distance, the ROVITA team decided on a emphasized the same brightly silk-screened polyester banner four meters core messages deliv­ promoters at vitamin A. long and one meter high. Each one was fitted with ered through the grommets at the top and bottom and had wrap­ other media. In around edges so it could be strung from a rope or addition, tramees were encouraged to conduct regis­ hung on two posts. The banner went through tration of children and were mstructed m the logis­ numerous pretests with rural mothers. The draw­ tical details of distnbutmg the vitamm A capsules. ings of the bottle and pills had to be revised several They also received basic mformation on how to times to make them clearly recogmzable to moth­ diagnose eye problems. ers. The colors for different parts of the banner also A tiered system of training had been used suc­ were of great importance to mothers. cessfully in Indonesia for other programs such as The ROVITA Project sent the 450 banners for family planning and diarrheal disease case manage­ the first monthly campaign to county health offices ment and was also used by ROVITA. The first step for distribution to village chiefs ten days before the consisted of traimng two groups of 40 puskesmas first of the month. The head of the Central Java workers from throughout the project area. The fol­ Department of Health sent a cover letter with the lowing month, small groups of trained puskesmas banners asking village chiefs to mount them m staff then trained groups of 20 kader each, reachmg prominent places by August 1st. Additionally, 40 a total of 2,200 kader with the vitamm A program. seven-meter banners were sent to all the puskesmas Ultimately, the volunteers were to train mothers to be hung at theH entrances. mformally about vitamm A deficiency. The central I In addmon, three large-scale quantitative surveys were earned out to measure the impact of the vita­ mm A promotion activities and to determme, to the extent possible, what worked-and what didn't­ and 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 per­ cent by 1990, although the number of posyandu (and therefore children reached) may have greatly increased dunng that time; this level was mam­ A manual for kader reinforced then role as distributors of vit­ tamed dunng the second year and then mcreased to amin A capsules over 50 percent m year three. No significant changes m awareness or capsule coverage were trammg principle was that one learns by doing, and recorded m the control area. Awareness of capsules the central method was role-playmg. Each tramee increased from 57 to 69 percent among all mothers played the role of a kader and a mother and had the within the mtervention area, with the largest opportumty to learn from the suggestions of the increases among those livmg near a health post. other tramees. Awareness among the latter increased beyond 80 The proJeCt team also designed a manual for percent durmg the second year. kader to use with mothers. The manual mcluded Interpersonal channels (volunteers and health detailed illustrations and was carefully pretested care workers) were the most effective means of with mothers. Trainees used the manual in their reachmg mothers about vitamm A distnbution role-playing. Each kader received a certificate upon days. Coverage of eligible children was highest for completion of trainmg. those living close to a posyandu and for those chil­ After the training the volunteers were encouraged dren who were brought regularly (for immuniza­ to conduct an intensive canvas of their respective tion or weighmg). In 1989, about three quarters of areas to register all mothers with children between women who attended the health post regularly had the ages of one and five m preparation for the next heard of the capsules, compared to 35 percent capsule distnbution. awareness among mothers who never attended. Reliance on the posyandu system limited the pro­ Ject's reach because these volunteer health posts MONITORING AND IMPACT EVALUATION were only active in 50 percent of the precmcts in the mtervention area and were only open for three Momtormg after the first promotion consisted of a to four hours on the designated distnbunon days. qualitative study of 78 mothers, 33 kader, and 15 Exposure to radio and banner messages was sig­ puskesmas workers. Questions were simple and mficantly related to mothers' awareness of vitamm focused on whether the audience had heard or seen A capsules. About two-thirds of mothers with high the messages and whether they had acted on them radio exposure had heard of the capsules, compared I THE USE OF INTEGRATED MEDIA IN INDONESIA

Vitamin A Coverage in Communities they listened to the rad10 one day a week or with a Health Post 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 • Intervention messages were designed to encourage mothers Control 40.6 to seek help m findmg the posyandu, but spe­ cific directions ultimately had to come from a face-to-face source. The special role of mter­ personal networks was unusual m this cam­ 30 paign, and planners realized future interven­ ~ tions could be strengthened by g1vmg them 242 25.1'""' greater support Providing mothers access to 20 current sources of information, as well as 1988 1989 1990 adding new sources, would also be pnorities n=223 n=203 n=350 during the next phase of act1vmes. n=267 n=283 n=257 Bmldmg on the project results and lessons learned, Difference m intervention area between 1988 and 1989 zs szgmficant the Indonesia Department of Health at p<.001. Changes in the control area were not significant and m designed a nationwide program, mmally tar­ 1990 may have been influenced by sule effects ofthe intervention geting the 13 provmces with the highest mci­ dence of v1tamm A deficiency. Dunng this Source Annen berg School for Commumcatzon, Unwerszty ofPennsylvania next phase, greater emphasis was to be placed on sooal mobilization through local leader- ship structures and the nat10nal women's to only one-third with no radio exposure. Of orgamzation, or PKK. Continued expans10n of the mothers who had seen a banner, 93 percent said posyandu system would also contribute to greater they had heard of the term "vitamin A capsule," coverage rates. compared to 44 percent who had not seen a banner. However, exposure levels to both the radio messages and the banners CONCLUSION were disappointing. By 1989, only 21 The Bespite amodest ROVITA Project's expenences promoting v1t­ percent of mothers amm A capsules demonstrated a number of simple in the mtervent1on communication budget, but important lessons. First and foremost was that area said they had the province made a communication campaign must be based upon heard rad10 messages careful audience research and materials pretestmg. about vitamin A significant progress in Every product has unique aspects that must be capsules and only 9 expanding coverage. fully mvest1gated from the target audiences' per­ percent had ever spectives. Second, if the basic communication seen a banner. program messages are concise, memorable, and Both media access action oriented, they can be conveyed through a and logistics limited the reach of messages. number of different media. If these media are cul­ Although mcreased frequency of broadcasts (or turally appropriate, they can effectively remforce careful t1mmg during heavy listening hours) might each other even if a single channel has a limited have helped reach more mothers, it would likely reach; however, no communication program can not have helped the 45 percent of mothers who said succeed if the aggregate reach of these media ts I inadequate. Third, different media can commum­ the CIHDC and ROVITA and carried out by Survey cate core messages m umque ways. Radio can con­ Research Indonesia For further mformanon on these, con­ vey a more complicated message than a banner, tact CIHDC, Annenberg School for Commumcation, and face-to-face commumcauon can convey yet Umvers1ty of Pennsylvama, 3620 Walnut Street, more detailed information. Consistency of mes­ Philadelphia, PA 19104 The third survey (1990) was ear­ ned out by ROVITA and Survey Research Indonesia The sage and ummg of delivery are at the heart of an results are unpubhshed mtegrated social marketing activity. Lastly, a commumcation effort can only be as successful as the capacity of the service delivery sys­ Thomas Rezs was resident adviser for HEALTHCOMI tem to satisfy the created demand. An impact eval­ Indonesia and zs now wzth the Kellogg Foundation Renata uation that identifies who responded and what Seidel zs wzth the Academy for Educational Development m mfluenced them to act can provide powerful infor­ Washington, DC Sartono ts wzth the Indonesian Department mation not only for the design of subsequent com­ of Health, Central Java. Sudaryono zs with the Indonesian mumcat10n activmes, but also for considerat10n by Department of Health, Central Java Anne Palmer was with those who can affect the delivery of health services. Helen Keller Internatzonal!Indonesza, and ts presently a con­ sultant based m Manz/a 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 ofExperience 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 Vitamin A Proniotion in Indonesia: Scaling up and Targeting Special Needs

Willard D. Shaw Cynthia P. Green Vitamin APromotion in Indonesia: Scaling up and Targeting Special Needs

Willard D. Shaw Cynthia P. Green

BUILDING ON PILOT Ef fORTS provides examples of "campaign" strategies smtable to the nature of different vitamin A interventions Indonesia's SOMAVITA Project was a bold appli­ and contexts, sustainable with existing resource cation of social marketing principles to vitamin A levels. SOMAVITA's multi-pronged approach sup­ promotion across the world's fourth most popu­ plied a framework for the entire program while lous nation, composed of 13,000 far-flung islands promoting provincial and local capacity building, and populated by some 300 ethnic groups. The as well as creativity m planning appropriate local project demonstrated the ability of national leaders strategies for increasing consumption of capsules to study the results of well-organized and evaluat­ and foods. ed pilot projects and immediately apply findings Smee 1984, the Government of Indonesia has and successful elements to a national program. It given high pnonty to promoting adequate intake of

INDONESIA 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 ,,. -- ......

