Pakistan's Iodine Deficiency ProgramThis is a featured page Mahwish Khan June 2008 Social Marketing CASE STUDY: Pakistans

"Iodine Deficiency Project" BACKGROUND: The Iodine Deficiency Project was a joint effort between the government of Pakistan, UNICEF and Population Services International (PSI) in the early nineties. These three groups collaborated to tackle the issue of iron deficiency, which causes health problems such as goiter, cretinism, stillbirths and deaf mutism. About 20 million people live in iodine-deficient areas of Pakistan. Of these, 8 million show some manifestation of iodine deficiency, and at least a million show some degree of mental retardation. In 1993, an estimated 70% of the population was at risk for iron deficiency. Previous efforts to fortify oil with iodide had been met with limited success. The next simplest option was to fortify salt with iodine. However, previous examples where such a program existed showed that a large portion of the population was still unreachable. Therefore, this project aimed to provide the laborers at salt processing plants with the technical abilities to iodize the salt. Instead of focusing on the harmful and negative aspects of the disease, the campaign chose to concentrate on positive images. It placed heavy emphasis on cultural values, while also illustrating a constructive message through its Hand & Pot logo. The goals of the campaign were to increase iodized salt consumption to combat iodine deficiency, as well as to create demand for iodized salt through social marketing while also increasing production. RESEARCH: Pakistans Iodine Deficiency Project followed other similar iodine deficiency programs that had been developed for other countries. The organizations involved could select attributes of similar program that would be complementary to Pakistans country dynamics, considering the political, social and economic aspects. The lessons learned from Pakistans program have been noted so that when possible, it can be applied to other iodized salt social marketing projects in other countries. Research is vital to measuring the effects of the campaign at every point. Social marketing differs from general marketing in that general marketing sells a tangible product, whereas social marketing tries to implement ideas and behavior changea more complex product to sell (MacFadyen, Stead and Hastings, 1999). After the program achieved a 15% increase in iodized salt consumption, the market share in Pakistan dropped. Because the consumer is assumed to be an active participant in the change process (MacFadyen, Stead and Hastings, 1999), the organizations involved in the program reassessed the campaign and integrated more training and alliance-building activities into their communication strategy. COMMUNICATION STRATEGIES: MacFadyen, Stead and Hastings write that Social marketing also has a great deal to offer here by influencing the behavior, not just of the individual citizen, but also of policy makers and influential interest groups. Social marketers might target the media, organizations and policy and law makers (1999). In recruiting the Government of Pakistan and Unicef, PSI was able to root itself and give the social issue some necessary grounding and back-up. Marketing occurs between two or more parties that have something to exchange, as well as the ability to carry out communications and distribution" (MacFadyen, Stead and Hastings, 1999). Therefore, to generate awareness about iodine deficiency, the campaign chose to target publics that would be most influential in harnessing the general publics support, and getting them to change their behavior. The campaign chose to use traditional forms of mass media, utilizing television breaks, sponsorship of Urdu dramas, Urdu newspaper advertisements, radio advertisements, posters, Hand and Pot logo stickers, and plastic salt containers, and package

