Mass Media and Health Practices Project
The Mass Media and Health Practices project was the first major test of social marketing applied to reduction in infant mortality in developing countries. The project soon outgrew its name and became a full-fledged social marketing program as data poured in from grassroots consumer research pointing out the needs for new products, lower complexity costs and massive teaching of new skills. Mothers were being asked to adopt a new product - an oral rehydration solution - that required they learn when it was needed, how to find and prepare it, and then how to administer it safely to their child. The product was differentiated in the two test sites, home-mix sugar, salt and water in Africa and pre-package salts in Latin America. In Africa a mass mobilization strategy was taken, driven by the use of a radio course that involved thousands of women learning and then practicing to mix the home-mix safely. In Latin America the program evolved from a package salts to a broader childcare during diarrhea product. In Latin America infant mortality due to diarrheal dehydration dropped from 47.5% to 25% in the first year. Both programs became models for a decade of child survival programs that successfully attacked infant mortality in a dozen countries around the world.
In 1978, the World Health Organization, UNICEF, and the US Agency for International Development (USAID) embarked on a crusade to combat infant mortality in the developing world, which during this time averaged more than 200 per 1000 live births. Children in developing countries were dying in large numbers from such preventable diseases and illnesses as diarrheal dehydration, measles, and respiratory infections, all of which had long been under control in the rest of the industrialized world. Inadequate medical resources and facilities and the lack of effective immunization programs in developing countries allowed diseases such as these to persist, and kept infant mortality inordinately high.
As part of this movement to significantly reduce infant mortality in developing countries, USAID contracted a number of non-profit development organizations to take the lead in developing and implementing consumer-oriented social marketing programs. One such program was the Mass Media and Health Practices Program initiated by the Academy for Educational Development to address the growing epidemic of acute diarrheal dehydration in infants in Honduras.
A year after AED's Mass Media program's implementation, an evaluation conducted by Stanford University to chart the project's impact. Consisting of a data sample collected from 750 randomly selected families from more than 20 communities, the study showed that the diarrheal dehydration project in Honduras had achieved significant results in both disseminating important health information and in fostering specific changes in behavior related to treating infant diarrhea.
Decreased mortality: Between 1981 and 1982 mortality rates for children under five years of age had decreased from 47.5 percent to 25 percent.
Significant campaign awareness: After little more than a year of the project's start, 93 percent of the mothers sampled from rural Honduras knew that the program's radio campaign was promoting Litrosol, the brand name of the locally packaged oral rehydration salts (ORS) used to treat diarrhea; and 71 percent could recite the radio jingle used to promote the administration of liquids during diarrhea affliction.
Increased health knowledge and changed behavior: Of the mothers sampled in the study, 42 percent had knowledge that the use of Litrosol prevented dehydration; and 49 percent had actually used the ORS Litrosol. Of those that had used Litrosol, 94 percent were accurate in describing the correct mixing volume and 96 percent knew that the entire package of ORS was to be used in treatment. Sixteen months after the program's start, 39 percent of all of the cases of diarrhea within the prior two weeks among the sampled families had been treated using Litrosol.
The Diarrheal Dehydration Problem in Honduras
Before the start of the USAID funded program, diarrheal dehydration accounted for 24 percent of all infant deaths in Honduras and represented the single leading cause of infant mortality. In 1977, the year preceding the program's commencement, diarrheal dehydration caused the deaths of 1,030 infants. Treatment during this time was expensive and limited both in scope and availability. The only treatment available to Hondurans for diarrheal dehydration was intravenous (IV) therapy, which requires trained medical personnel and a sterile environment, and was offered exclusively in fixed health facilities serving only a small percentage of the country's rural population.
Initiating the Program
To address the limited availability of medical treatment for this illness, the Honduran Ministry of Health collaborated with the Academy for Educational Development (AED) to develop a comprehensive public education campaign. The project was designed to deliver information for the home treatment of infant diarrhea, and to demonstrate the proper preparation and administration techniques of oral rehydration therapy (ORT), the primary home diarrheal treatment.
In January of 1980, after considerable investigation of the medical and social issues being addressed and preparation of the instructional and training tools, AED's Mass Media and Health Practices Program was launched; its primary objectives included: 1) substantially reducing the number of deaths from diarrheal dehydration among children under the age of five; 2) extending rehydration therapy to isolated rural areas of Honduras; 3) Reducing the per-patient cost of rehydration therapy; and 4) Introducing a significant portion of Honduras' isolated rural populace to diarrhea-related prevention behaviors.
The program operated in a carefully chosen site that included a representative population of 400,000 individuals. The campaign began by providing 900 health care workers with four to eight hours of ORT training. The training program concentrated on teaching the proper mixing and administration of ORT salts and instructing other village assistants, who would ultimately have to conduct the same exercises directly with rural families. Using props and training dummies, the program trainees repeatedly practiced each step of the mixing and administration processes. The health workers and village trainees then began instructing mothers and grandmothers in ORT and other health behaviors such as breastfeeding, infant food preparation and person hygiene. When rural families completed their ORT training, a flag was posted at their house to let other mothers in the area know where they could obtain health advice and instruction.
Marketing and Media
As the training program was being carried out, a media campaign was implemented to reinforce the health care instruction effort. The campaign developed print materials and radio advertisements to issue basic messages related to the diarrhea rehydration therapy and the AED training program. The messages emphasized the correct administration of oral rehydration salts "Litrosol," the continuation of breastfeeding during infant diarrhea periods, and encouraged mothers to seek medical assistance if a child's condition deteriorates. Posters and flipcharts were also created to illustrate ORT and to deliver supporting messages. The radio advertisements were placed in 30-60 spot announcements and often included some form of jingle, slogan, or song. Many of the ads included a familiar announcer, Dr. Salustiano, the program's spokesman for technical information, who subsequently became a nationally known figure.
The tone of the campaign was serious, straightforward and caring. It successfully promoted a mother-craft concept, where a mother's current actions and beliefs are supported and the program's health techniques become an added complement to her care-giving regimen. ORT training was presented as a new development in modern medicine: the latest remedy for lost appetite and a recovery aid. With a high rate of literacy (87 percent of each household with at least one literate member), and 71 percent of all households owning a functional radio, the media campaign became an effective communication and education tool.
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