I VITAMIN A PROMOTION IN INDONESIA

vitamin A, mamly through megadose capsules or dren in two districts of Central Java dunng 1987- consumption of vitamm A-rich foods. In addmon 1991. (See previous case study.) to its ongomg nutnt10n education programs, the • SOMATA, or the Social Marketing of Department of Health conducted two pilot projects Vitamin A Project, promoted v1tamm that developed many of the, strategies eventually A capsules and vitamm A-rich foods among 40,000 children used in the national program: m one district ofWest Sumatra during 1987-1989.1

• ROVITA, or the Oral Rehydration and In 1990-1991, the Indonesian Department of Vitamin A Project, promoted vitamin A capsules Health determined the broad outlines of its subse­ and oral rehydration therapy among 230,000 chil- quent Social Marketing of Vitamin A (or

Partners for a National Effort

OMAVITA "worked" Department of Animal Survey Research Indonesia con­ because many different Husbandry encouraged poultry ducted audience surveys in organizations were able to raising. The Department of three of the target provinces and work together-at the national Home Affairs helped mobilize focus group research among level, across different levels of the support of provincial gover­ mothers; the University of the health administrative sys­ nors and village administrators, Indonesia and Atma Jaya tem, and down to the extensive ensuring that village health University also assisted with voluntary network which sup­ posts (posyandu) staffed by vol­ research studies. Private sector ports village health services. unteers were in place in as firms produced radio and televi­ Each of these different levels of many areas as possible. sion spots, and radio and televi­ collaboration required new This broad net of govern­ sion stations contributed air partnerships and sometimes mental involvement was com­ time. Indonesia's news media new ways of funding and plemented by the work of non­ covered the campaigns, helping administering activities. governmental organizations to promote special activities The Department of Health which have deep contacts with­ throughout the nation. served as the major implement­ m the community. More than Donor assistance was largely ing agency for SOMAVITA, 30 nongovernmental NGOs technical. Helen Keller with the active involvement of participated in SOMAVITA International provided overall the Directorate of Nutrition, promotional activities in the 13 management of USAID sup­ the Center for Health priority provinces. Fatayat port and coordination with the Education Center (PPKM), Nahdlatul Ulama, a young DOH. USAID's HEALTH­ and the Directorate of Muslim women's organization, COM Project provided techm­ Community Participation. received special assistance and cal assistance and traimng in Provincial and district officials actually conducted the urban health communication, responsible for health, nutri­ demonstration project. research, and community tion, and community participa­ Universities and private sec­ mobilization. UNICEF donat­ tion were also heavily involved tor firms provided special exper­ ed vitamin A capsules for the in promotional activities. The tise. MJM, a firm experienced DOH to distribute to the pub­ Department of Agriculture in drug management studies, lic free of charge, and also pro­ used its extension workers to reviewed the DOH logistics sys­ vided supplementary funds for promote home gardens and the tem for capsule distribution; the campaigns. I SOMAVITA) program strategy. Counterparts from The program focused the existing but loose­ Helen Keller International and the Academy for ly-orgamzed nanonal Educational Development, who had assisted mainly on capsule effort to distribute ROVITA through funding from USAID, initially distribution because of vitamin A capsules. In advised the Department of Health to enlarge the addition, it decided to pilot site in Central Java, which focused on twice­ its mandate to reduce concentrate special yearly capsule distnbunon, by expandmg from two vitamin Adeficiency as resources on the 13 districts to the entire province (28 million people).2 provmces with the However, the government was faced with evi­ rapidly as possible. highest incidence of dence of widespread vitamin A deficiency and stud­ vitamin A deficiency 3 ies showing the positive impact of vitamin A sup­ SOMAVITA's prima­ plementation upon morbidity and mortality of ry objective for its three-year duranon was to ensure children; it was impatient to move qmckly to reach that at least 40 percent of 18 million Indonesian at-risk children. Decis10n makers were convmced children aged one to five received a megadose that the new capsule promonon model was ready (200,000 IU) vitamm A capsule every six months at for national application, and they were not content a local health post. This ambmous goal would dou­ with a gradual phase-m until all 27 provinces were ble the percent of children who had received a cap­ covered. sule m the six-month distribution period precedmg the SOMAVITA launch. Strengthening of govern­ mental and nongovernmental capacity m project AN INTEGRATED STRATEGY design and implementat10n was an important, explicit part of the government's strategy to increase The Department of Health (DOH) decided to coverage nationwide. apply the framework used in the pilot projects to The program focused mamly on capsule distnbu- tton because of its mandate to reduce vitamin A deficiency as rapidly as possi­ SETIAP ANAK. ble. Megadose capsules provide ade­ - quate levels of vitamm A for three to six months. The DOH decided that distn­ but10n at stx-month mtervals was suffi­ oent 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, USIA 1 SA,MPA,I 5 TAHlJN the recurrent distribution costs mount up over nme More importantly, cap­ P lLR L U sules are not a long-term solut10n for the KAPSUL VITAMIN A general populatton. PEBRUAlu DAN AGUSTUS DI PosYANDU At the same time, the government therefore launched an effort to develop a long-term strategy of mcreasmg the production and consumption of vita- Semi-annual capsule distribution was aimed at one- to five-year old chtld1en, min A-rich foods. Previous studies had as illustrated m this poster/flyer distributed throughout the country shown that vitamm A-nch foods are readily available in Indonesia but are I VITAMIN A PROMOTION IN INDONESIA

dren aged 6 to 59 months Kenyataan Yang Sudah Dibuktikan Pengabdian Kita: with­ Tumpuan Harapan m a one-year time frame. Peneltt1an d1 Aceh 22 Juta Anak Concern about health and dan Jawa Barat Indonesia yang diperltuat oleh Pengabd1an ktta amat menentukan keberhas1lan nutrition problems m urban penellt1an d1 India dan program Vitamin A mt Bila seluruh 1a1aran slums led to a third intervention Nepal, membuktl­ kesehatan dan sektor-sektor terka1t dapat men­ Jalankan perannya mas1ng~masmg dengan bruk, kan bahwa pembe­ maka 22 iuta anak Indonesia dapat tumbuh under the SOMAVITA Project. nan V1tamm A dapat kembang sempurna Three out of ten Indonesians mPrekan Argha T1dak banyak yang harus d1keriakan Kemat,an BalttF " L1batkan Carnal, Kepala Desa, Kader Kesehat­ now live m urban areas, where an, LKMD, PKK dan Tokoh Masyarakat lain antara JO''\ hmgg:; .. dalam program Vitamin A vitamin A deficiency and other 54°'0 a Manfaatkan semua wadah dan keg1atan Hanya l1ma det1k masyaraka1 untuk menga1ak 1bu membawa forms of malnutrition are more d1butuhkan untuk Anak Bahtanya ke Posyandu guna mendapat­ kan Vitamin A prevalent than m the country as rnembenkan kapsul a 111 Pastikan reg1stras1 semua Anak Ballta d1 desa, Vitamin A Tap1 manfaatnya sangat nya1a dengan memanfaatkan Formuhr Reg1stras1 whole, and where poverty, multr­ meningkatkan daya tahan tubuh anak sekahgus Kapsul VJ1am1n A dan UPGK d1 bawah koor­ plimy menurunkan resrko kesak1tan dan angka i..ematran dmas1 Kepala Desa of ethmc groups, and dif­ • Bantulah Posyandu dalam membma kader, terutama dalam perannya memben kapsul ferent commumcatron patterns DAMP AK SUPLEMENTASI VITAMIN A V1tammA PADA PENURUNAN ANGKA KEMATIAN BALITA create challenges qmte distinct 60 " Untuk wilayah yang belum mem1hk1 Posyandu atau yang kun1ungan Posyandunya rendah, from those m rural areas. The 50 50 Puskesmas seba1knya membenkan perhat1an dan upaya khusus untuk membag1 kapsul pada HEALTHCOM Project there­ 40 40 Anak Bahia Tugas 1rn akan leb1h mudah b1la menggatang ke~asama d1 antara Kader, LKMD, 30 30 PKK dan Tokoh Masyarakat fore focused some of its funds on 20 20 " Jagalah agar persed1aan kapsul selalu cukup d1 mvestrgatmg constramts to cap­ Posyandu sebetum bulan pembag1an kapsul 10 10 " Cata! dan laporkan persed1aan dan pembenan sule consumption m slum areas kapsul Vitamin A