inserts. In addition, a range of other communications channels were used to reach the audiences, much of which was done through events that include public gatherings, seminars, training sessions, and conferences. Pakistans rural population made it imperative for the use of other forms of communication, since signals and transmission are not received in many parts of the country. These target groups are hard to reach, which is one aspect that typically defines many social marketing campaigns (MacFadyen, Stead and Hastings, 1999). Those that are least accessible, hardest to reach and least likely to change their behavior are the audiences that social marketers craft their messages for, and for the Iodine Deficiency Disorder (IDD) program, the following alternative communication avenues were used: Salt producers were educated on the benefits of iodization, and they were also given financial assistance to lower the costs of the iodization process. Furthermore, they were given supplies of potassium iodate, marketing training, and assistance in developing packages that hand and pot logo with the brand name. In rural and poor areas where the population had limited access to the media, salt retailers were targeted to encourage the local consumers to buy iodized salt. A retailer's kit aided retailers to promote iodized salt. The kits consisted of brochures, calendars, cell phones, stickers, and posters to motivate them to sell iodized salt. Doctors are given the opportunity to learn more about IDD through seminars, and are also given other materials for their practices such as prescription pads that are inscribed with the program logo and slogans. Approximately 25,000 doctors were targeted. Teachers attended seminars and were given quarterly news bulletins. They were trained to pass the message along to school-aged children and the families of these students. These teachers were given fun kits to administer to their students. Part of the kit was a test that turned purple if the salt was laden with potassium iodide. Teachers were also given resources such as story books, school dust jackets, pencils, coloring books or pencil games upon which the iodized salt name, logo, and slogan were placed. Because of the great influence of religion in Pakistan, religious teachers were also targeted to spread awareness about IDD and the benefits of using iodized salt. Furthermore, volunteers from participating NGOs were asked to integrate the issue in other social and health communication campaigns when visiting rural villages. THE HAND AND POT MacFadyen, Stead and Hastings write It [social marketing] is a framework or structure that draws from many other bodies of knowledge such as psychology, sociology, anthropology and communications theory to understand how to influence peoples behavior (1999). After researching the cultural and psychological dynamics of Pakistanis, the social marketing campaign produced messages that aligned with values and traditions. Central to the marketing campaign was the development of the "Hand & Pot" logo, which has become the universal symbol for iodized salt in Pakistan. The campaign has made the "Hand & Pot" logo a positive image, emphasizing the healthy family, rather than the negative aspects of IDD. MacFadyen, Stead and Hastings describe voluntary behavior, and state that voluntary exchange is made easier when it is felt that social marketers are offering something that is helpful and useful (1999). They claim that through highlighting benefits of the product, consumer research can identify the benefits which are associated with a particular behaviour change, thereby facilitating the voluntary exchange process (MacFadyen, Stead and Hastings, 1999). They further write that the benefits may be tangible, intangible, relevant to the individual or relevant to society. Demand is easier to generate where the benefits are both tangible and personally relevant. In social marketing, this goal is difficult to achieve because benefits are difficult to personalize and quantify (MacFadyen, Stead and Hastings, 1999) For communication, the logo of "Hand and Pot" shows salt being dropped into a cooking pot by a woman's hand, with the words "iodized salt" in Urdu. The national slogan translates "health from generation to generation," to appeal to sentiments of family and long term use. Social marketers develop campaigns that are meant to be continuous and lasting, and in the case of Pakistans IDD program, the program asked individuals to change his or her behavior, as well as their familys

behavior, in consuming iodized salt for its health benefits. IMPACT: The campaign was met with a handful of challenges. It faced negative propaganda, where rumors about iodized salt were circulated. Additionally, the health-care industry did not treat iodine deficiency disorder as a priority, and the subject was sidelined and thus undelivered. There was also a lack of interest among salt producers because of the low demand for iodized salt and the costs attached to it. The smaller-scaled salt producers lacked the technology, the technical skills, and the resources for purchasing iodide. This made it difficult to recover the cost from consumers. Additionally, there was no national and provincial legislation that would enforce salt iodization. The two most populated provinces lacked salt iodization legislation. In the provinces having legislation, the legislation was not enforced nor did it monitor the consumption of iodized salt. The availability of non-iodized salt in the market also made it difficult for the program to achieve its goal. Because there were no policies in place, it has made achieving the target of raising the household consumption of iodized salt to 50% in 2010 unfeasible. Although legislation is useful, the enforcement of it in countries like Pakistan is difficult. PSI has found that legislation should accompany programs, such as the Pakistan program, which work with the private sector. Through the iron deficiency project in Pakistan, the coalition of organizations learned that it was imperative that the supply and demand of iodized salt was simultaneously stimulated. Merely raising awareness of the health implications related to iodine deficiency or increasing the supply of the product are not effective methods to decrease iodine deficiency disorder. The program also found that if salt manufacturers had invested their own resources into iodizing salt, they would have perhaps been more motivated to keep the program running. This is mirrored in other PSI programs, which have shown that the consumer who pays for the product is more likely to value the product, thus ensuring the longevity of the program. Because the government and international donors often do not have the relevant experience working with the public and private sector, it becomes imperative for social marketing organizations to become involved. These organizations are better able to generate effective outcomes. A national strategic plan was developed and approved by theGovernment of Pakistan and the five year plan (2005-2010)to phase out the project is to be carried out in three phases. In this plan, UNICEF will continue to provide the substance KIO3 (iodide) until arrangements of importation is in place. These plans also involve the private sector in importing, distributing and utilizing iodide. The Provincial Health Departments in Punjab and Sindh, the two most populated provinces in Pakistan, have promoted legislation and quality-control. The North-West Frontier Province has further established the Association of Salt Industry, which will be instrumental in storing and distributing iodide, and will also regulate salt processing units. A national coalition on iodine deficiency control has also been formalized as part of the plan. CONCLUSION: When the program started, only 2% of all salt was being iodized. By August of 1995, that number jumped to 17% of all edible salt becoming iodized. According to PSI, approximately 30% of all edible salt in Pakistan is iodized, and between 1993 and 1995, the campaign produced 35 million new users. Initially, only three salt processors were iodizing salt, but that number had increased to over 400 less than two years later. Pakistan has about 600 salt processors, most of them using simple technology on a small scale. The project has offered technical support to these salt processors, but each has individually invested approximately $300 on its own to buy the necessary technology to iodize the salt.