Socially Marketing Micronutrients: The Development of a Multi-channel Communications Campaign in Bolivia.

Objectives: To describe the process for developing a national multi-channel communications campaign, emphasizing mass media, to increase demand and utilization of micronutrient supplements for women and children in Bolivia as part of the national Programa Multisectorial Desnutrición Cero. Methods: The design of campaign materials and messages was informed by a baseline knowledge, attitude, and practice (KAP) assessment (n=452), conducted in four departments. Findings were used, along with channel analysis, to develop a dissemination plan. Draft materials were field-tested using focus groups (n=12) with target audiences (n=120) and modified based on feedback. All activities were carried-out in collaboration with the Ministry of Health and Sports. Results: The baseline KAP survey showed variation across different micronutrient supplements and departments, for example any knowledge of vitamin A ranged from 55-100% and any knowledge of therapeutic zinc for diarrhoea or stunting ranged from 10-30%. Television and radio were the preferred channels for receiving health and nutrition information, including on services available. Field-testing of draft materials found generally high acceptance and valuing of the materials; feedback led to modifications which increased emphasis on enablers for how to conduct the recommended practices. Final materials included television and radio advertisements, roadside billboards, health center banners, and calendars for caregivers. Conclusions: A national multi-channel communications campaign to promote micronutrient supplementation was developed. After seven months of implementation, an endline survey will be conducted to assess the association between campaign exposure and KAP, which will allow us to understand the potential influence of each communication channel on coverage and utilization of micronutrient supplements.

Complexities and Opportunities for Implementing the National Vitamin A Supplementation (VAS) Program in Haiti.

Objectives: In Haiti, limited coverage of Vitamin A supplementation (VAS) in children under 5 years of age is associated with a weak and fragmented health system. To address this, the government and partners implemented a process to identify and remedy problems and bottlenecks. Methods: Evaluative activities that were conducted include: 1) participative and de-centralized stakeholder workshop to assess the Child Health Week (CHW) platform for distributing VAS; 2) NGO-mapping conducted in all 10 Haitian departments; and 3) interview-based and observational supply chain assessment. Results: Each assessment highlighted enabling factors and barriers for improving coverage of VAS in Haiti. 1) The CHW workshop identified weak national program coordination and ownership, and bottlenecks in data collection and reporting. The existence of trained departmental data managers was identified as an opportunity to improve VAS Program reporting. 2) The NGO mapping identified 43 organizations currently involved or interested in getting involved in the VAS program, which can serve to extend program reach. Inadequate knowledge of VAS protocols by NGO personnel was limiting their potential involvement. 3) The supply chain assessment identified inadequate forecasting, a fragmented stock management system, and under-utilized supply warehouses. New stock management tools and opportunities for shared transportation represent potential areas to improve the supply chain. Conclusions: Strengthening the health system in Haiti remains a long term goal. These three assessments identified short term strategies - including synergies with existing health resources and utilizing the capacity of NGOs - that could help improve coverage of the national VAS program.

Practice-Based Implementation Research on the National Scale-Up of Micronutrient Powders in Bolivia.

Objectives: Bolivia is among few countries to have scaled-up Micronutrient Powders (MNPs) for children to the national level. Here we explore Bolivia’s experience as an early-adopter and in doing so, identify enabling conditions and stakeholders that led to scale-up, and barriers to increasing coverage and adherence. Methods: We reviewed a wide variety of documents spanning several years of program implementation (2006-2012) and communicated with those involved with the program. We defined scale-up as the process of increasing coverage to benefit more children and used a health system model to identify programmatic components. Results: Bolivia replaced iron syrup for children 6-23 months of age with MNPs in 2006. In 2012, MNP coverage reached 65% of Bolivia's approximately 536,000 children in this age group. Adherence rates in 2010 for children consuming all 60 sachets were 45% and 52% in urban and rural areas, respectively. Enabling political factors included integrating MNPs into the existing public health system. Politicians and policy makers helped accelerate scale-up by including MNPs within the national development plan and prioritizing effective coordination, including private sector engagement. Training of healthcare providers, support for supply chain management, communications, and program monitoring remain critical components of MNP scale-up. Behaviour change and demand creation strategies targeting the healthcare provider and caregiver were identified as key factors to sustain and increase coverage and adherence rates. Conclusions: Countries considering replacing iron syrup and transitioning to MNP implementation can benefit from Bolivia’s experience, particularly in creating an enabling environment whereby MNPs can be integrated within existing health and nutrition programs.

Designing Co-packaging for Zinc & Oral Rehydration Salts (ORS) to Influence Caregiver and Provider Behaviours for Treating Childhood Diarrhea in Guatemala.

Objectives: The Guatemalan Ministry of Public Health and Social Assistance has scaled-up co-adjunctive zinc as a national policy, yet utilization of this newly-available life-saving commodity remains a concern. The purpose of this study was to design effective co-packaging for zinc and ORS, informed by social-marketing, to influence both caregivers' and providers' behaviours in a demonstration project at the health post level in the department of San Marcos, Guatemala. Methods: Local concepts, perceptions and experiences relating to diarrhea and care seeking were explored in 8 focus group discussions (n=82) and 24 key informant interviews with caregivers. Prototype co-packaging and messages were developed and reviewed with 14 mothers and 10 providers in 4 municipalities to pretest the candidate materials. Results: Formative research identified two major challenges to correctly using zinc and ORS to treat childhood diarrhea: 1) the concept of adherence to zinc once symptoms disappeared; and 2) dissolving a tablet in a spoon was a new skill. A campaign of Zinc-10 was created and tested to promote the concept of 10 days of adherence to zinc; additional visual aids focussed on showing dissolving of zinc on a spoon. These candidate concepts and messages were highly accepted by caregivers and providers, yet revisions were needed for images and materials used. Conclusions: Using a social-marketing approach, packaging and promotional messages were developed that were more acceptable to caregivers and providers than the original prototypes. These materials will be tested in a randomized community trial to see the effectiveness of the co-packaging on caregiver adherence and provider behaviour.