Aeeh Jab~r of Jakarta, providmg technical 1986 1988 assistance to a nongovernmental organization which earned out a umque volunteer-based effort to A flyer for health professionals emphasized the new message, that vitamin A helps expand capsule coverage among increase children's resistance to disease hard-to-reach groups. not eaten by children m sufficient quantmes due CAPSULES-COORDINATING LESSONS ANO to lack of information among caretakers, time RESEARCH constramts, or cultural beliefs. These foods can be cultivated m home gardens or obtained through Policies and Posyandu fishmg or poultry-raismg by low-mcome families. Although promotmg dietary changes may be Lessons from the pilot projects provided a basis for more difficult and costly than capsule distnbu­ laying a firm policy foundation for the capsule dis­ t10n in the short term, the Government of tribution program. The first of these lessons was the Indonesia considers it an essential part of a sus­ value of standard mtervent10n nmmg. In 1990, the tamable and cost-effective program to address Department of Health began setting the stage for a micronutrient needs. nat10nal campaign by announcing a new, country­ This second SOMAVITA imtranve was launched wide policy of semi-annual capsule distribution. A in 1992 on a pilot basis m a total of four districts m semi-annual mtervennon would fix m the public two provmces: Central Java and West Sumatra. The mmd the assooation of vitamm A with these primary objective was to develop and test a strategy months and the local health post, or posyandu, appropriate for replicat10n on a large scale. Each where capsules are distributed. By concentrating pilot was expected to produce an increase in con­ commumcanon acnvmes on the February and sumption of selected vitamm A-nch food by chil- August capsule distribution, the proJeCt could I Assuring Access - through Professionals and Volunteers

ndonesia, a country of vide immunizations. tle in urban areas without 13,000 islands, faces enor­ Posyandus are the main the required residence permits Imous logistical challenges in delivery mechamsms for vita­ avoid going to the health post delivering health services to its min A capsules. In areas with and officially registering their population. The Department of no health posts, capsules are children. Health has created an infrastruc­ available from the local health Half of the villages in the ture that reaches down to the center. Families who miss the ROVITA pilot areas did not village level and relies upon both capsule distribution cycle at have posyandu Even in areas profess10nals and volunteers. the health post in their village with a posyandu, many mothers A network of community can also obtain capsules at dis­ did not know the day of the health centers (puskesmas) oper­ trict health centers. month when theirs was active. ates at the subdistrict level. To This delivery system works Because there was no common provide basic health care in the reasonably well, but it has many day or date for posyandu to be nation's 200,000 villages, the flaws that can affect a time-sen­ held from village to VIllage, the DOH has also established vil­ sitive program. Fitst, the limited mass media could not carry the lage health posts (posyandu). schedule of the posyandu (a few important messages on time and Volunteers known as kader hours once a month) provides a place. Mothers who knew of (primarily village mothers) who narrow window of opportunity their local posyandu saw it as a have received one to three days for mothers to attend. Second, source of health services (e.g., of training in one or more the turnover rate among volun­ growth monitoring, immuniza­ child survival interventions, teer kader is high. Some esti­ tions, etc.) only for their gather at a central location m mates place it at 50 percent a youngest children. their villages and conduct year although some kader do Under SOMAVITA, the monthly sessions to weigh chil­ continue to work for many government continued its poli­ dren and provide advice on years. Third, once children have cy of expanding the posyandu diarrheal disease treatment, completed their immunizations system, but also recognized nutrition, and family planning. at around age two, many moth­ that additional distnbunon Puskesmas staff periodically ers do not bring them to the channels for vitamin A cap­ travel to the posyandus to pro- posyandu. Also, families who set- sules would be needed.

mobilize extra effort from village heads, commum­ system for distnbutton of vitamin A capsules and ty orgamzations, political leaders, and health other services; however, it also recogmzed that providers. The new strategy lessened the possibility short-term goals could not be met without increas­ of donor and volunteer "fatigue." It also enabled the mg access to capsules and mformat10n on foods. In DOH to focus its modest commumcat10n budget a significant departure from previous policy, the on more intensive promotion during January/ DOH authonzed the distribution of capsules by February and July/August. approved groups (primarily NGOs) outside of the In addition, ROVITA had confirmed that access posyandu system. was a major obstacle to achieving high levels of vit­ In the past, volunteers had assisted with commu­ amin A capsule coverage. (See box.) The DOH con­ nity nutrition education mmatives and with capsule tinued to mvest in the expansion of the posyandu distribution at the health post itsel( Now, however, I VITAMIN A PROMOTION IN INDONESIA

mamtain records of capsule distribunon V1tammA mem.mg pentmg and forward these to the provmcral untuk ke,ehatan mdta dan mcncegah 1-..ebuta.m an.1k health departments. Dan In a survey of logistics in three lebth pentmg !Jgt Vitamin A provinces, MJM found that rt took an meningkatkan daya tahan tubuh average of 14 months for capsules to schmgga reach the health post, from mmal plan­ peny•hll dldrc. h.1tuh ptlch .lldll .amp•h t1dak mud.1h mcnJ.id1 p.1r,1h mng through the process of procure­ d•n ttddk memh.1hJyakJ.n JIW

Karena 1tu se was found not to be an obstacle to &ebap anak 1·S tahun pcrlu rnendapat salu kapsul Vitamin A, mcreased coverage. A manual on capsule :! h.cth M;tdhun~ lnifab Rah:manya1 l>ulan Pebruan dJn Agustus. logistics focusing on points recommend­ Vitamin A Selam kap,ul ed by the study was developed dunng the settap han anah perlu d1ben mbuat anak lebib '>Cbat dan lmat mdlanan &umber VJtdmm A ~cpert1 proJect and sent to health centers. b.1yam daun smgkong, pCJ'

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 five­ member 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 respon­ sible for strategic planning, project planmng, and mtegrat10n of activi­ ties with DOH poli­ This booklet on the "Safe Use o/Vttamm A Capsules" All at the 13 priority responded to questions asked most frequently by health cies. Within six professionals provinces received months of Its forma­ small "seed grants" tion, the Committee culturally drstmct and provided an opportumty to developed a detailed examine cultural differences m attitudes and prac­ equivalent ta us implementat10n plan tices. Smee the DOH also planned to carry out vit­ 82,DDD tar their awn for nat10nal efforts. amm A-rich food interventions in these provinces, These focused on: focusmg research m those locations was efficrent. 5 promotion activities. • launching an The survey showed that most mothers already "umbrella" media knew about vrtamm A capsules and had a positive campaign throughout the country to promote cap­ attitude about obtammg capsules for their children. sules on a semi-annual basis; and Accordmg to those mtervrewed, the maJor con­ straint was their limited access to a health post at • providmg trammg, guidance, and momtonng the reqmred ume. An addmonal problem for the to the provincial teams as both a support for theu capsule promouon program was that women large­ ind1Vldual campaigns and m order to bmld long­ ly tended to bring children under the age of two to term capacity. the health post. The majority of services, such as growth momtoring and 1mmumzauon, are armed at Given the scale of acnvmes planned, trammg was these younger children, providing only partial over­ key. Beginnmg m 1991, the Duectorate of lap with the target group for capsule coverage (one Nutnnon sponsored trainmg courses for two nutri­ through five years old). tion officers from each of the 27 provmces to pro­ The survey also provided mformation on media vide basic mformatron and skills m social market­ usage. Most mothers, even those hvmg in rural ing. A health educat10n specialist and an NGO rep- I VITAMIN A PROMOTION IN INDONESIA

resentative from each of the 13 priority provmces religion. The 13 provinces were mobilized m phas­ also attended. The goal was to create a small, core es between February 1992 and August 1993. social marketing team in each province. In addi­ All of the 13 pnonty provmces received small tion, a trammg-of-trainers course on social market­ "seed grants" eqmvalent to US $2,000 for theu own mg was held m April of 1992 for DOH nutrition promotion activmes. Receipt of these grants was educators and leaders from national NGOs so that contingent upon preparation of written proposals traming could be disseminated down to lower lev­ for communication activities before each six-month els. The DOH is workmg toward the goal of having capsule distribution cycle. The grants were success­ one person m each district of the country trained in ful in motivating creative responses from the differ­ social marketmg. ent plannmg groups; however, provmces also added Following the national trainmg course, the funds from their own sectoral budgets. National Implementation Team visited each of the Before each campaign cycle, the National 13 priority provmces to explam the SOMAVITA Implementation Team held workshops to review program Each province established a SOMAVITA program progress and plan upcoming national pro­ lmplementat10n Team consistmg of the three peo­ motional activities. SOMAVITA also encouraged ple who attended the soClal marketmg traming NGOs to participate m program planning and course and representatives of government depart­ implementat10n in order to investigate additional ments such as agriculture, village development, and distribution channels and expand the scope of mterpersonal communicat10ns. As the SOMAVI­ TA program progressed, the benefits of widening FORMULIR REGISTRASI KAPSUL VITAMIN A the distribution pomts and mvolvmg NGOs UNTUK ANAK UMUR 1-5 TA HUN (12 • 60 BULAN) RT/RW I {l'VA/!T/1991) Duson became clear. Posyandu " Tahun 1991 Desa NamaAnak LIP Tg1 Lahtr Orang Tua Tgl Peinbenan Kapsul Kere:rangan (!) (2) (3) (4) Februan (S) Agustus (6) Messages and Audiences

Gmdance from the national level mcluded elements of the overarching vltamm A capsule-promotion strategy. Most important among these was the mes­ sage strategy. The ROVITA ProJeCt messages pro­ vided 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 Ketua Kader Ketua Posyandu RT /RW and five; • Vitamin A is for healthy eyes.

A 38-page manual for health officials covered all aspects of vitamin A capsule pwmotion, and included explanations of However, research had shown that the credibility various campaign forms-such as this one for recording cap­ of "Vitamm A is for healthy eyes" was being under­ sule distribution at the vzllage health posts mined (among both parents and health providers) 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

PEMBINMN KESEJARTERAAN KELUARGA for capsules. This age group contmued to have PKK TIM PENGGERAK PUSAT lower coverage rates than younger children. l -i The pnmary audience for SOMAVITA mterven­ HIMBAUAN KEl'UA UMUMTIMPENGGERAKPKKPUSAT tions was mothers of children aged one through ' KEPADAPARAKADERPOSYANDU five. The national and provmcial campaigns mamly targeted rural mothers. Secondary audiences were: ~ ' Denu ke.~ehatan dan kc.lang.rungan ludup anak~anaJ... lata, kepada para kader PKK : .r }angakltfdt 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 • health care providers at the provmcial, Anda- • Meng_a1ak para tbu a!J4f membawa anak Balua merer.a tw.p bulart ke district, and subd1stnct levels; Posyandu untuk men.1agal..esehatan anaknya, dan mr.ndapatkankapsul v11amm A ttap bu/an Fi:.brunrt dan Aguslus. • village health volunteers (kader); Amal baktl Andat1dakakansm-s1a SemuapiliakamJ.tbertenmakasth dru.lsangat rnenghargm Jenh payah Anda semua Semoga Tultan mehmpahkan karunta dan raJunatNya atns ketuJusan amal Anda. • village leaders; ' - ' Im leaders of community orgamzations; and

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

Health care providers Bue to cost, logistical and village health vol­ Promotional posters such as these encouraged volunteer kader unteers are the maJor and reminded them to participate zn the new semi-annual difficulties, and literacy sources of vitamin A capsule distribution cycles limitations, print mate­ capsules and advICe rials were targeted on child nutrmon because of the gradual drop m cases of vitamm A­ The project had to related blindness This situat10n required an impor­ mainly to the secondary convmce them of the tant thematic shift. In order to emphasize the role audiences. importance of vita­ vitamin A plays in strengthening the immune sys­ min A and motivate tem and reducing childhood mortality from several them to make an causes, another message was added: extra effort dunng the intensive campaign months Village leaders and commumty organizations pro­ • Vitamin A keeps children healthy and vide essential support m mobilizmg local popula­ strong. tions. SOMAVITA encouraged NGOs and com­ In a commumcat10n program, any shift m basic mumty orgamzations to take an active role in plan­ messages is nsky and reqmres careful pretestmg and ning the local campaigns, m providing face-to-face persistent remforcement among target groups. communication with mothers, and m actually dis­ Broadcast media directed at families, as well as tnbutmg capsules. extensive print materials directed at health care providers, promoted this new rationale for vitamm A consumption NATIONAL MEDIA PLANS

The core messages emphasized that even a child One year before the national vitamm A capsule who appears healthy needs vitamm A Mothers who campaign was officially launched, the DOH pro- I VITAMIN A PROMOTION IN INDONESIA

mated the new semi-annual distribution system to personnel. (The team received 153 entrees from 24 the national media. The Minister of Health provinces.) Durmg each campaign month, the radio appeared on television promoting capsules and the spots were broadcast an average of 90 times. DOH held a press briefing for journalists. • Leaflets for Health Workers- Each com­ The national communication program, with a munity health center received copies of a leaflet for potential countrywide audience of 179 .3 million health workers m time for the August 1992 cam­ people, aimed at achieving the greatest possible paign. More than 47,000 copies were printed. The reach with simple but significant messages. It relied leaflet stressed the child survival benefits of vitamin heavily on radio and television public service A and suggested activities that staff could undertake announcements (PSAs) to disseminate basic infor­ to mcrease capsule distribution. These ranged from mation to mothers and snr up interest and support involving local groups in the program, to helpmg for the vitamm A program. Broadcast messages establish alternate distnbunon methods where were also designed to remind health workers, vol­ needed, to making sure that all children are regis­ unteers, and influential villagers of their own roles tered, and monitoring the supply of capsules. The in capsule distribution. SOMAVITA staff worked leaflets also aimed to motivate health workers, with the Indonesian Ad Council to produce one of remmding them that, "A drop of our dedICation the television spots and to mcrease the amount of lowers the death rate of children under five." free time provided for its PSAs. The rad10 spots were produced in Jakarta based on data from the • Leaflets for Community Leaders­ field and sent to all 660 radio stat10ns with the Community leaders around the nation received a leaflet entitled "Secret for Keeping Children More request to give them air time. Print materials helped Healthy and Strong." It was designed for village motivate health workers and also provided stan­ dardized mformanon about both campaign activi­ heads and their wives, who are usually members of ties and vitamm A itsel£ the volunteer-based Family Welfare Movement (PKK) that helps to organrze village health posts. Due to cost, logistical difficulties, and literacy limitations, print materials were targeted mamly to The leaflets stressed the new message that vitamm A increases children's resistance to disease. About the secondary audiences. All materials were designed to encourage face-to-face promotion by 124,000 copies were distnbuted. village volunteers, health workers, doctors, and • Management Guidelines- More than community organizat10ns. 20,000 copies of "Guidelines for Capsule The Center for Health Educanon in Jakarta and Distribution" were sent to provincial and district the Directorate of Nutrit10n, with assistance from health offices and all community health centers. HEALTHCOM and HKI, developed a range of The gmdelmes were developed to standardize pro­ materials for national dissemination.6 These included: gram management and the method of calculatmg capsule coverage. They encouraged health workers • Television Spots- One television spot pro­ to go door-to-door after the distribution cycle was moted the message that vitamin A is good for over m order to give capsules to children who had healthy eyes; a second spot emphasized the role of not received them. The gmdelmes also gave permis­ vitamin A in strengthening children's resistance to sion for local NGOs to help in capsule distnbut10n disease. The spots were aired as public service and promotion. announcements on 12 stations. • Resource Packets- To provide health staff • Radio Spots- SOMAVITA produced three with background information on the mortality radio spots. The project conducted a nationwide effects of vitamin A and other new developments in competinon for the third script m 1993, m order to vitamm A research and policy, SOMAVITA distrib­ stimulate the interest of provincial and district health uted 440 Resource Packets Each packet consrsted I of a folding file box with vanous nationally- and • The lnan Jaya team designed materials suit­ internationally-produced documents about vitamin able for its particular ethnic group (posters and A translated into Bahasa Indonesia. radio scnpts) and mobilized village leaders. • Informational Booklets- Nearly 20,000 • The West Sumatra team mobilized traditional booklets entitled "Safe Use of Vitamin A Capsules" medicme sellers in urban areas to promote vitamm were distributed to health institutions throughout A capsules The team produced radio spots, posters, the country. The booklet answered the most fre­ and slides for cinema. The military also contributed quently asked questions about the safety of capsules. by parucipating m "sweepmg" activmes. • Newspaper Articles- Staff prepared articles • The West Kalimantan team orgamzed panel about the health benefits of vitamin A for newspa­ discussions about vitamm A m every distnct. pers and specialized health publications. • In Southeast Sulawesi, the team designed a • Other Print Materials- These included a brochure for relig10us leaders and special materials poster for community health centers and village for the local market. health posts, a health education monograph, and a one-page traming module on nutrmon counseling for the village health volunteers' basic trammg book. (,lfHJ1Ri"

PROVINCIAL MEDIA PLANS

During the three years of SOMAVITA, the 13 pn­ onty provmces developed theu own implementa­ tion 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 1· Saudara Petugas approved and monitored by the National Team, Pamong, dan Kader, decentrahzat10n of planning effectively encouraged Saya bentahukan bahwa local mnovat10n and sustamability. Kapsul Vitamin A sangat pentmg unluk Kesehatan anak balita Channels and creative approaches varied by Bulan Februari dan Agustus ialah provmce bulan prunbag1an kapsul Vttamm A melalui Posyandu tanpa membayar 1111 In South Sumatra, Boy Scouts assisted with Tugas saudara 1alah men1amm agar SEMUA anak bali!a dt w1layah keria saudara capsule distribution. A new ment badge was d1daltar dalam Formuhr Reg1strasi Kapsul Vitamin A, dan mendapat Kapsul Vitamin A langsung designed for those who met distribution targets m dart Kader 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 The Governor of Central Java appeared with his wife on this vitamin A episodes for a television senes on the poster promoting capsule distribution, and "signed" this letter "family doctor" and also for a comedy program. encouraging kader I VITAMIN A PROMOTION IN INDONESIA

• The North Sumatra team held capsule distri­ as "increasing child bution competitions for health centers. Pretesting was mortality." They expedited by sending explained that, "Only • The Central Java team produced guide­ God is responsible for lines for distributing capsules through local materials through the decidmg who will kmdergartens. mail to pretest sites. die." The reference • In East Timor, additional capsule distribution was changed to posts were opened and identified for the public "Vitamm A increases with signboards. your child's resistance to disease."7 Midway through the project, the team wanted to • In West Nusa Tenggara, materials ranged assess mothers' reactions to new messages highhght­ from cinema slides, to radio spots, to mobilization mg the impact of vitamin A upon morbidity and meetings at the district level. mortality. A special vitamin A "posmonmg study" • In South Kahmantan the Governor and an was therefore conducted in 1993.8 Focus group dis­ important religious leader appeared on posters. cussions with mothers (rural/urban; nch/poor) m Volunteers from a women's relig10us organizat10n three provmces explored possible themes for radio promoted capsules through kmdergartens, home and television spots and the leaflet for caregivers. vISits, and Koramc readmg groups. The study found that mothers were well informed about vitamins in general but felt that vit­ These programs were aimed at province-wide amm A had no special claim to improvmg or pro­ populations varying from 747,557 (in East Timor) tecting a child's health. Mothers found three of the to 28,555,737 (in Central Java). Together, the 13 five promotional messages pamcularly compellmg. provinces had a potential audience of more than 70 These emphasized themes of "the good caring million people. mother," "preventing blindness," and a child's eyes as being "the wmdow of God." The project ulti­ mately reJected the last of these as inappropriate for PRETESTING AND MONITORING non-Islamic audiences. Consequently, a radio spot developed for the subsequent campaign stated: All materials used in the nat10nal campaign were "Good, canng mothers bring their children to the pretested at the provincial level with intended health post for capsules." audiences and revised as indicated. The National Regular monitoring of program implementat10n Team developed specific guidelines for pretesting occurred through both periodic site visits and also each item, including tips on how to set up a focus an innovative process of direct-mail surveys. group, what quest10ns to ask, and how to record Durmg each campaign cycle, a two- to three-person what the pretesters had learned. Pretestmg was team from the national level visited provmcial and expedited by sending materials through the mail district health offices as well as village health posts to pretest sites. Health education staff and/or and observed ongoing field activmes. The team members of NGOs who were tramed in social used a "momtonng checklist" to prepare a stan­ marketmg conducted the pretests at the village dardized report on program management, IEC level. The project provided funds for travel to vil­ materials and distribution, involvement of NGOs, lages and for reporting. capsule supply, and follow-up of participants Pretests of the leaflet designed for commumty trained m social marketing. During one of these leaders led to substantial changes. Focus group par­ visits, teams learned that health care workers had ticipants found that the leaflet was overloaded with questions about the safety of high dose vitamin A mformation and techmcal jargon. Women object­ capsules. This led to the booklet described above on ed to a proposed reference to vitamm A deficiency "The Safe Use ofVitamm A Capsules," which was I distributed before the February 1994 campaign. knowledge of capsule distribution months, vitamin Direct-mail surveys helped assess the reach and A benefits for child survival, and the DOH policy impact of communicat10ns. In September 1992, of giving extra vitamin A to children with measles. the team designed a one-page, self-addressed ques­ Over 1, 100 quest10nnaires were returned after the tionnaire to provincial and district health offices, first mailing, yielding a response rate of 59 percent. community health centers, village leaders, and vil­ Over time, the response rate fell to nearly half that. lage members of the Family Welfare Movement Respondents who received a questionnaire after (women who usually manage the health post cap­ every campaign cycle were less likely to send it back, sule distribution). The questionnaire was then suggesting the need to vary the respondent sample. mailed out after each campaign. It was designed to monitor exposure to television and rad10 spots, understanding of the main messages in spots, recep­ CAPSULE PROGRAM RESULTS tion and use of printed materials, presence of an active posyandu, local program activities, capsule The SOMAVITA capsule campaigns clearly had a supplies, and possible constraints. The surveys dramatic impact, according to DOH national sta­ found that materials were reaching their intended tistics. Children's consumption of vitamin A cap­ audiences. They documented a large increase in sules tripled in less than three years. In 1991 at the

Figure 1: Vitamin A Capsule Distribution in Figure 2: Vitamin A Capsule Distribution in All Indonesia (27 provinces) the 13 High Risk SOMAVITA Provinces

80 80

70 70

... BO ... BO =...=- ...... =...... =- =i 50 =i :E...= :e:...= 50 ...... 2 40 2 40 ...= ...= ::e ::e... -=.... 30 .... 30 = = =...... -=...... = ... 20 ... 20 a.... a....

10 10

0 0 Aug 91 Feb 92 Aug 92 Feb 93 Aug 93 Aug 91 Feb 92 Aug 92 Feb 93 Aug 93

Note Data for August 1991 includes capsules distributed in the Note- Data for August 1991 includes capsules distributed zn the previous six months Subsequent data are for capsules distrib­ previous six months Subsequent data are for capsules distrib­ uted during the semiannual distribution cycles Denominator uted during the semiannual distribution cycles Denominator ts (NJ = 23,319,270 chzldren 1-5 (according to 1990 census) number ofchildren 1-5 according to 1990 census I VITAMIN A PROMOTION IN INDONESIA

start of SOMAVITA, only 20.7 percent of all attempting to shift important health messages, and Indonesian children aged one through five had mdicates that focus needs to remam on getting this received a capsule m the previous six-month peri­ new idea across to various audiences. od. With the first national campaign in February 1992, this proportion jumped to 43.4 percent. SOMAVITA's goal of 40 percent coverage was thus DIVELOPING AMODEL FOR DllTARY CHANGI achieved m the very first campaign. By August of 1993, overall coverage m the last distnbution peri­ SOMAVITA's pilot projects for promoting dietary od reached 56.2 percent according to DOH statis­ change were conducted to develop a model that tics. (See figure I.) could be used on a national scale. Dietary change In the 13 high-risk provmces, capsule distribu­ interventions often focus on mvestigatmg what is tion Jumped even more impressively. With an mi­ feasible in relatively small geographic areas. tial coverage rate of 24.4 percent, coverage rose after Although the SOMAVITA pilot areas were well the first campaign to 46.6 percent, and by the defined (two districts each m Central Java and West August 1993 distnbution cycle to 65.5 percent Sumatra, totallmg 2.2 million people) project plan­ according to DOH statistics. (See figure 2) ners hoped to select foods and design strategies An endlme survey of two of the three provinces which would have nationwide applicability. surveyed as a baseline measure in 1991 (Central Later known as SUVI­ Java and West Sumatra) was conducted m October TAL (Promoting 1993.9 Evaluation results showed that capsule cov­ The study also Natural Sources of erage had increased but that the proportion of chil­ Vitamin A), the mitia­ dren aged three through five receiving capsules had concluded that no tive set out to develop not changed. About 70 percent of the children single food could be approaches that would receiving capsules were aged one to three. Program also mamtain low managers realized that the messages about older selected that was costs and management children had not penetrated. A radio spot empha­ appropriate tor all efficiency. sizmg children's age was made for the February The first step was a 1994 campaign, and a poster featuring an older three provinces. Nat10nal Food Strategy child was sent to village health posts for the August Workshop organized 1994 campaign. in June of 1992 and Results from direct-mail surveys provided addi­ attended by representatives from the National tional insights. More than 90 percent of respon­ Planmng Board, Departments of Health and dents (village leaders and health workers) knew the Agriculture, research mstitutes, and umversmes. capsule distnbution months. Approximately half Based on information from the 1991 baseline survey had seen or heard radio or televis10n spots and 81 of mothers m Central Java and West Sumatra, work­ percent had received a leaflet on vitamin A One­ shop participants selected ten foods that were rich m thlfd of respondents (from provmcial to village lev­ vitamin A and were available m sufficient quannnes els) had learned the new campaign message that vit­ that consumption could be mcreased. These mcluded amin A promotes resistance to childhood disease amaranth, cassava leaves, carrots, swamp cabbage, and reduced mortality. In addition, 24 percent papaya leaves, papaya, a type of banana, mangoes, reported that measles should be treated with vita­ eggs, and liver. The origmal goal was to identify a sm­ mm A. Neither of these facts had been disseminat­ gle food from this IISt for promotion throughout the ed to these audiences before the SOMAVITA effort. pilot reg10ns. The ma1ority of volunteers (87 percent) still SOMAVITA then conducted a qualitative study responded that the ma1or benefit of vitamm A was in a subsample of six villages m each of the sur­ to prevent blindness. This reflects the challenge of veyed provmces Using observation, focus group I d1scuss10ns, and in-depth interviews, the study Messages emphasized the benefits of the recom­ assessed the ten vitamm A-nch foods in terms of mended foods and the importance of eating them their nutnt10nal value, availability, pnce, accept­ every day. Central Java's chief slogan, "Never a day ability, and current level of consumption. The without eggs," appeared m all campaign matenals. study narrowed the select10n to five foods (ama­ West Sumatra's materials stressed that ''Amaranth 1s ranth, cassava leaves, papaya, eggs, and liver) but a good source of Vitamin A that's cheap and easy to also concluded that no smgle food could be select­ get." Target beneficianes for the pilots mcluded ed that was appropriate for all three provinces. those younger than those for the capsule programs, Local conditions, amtudes, and behaviors were too children begmning at six months of age (through diverse. As a result, SOMAVITA's strategy shifted five years) were emphasized, given the importance to a provmce-by-provmce food selection and pro­ of the weanmg period. motion approach. In May 1993, each province held a plannmg Implementation workshop. Participants mduded key DOH staff, rep­ resentatives from other mtersectoral agencies, local Provincial nutrition offices in Central Java and universities, and village health volunteers Usmg West Sumatra prepared one-year implementation social marketing plannmg worksheets developed by plans for their mtervennons. The DOH provided the HEALTHCOM Project, pamc1pants selected a about US $10,000 to assist in carrymg out the food to promote. Cntena for select10n included plans. Each provmce availability, consumer acceptance, current consump­ launched its pilot tion and the possibility of increasing this level, vita­ On specified days, effort with distnct min A content, current practices, pnce, and children brought onentat10n meetings; ease/time of preparat10n. In Central Java, planners West Sumatra also selected eggs. In West Sumatra, planners selected eggs to sc/1001 and conducted trammg at amaranth-a green leafy vegetable. Participants also ate them together. the sub-d1stnct level. identified target groups and test sites, and developed Although mass major components of the communication strategy. media played a part The next step was to select specific program m both pilots, community events and Interperson­ objectives based upon current practices regarding al communication were stressed. Collaboration selected foods. A rapid baseline study in the target among different government agencies and with distncts provided mformat10n from over 800 moth­ local NGOs helped "get the word out" through ers regardmg their consumption patterns and basic multiple channels. In Central Java, the provincial knowledge, attitudes, and practices relevant to the health office developed a range of matenals selected foods. 10 Based on the survey results, district including: planners set goals for the pilot programs: • six ind1v1dual radio spots, which were broad­ • In Central Java- to mcrease the proportion cast about 60 times m each district as public service of children who ate eggs three or more days m the announcements, plus a radio spot for a family prev10us week from 40 percent to 60 percent w1th­ series, broadcast 12 times; m one year. • a poster for subdistnct health centers; • In West Sumatra- to mcrease the propor­ tion of children who ate amaranth three or more • leaflets about eggs and other vitamin A-nch days In the previous week from 27 percent to 50 foods for agricultural extens10n workers. percent withm one year. I VITAMIN A PROMOTION IN INDONESIA

Extension workers from the Central Java The Potential Problem of Taste Fatigue Department of Animal Husbandry encouraged poultry farmers to mcrease egg producnon and the rograms that promote increased consump­ Department of Trade monitored the pnce and mar­ tion and product10n of specific foods need ket supply of eggs dunng the mtervennon. The Pto be conscious of the potential for "taste Education Department orgamzed monthly mstruc­ fatigue" in the target audience. Indonesia's pilot t10n for elementary school and kindergarten teach­ foods promotion project (SOMATA) found ers about vitamm A. On specified days, children that women might serve greater quantities of a brought eggs to school and ate them together. The particular food but would not cook it more fre­ Family Welfare Movement held egg recipe demon­ quently unless the recipes could be varied. strations and contests; village volunteers gave out When the SOMAVITA program in West cooked eggs to children brought to the posyandu for Sumatra developed a radio spot to promote vitamin A-rich amaranth, planners included weighing and immumzauons Fatayat Nahdlatul hints about how to avoid "boring'' the family Ulama, an Islamic young women's orgamzat10n, with too much of a good thing. dissemmated vitamm A mformauon dunng its reli­ g10us teachings. Radio Spot: Conversation between two Housewives at the Market The public health offices m West Sumatra were also prolific. They produced: Ida: Oh my! You are buying amaranth at the market every day1 Ill a rad10 spot encouraging vaned ways to use amaranth m local dishes; Heri: I certainly am! Amaranth is a great source of vitamin A and it's easy to get. Ill banners for subdistrict health centers;

Ida: But don't you get bored with eating II a poster for health centers featunng amaranth amaranth every day? and vanous vitamm A food sources,

Heri: Why should it be boring? That Ill leaflets for rehg10us leaders, encouragmg them depends on how I cook it. to ment10n vitamin A messages m their teachmg; Ida: How do you cook it? • a cassette recordmg of such a sermon; Heri: Well, you need to vary how you prepare it. For example, I serve it simply as a Ill a cassette contammg traditional muslC and vegetable, or within kripik, or perkedel, songs about v1tamm A m a local language, for or bakwan. I can put amaranth in all health centers and village health posts. these dishes. Extension workers from the Department of Oh, so 1t depends on how you cook it. Ida: Agriculture encouraged families to plant amaranth Heri: Yes, amaranth can be in all these and other vitamm A-nch vegetables. Volunteers dishes, but it tastes different. from the Family Welfare Movement orgamzed recipe contests and cookmg demonstrations m the Ida: Well, if that's the case ... villages. Previous pilots had held recipe contests Heri: Sure! Try it yourself later! that were successful in drawmg attention to the food promonon effort but often resulted m com­ Announcer: Amaranth is a good source of vit­ plex "wmnmg" recipes not readily adopted by the amm A that's cheap and easy to get. Eat ama­ general populanon. The project team sent a nutn­ ranth every day served in all kinds of dishes! uomst and anthropologist to visit several villages and develop and pretest recipes based upon local I dishes commonly given to children. Volunteers THE URBAN PILOT STUDY organized recipe contests m these villages, and chil­ dren participated m selecting the winnmg dishes. Planning and Preparing for the Urban Experiment Monitoring SOMAVITA's third initiative was a pilot intervent10n The national team monitored the promotion of vit­ to experiment with innovative techniques for pro­ amin A-rich foods in Central Java and West moting vitamin A capsule consumption in urban Sumatra through visits to provmcial and district slum areas. Capsule and food promotion programs health departments. Using a standardized monitor­ had so far focused on delivery and promononal mech­ mg checklist, the team checked the status of pro­ anisms for rural populat10ns. However, a high urban­ motional materials and assessed the impact of mes­ izat10n rate in Indonesia, with an accompanying sages disseminated through the provincial mass rapid growth of slums, media campaigns. requires design of District health department supervisors also visit­ Capsule and food appropriate new ed community and village health centers to observe strategies for these local promot10nal activmes. The supervisors found promotion programs high-risk populations. that the pnce of amaranth m West Sumatra had had so far focused on Besides the different doubled and even tnpled in the course of the year. delivery and promotional logistic problems of Prices for eggs did not increase in Central Java, pos­ health delivery m sibly because the agricultural extens10n workers had mechanisms for urban slum areas, been promoting mcreased egg production. rural populations. populations face chal­ lenging social and economic situations FOOD PROMOTION RESULTS whICh differentiate them from rural populations as a target audience for In June of 1994, rapid endline surveys in the pilot health messages. Among these are a larger propor­ districts provided mformat10n on changes in the tar­ tion of households with wage-earnmg and smgle geted behaviors. 11 Both provinces saw substantial mothers (translatmg into less time to take children increases in desired practices since the baseline a year to health posts); greater time constraints affecting earlier In West Sumatra, the percent of surveyed meal preparation and breastfeedmg; high mobility; women who reported that their children had eaten high population density combmed with a multiplic­ amaranth three or more days m the prev10us week ity of ethnic groups; and large cultural diversity m rose from 27 to 48 percent, almost meetmg the tar­ health attitudes and feeding practices. Furthermore, geted goal of 50 percent. Central Java exceeded its many mothers are simply afraid to take their chil­ objectives. The percent of women who reported giv­ dren to the local health post, or posyandu, because ing their children eggs three or more days in the pre­ the family has not been granted permission to regis­ vious week Jumped from 40 to 77 percent. ter legally in the city. This is a problem for many The survey did not show mcreases in consump­ urban slum dwellers who have migrated from other tion of any other vitamin A-nch foods in the target provinces. (See box) reg10ns. However, some other important behav10rs In 1992, the HEALTHCOM Project conducted did improve. In Solak district of West Sumatra, for background research for the urban pilot through example, research showed a great reduction in the mterviews with representatives of 16 organizations number of mothers supplementing breastmilk carrymg out health programs m the city. The study before the desired age of four months. highlighted the difficulty of reaching the poorest urban dwellers m any systematic way Ethnic I VITAMIN A PROMOTION IN INDONESIA

its volunteers to public health programs (mcludmg immu­ nization, oral rehydrat10n, and prenatal care) and was mterest­ ed 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. In February 1993, SOMAVI­ TA began a iomt project with Fatayat Nahdlatul Ulama to pro­ mote capsules and support the Promotional activities included song competitions among traditional singing groups work of the local posyandus in which were required to compose songs on a vitamin A "theme " three subdistricts of East Jakarta. Target areas were selected based groups tend to cluster together in one neighbor­ upon low vitamm A capsule coverage rates, high hood, with more than 30 different groups livmg prevalence of communicable diseases, and the avail­ w1thm a few blocks' radms. Residents often avoid ability of Fatayat motivators at the community level. government services that have registranon require­ Officially, 161,930 families lived in these subdis­ ments. On the other hand, religious figures have tncts. An addinonal four subdistncts were selected been successful m influencing these disparate and for the second phase of acnvines. otherwise ISolated groups. Together with the DOH national and local offi­ The study also aimed to identify potennal part­ cials and HKI, HEALTHCOM and Fatayat devel­ ners for an expenment in improving vnamm A cap­ oped a plan with three important goals: sule coverage m poor areas. Fatayat Nahdlatul • to increase capsule coverage in the target Ulama (FNU), an Islamic young women's orgamza­ areas by 50 percent after three distribunon penods; tion with six million members nationwide, emerged as an important collaborator. Within Jakarta as a • to develop a model distribution strategy to whole, 382 FNU motivators and 40 supervisors reach the hard-to-reach, complementmg the gov­ provide a regular network of face-to-face, neighbor­ ernment's standard delivery mechamsms; hood-based communication. Their ongoing act1v1- ties mclude Koramc study groups, Ansan (women's • to assist FNU to build their institutional credit and loan assoc1at10ns) and other relig10us capacity through trammg and through plannmg assemblies in homes. Gatherings often provide the and implementing a pilot intervention. opportumty to convey social messages. A collaborative foundation was essential to the FNU offers an effective and sustainable channel success of this unusual effort The Fatayat project for reachmg the poorest segment of urban dwellers. team met with DOH offioals at each admm1stra­ Its members are trusted because they live within t1ve level, with local government officials, and with the communities they serve, and denve high cred1- leaders of the Family Welfare Movement (or PKK, b1lity from their religious functions and ded1ca­ which assists m running the posyandus) to secure non. FNU had previously provided support from their approval and support for the project. I Training was the next important step. Many of • Weekly Koranic study groups- Volunteers the FNU volunteers had already participated m wove messages about the importance of preventmg SOMAVITA's national-level training in social disease and the benefits of vitamm A mto their reg­ marketmg methodology. The HEALTHCOM ular Koramc d1scuss10n meetings (Pengajzan, or Project organized two additional workshops for readings at the mosque, as well as Yasznan, or group the urban pilot. The first of these focused on readmgs in homes). Even new migrants who belong Rapid Assessment Procedures in order to give to virtually no other soCial groups often attend such FNU a simple method for gathenng information meetings. useful to the design of their program. Dunng the • Sermons at the local mosques- Rehg10us second day of trammg, Fatayat supervisors and leaders who were informed about the importance motivators went mto the commumties to inter­ of v1tamm A became enthusiastic about includmg view 270 mothers and observe theu hvmg envi­ information and motivat10n m theu sermons. ronments. Results were tabulated and discussed before trammg ended. B Music and song events- Traditional music A second workshop was designed to enhance the competitions were held combming Independence volunteers' interpersonal communication skills to Day celebrations with promotion of v1tamm A cap­ help them motivate mothers and to supervise or sules. FNU motivators, PKK volunteers, and ado­ provide feedback to their team members. Tramees lescent girls performed. Some smgers wore green also learned about the health implications of vita­ and yellow costumes representmg v1tamm A "col­ min A and, together with observers from the ors." Other events mcluded children's song festivals DOH, developed capsule distribution forms to be at elementary schools and performances of local used in their mtervent10n. bands. Cassettes were also produced with vitamm A songs and speeches. IMPLEMENTATION

The pilot implementation plan includ­ ed 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 Before each capsule campaign, Fatayat motivators developed wntten plans out­ lmmg theu proposed promotional activ­ ltles. 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 I VITAMIN A PROMOTION IN INDONESIA

Getting to Know An Urban Population-or Populations

akarta's urban capsule pilot work as daily laborers, petty rates much lower than other program began in three traders, pedicab/bus drivers. areas of Indonesia. About 43 subdistricts and expanded Social conflicts and crime are percent had received their to another four. The popula­ high, as are various forms of third dose of DPT; about 56 tions of these subdistricts faced gambling and prostitution. percent had received their some common problems, but • Cakung has an average of third dose of OPV by age two; were also tremendously varied. 5,000 people per square km. It and 42 percent were immu­ For example: has the highest concentration nized against measles. • In Pulogadung subdismct, of industry in Jakarta, with Although urban areas are in more than 55,000 families 702 industries registered in theory easier to reach through from 20 different provinces 1991. Residents work as daily mass communication than have settled in an area of just laborers, or collect waste. rural audiences, the multiple 15.6 square kms. A central bus Women work as food traders, languages and varied customs depot makes it the "gateway'' seamstresses, or servants. and cultures of slum areas to Jakarta for migrants. Most of the children in make it difficult to design use­ Pulogadung is one of the pri­ these areas do not attend ful messages. Very low literacy mary termmals for waste dis­ school either because of family levels undermine the usefulness posal in Jakarta. Many of the poverty or because their fami­ of print materials as well. High residents therefore work as lies do not have legal residence. intensity interpersonal commu­ waste collectors. The children often work in nication is the most promising • Matraman subdistrict has petty trade or small scale medium. SOMAVITA's urban a population density of more industry. When FNU volun­ pilot therefore focused on than 37,000 people per square teers conducted their rapid developmg the outreach capac­ km. Residents live in 62 dif­ assessment of the target subdis­ ity of a credible volunteer net­ ferent "hamlets" in an area of tricts, they found that health work to support its capsule­ just 4.85 square kms. They cards revealed immunization distribution goals.

• Community media- Banners remindmg local posyandus and compared the lists of children mothers to come to the posyandu for capsules, loud­ who had received capsules with rosters provided by speakers mounted on cars announcmg the day and heads of the individual hamlets. Names of children time of capsule distribution, puppet shows, drum and parents were then compiled as the basis for bells, parades of volunteers wearing vitamin A home visits m September. Each volunteer took cap­ T-shms, and a simple flyer promoted capsule-dis­ sules for the children m her parncular area and went tnbution days. to ind1v1dual homes to distribute them and also to provide counselmg about the vitamin A promotion • Home visits- Person-to-person commum­ effort. In addition, motivators kept their own lists cation dunng home visits, especially with families of families who attended their regular religious whose children had missed the posyandu distnbu­ meetings but had not established legal residence. tion cycle, gave volunteers an opportumty to pro­ Volunteers were able to visit these homes as well vide mformation and also help establish trust. during the "sweep." Followmg the end of the August dIStribution Volunteers recorded all the capsules they dismb­ penod, the Fatayat volunteers returned to their uted m the children's health cards and also reported I this mformat10n to their supervisors who relayed it Results showed that total coverage in the mterven­ to the local posyandus In this way, distribution by tion areas increased from 15 percent to 60.1 per­ the FNU volunteers became a complementary and cent of children one to five after three semi-annual integrated activity withm that of the regular posyan­ distribution cycles. 12 After the fourth cycle in du effort. August 1994, coverage increased to 70.2 percent of Based on early successes during this first distrib­ eligible children. 13 ution cycle, the proJect expanded its target audi­ Four in five of the children receivmg capsules in ence to an additional four subdistricts (in North this cycle obtamed them from FNU, mdicatmg that Jakarta) for the February cycle, raising the number most of the increased coverage resulted from FNU's of eligible children to over 16,000. HEALTH­ home visits. This fact reflects the challenges to the COM repeated the two workshops on Rapid posyandu system in an environment where mothers Assessment Procedures and mterpersonal commu­ may not have the time or the necessary sense of nication for volunteers workmg in the new areas. security to take a child to a government-run service; Dunng this round of trainmg, greater responsibili­ it also reflects the dedication of the FNU motiva­ ty was given to the lead trainers of Fatayat's nation­ tors and the effectiveness of their person-to-person al office. FNU volunteers from other provmces also contact in the urban slums. attended these workshops. The goal was to bmld FNU supervisors m some other provinces are greater capacity withm the organization to carry begmnmg to replicate the pilot program on their out such interventions with little outside donor own. Some of the volunteers from other provinces assistance. HEALTHCOM also carried out a cost who attended the second round of training also sent study of the Fatayat intervention to help them m reports that they had mobilized their networks to develop a cost efficient model that could be repli­ begm support of the vitamm A program and had cated with local funding levels. already reached several thousand children without any external assistance. MONITORING AND RESULTS LESSONS LEARNED Fatayat supervisors held weekly meetmgs with their motivators and also met monthly with the commu­ The SOMAVITA program demonstrated that gov­ mty health post coordmators and FNU headquar­ ernments can bring vitamm A capsule promotion ters staff. After each "sweep," each FNU motivator programs to national scale quickly if national and completed a checklist indicatmg: provincial decision makers make a maJor commit­ ment of staff and resources. In this program, dele­ • number of children m the neighborhood; gatmg responsibility for program planning and • number of children brought to the posyandu implementation to provincial and district levels for capsules; helped create a feeling of ownership. It also encour­ aged local activism and led to mnovative promo­ • number of homes visited; tional activmes. A decentralized approach has bet­ • number of materials dissemmated; ter likelihood for sustainability because local agen­ cies gam the skills and confidence to contmue on • activities conducted and those involved; their own. Training of core groups is essential to the • number of Koramc readmg groups where success of this process. vitamin A was discussed. SOMAVITA's explicit objective of bringmg NGOs into the planning and implementat10n This detailed mformation provided a simple but processes-for the capsule, foods promotion, and appropriate method for gathering proJect data. urban pilot activmes-clearly added to program I VITAMIN A PROMOTION IN INDONESIA

impact. It demon­ needed to be revised, due to the reduced mcidence strated that non­ Seed grants were a of blmdness associated with vitamin A deficiency. Although such shifts m messages governmental and particularly useful are risky, forma­ local groups can tive research and mtensive commumcanon efforts contribute substan­ device tar motivating to both primary and secondary audiences can assure the tially not only to local creativity and credibility of new messages over time. promotion efforts • The "under five year old" or the "one to five (their usual role in encouraging a search year old" is not a single audience segment, but m public health pro­ tar matching funds. reality many segments. Child survival programs grams) but also to often reveal that the youngest child is a speoal program design and challenge. (Immunization programs often have to the mechamsms of health service delivery itself. difficulty raismg rates among the under-ones. The necessary investment m traimng and momtor­ Dietary change programs often find that mothers ing of these groups saves costs in the long run, con­ will serve recommended dishes to older children tributes to capacity building, and provides a tangi­ but not to those who are weanmg ) In contrast, ble benefit to participating organizations through SOMAVITA's capsule campaigns had most trouble skills development and motivat10n. reachmg older children who otherwise do not A number of addmonal key lessons can be drawn receive services at the posyandu New messages from the SOMAVITA experiences: were targeted accordmgly. • SOMAVITA's nat10nal capsule program effort had a dual role: 1) to provide an "umbrella'' • SOMAVITA planners originally hoped to design a vitamm mass media campaign which dissemmated uniform A food promotion model similar in some ways to messages in all provinces; and 2) to provide trainmg that of the national capsule pro­ gram. With a and monitoring for provincial staff and activities. uniform message strategy, an "umbrella" This approach, combmed with SOMAVITA's national campaign mdudmg mass media could be supported phased assistance to high-risk provmces, focused by mtensive promot10n activmes at the local limited resources effectively. Seed grants were a par­ level. However, experience showed ticularly useful device for motivatmg local creativi­ that the foods promoted must be selected at least as far down ty and encouragmg a search for matching funds. as the provincial level. Although both provmces involved m the vitamm A-rich food • Policy decisions based upon the lessons from promotion programs saw improvements m desired pilot proJeCts were central to the success of the practices, one year is not sufficient for achievmg nat10nal program. Standardizat10n of the six-month long-term dietary change m a populat10n. distribut10n cycle allowed for broadcastmg of mes­ Furthermore, promotion of a single food is less like­ sages nationally, and helped avoid volunteer and ly to have an impact on vitamin A mtake than pro­ donor "fatigue" at the commumty level. The gov­ motion of several foods. The need for variety m a ernment also looked squarely at evidence that the family's diet, as well as challenges of the market, cre­ posyandu system was not yet strong enough to serve ate difficulties for a single-food approach. as the sole system for capsule distribution, and responded with effective changes m policy. Th(l • The SOMAVITA experience confirmed the Jakarta pilot proJect demonstrated that an NGO necessity for special strategies geared to the realities can provide an effective complementary mecha­ of urban populations, especially the urban poor. nism for distribution. Working with groups who have a presence m the target communities, who are trusted, and who are • SOMAVITA found that the DOH's funda­ motivated and trained to provide effective face-to­ mental message about the benefits of vitamin A face counseling is vital. I • Monitoring of mtervenuon activities on a NOTES continumg basis (through site visits and question­ naires) revealed problems that could be responded 1 Pollard, Richard, Social Marketing ofVztamzn A, SOJ\.1A­ to quickly. For example, visits with health workers TA Pro;ect, West Sumatra Province, Indonesia Qakarta The Manoff Group, with the Department of Health, Duectorate convinced the national team that guidelines were General of Commumty Health, Republic of Indonesia, and necessary on vttamm A capsule protocols. The team Helen Keller International/Indonesia, 1989) was able to print these during the mtervention and dissemmate them on a nationwide basis. 2. SOMAVITA I was a one-year "bridge" between ROVITA and the nat10nw1de project, implemented m • SOMAVITA's capsule-promotion messages Central Java m 1990 In this document, "SOMAVITA" is were broadcast over more than 600 televis10n and used to descnbe the nauonw1de, three-year project radio stations throughout the country. The proJeCt launched m 1991 and techmcally named SOMAVITA II attempted to develop monitonng systems for the 3. The 13 provmces were Aceh, North Sumatra, West broadcasts but ran into both technical and cost dif­ Sumatra, South Sumatra, Central Java, Southeast Sulawesi, ficulties. Devising a simple momtonng system uti­ South Kal1mantan, West Kal1mantan, West Nusa Tenggara, lizing project staff personnel to collect data will be East Nusa Tenggara, East T1mor, Maluku, and Inan Jaya a pnority in subsequent efforts. 4 Information mcluded in this case study on the baselme • Direct mail proved initially to be a successful and endlme surveys, and regardmg data gathered by the way of monitoring program process and results m dis­ DOH on the SOMAVITA activities, are reported m· tant areas. The pilot proJeCt (ROVITA in particular) SOJ\.1AVITA Pro;ect Final Report 1 August 1991 - 30 had already expenmented with this channel, and September 1994 Qakarta Mm1stry of Health and Helen found the mail system adequate and recipients Keller International, September 1994). responsive. Over time (after two surveys), however, 5 East Nusa Tenggara was ongmally to be part of the vlta­ those who received quest10nnaires on a repeat basis mm A-nch foods mtervention; however a natural disaster began to lose mterest and no longer responded. in Flores m 1992 damaged villages, commumcation net­ Future programs will vary the list of those they survey. works, and mfrastructure A foods mtervention was later launched, but not as part of the program descnbed here.

Indonesia has promoted vitamm A capsules among 6. For further mformation about the campaign matenals the population for nearly 20 years. Even given the fact see the SOMAVITA project document, Taking the Message that "pills" and "vitamins" are both valued "products" Nationwide Soczal Marketing of Vztamzn A in Indonesia in the public's mind, coverage throughout the country Qakarta M1mstry of Health, Republic of Indonesia, and was low at the begmnmg of the SOMAVITA ProJeCt. Helen Keller International; draft, May 1994) The need for a major examination of the distnbution system, as well as systems for proVIdmg informat10n 7 Additional mformation about pretestmg is provided m "Gettmg the Word out on V1tamm A and Mortality: and promotmg demand in commurnties, was clear. At Developmg Pnnted Material for Commumty Leaders," the same time, the government knew it had to look Qakarta: Mm1stry of Health of the Republic of Indonesia, beyond capsules to the longer-term goal of dietary and Helen Keller International, February 1993) change. SOMAVITA's three-thronged program was a bold effort, m a short time-frame, to test and apply 8 Survey Research Indonesia (SRI), Vztamzn A Positzonzng new models to meet these challenges. Each of these Research-A Qualitative Report Qakarta· SRI, September mitiatives brought about impressive changes in health 1993) practices through cost-effective and sustainable means. 9 The endlme showed changes m mothers' reports of cap­ The lessons from SOMAVITA will be invaluable in sule coverage between 1991 and August of 1993 of 20 3 helping build a strong national program that meets the percent to 30.6 percent m West Sumatra and 45 7 percent needs oflndonesia's diverse population. to 58 percent m Central Java (p< 001) The West Sumatra I VITAMIN A PROMOTION IN INDONESIA

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 differ­ ences (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 pro­ gram 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 pre­ sented 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 consul­ tant based in Washington, DC

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