International Council for the Control of Iodine Definiciency Disorders

The International Council for the Control of Iodine Deficiency Disorders is a non-profit, non-government organization for the sustainable elimination of iodine deficiency and the promotion of optimal iodine nutrition worldwide.

Communications Guide Chapter 2

2
Building Partnerships

Truly ending IDD once and for all depends on building and maintaining a network of partnerships. The involvement of many partners, who know and have immediate access to their own constituencies, helps ensure iodized salt consumption by future generations. This is because these groups and individuals have the power and influence to make institutional changes that help reach children in schools, teachers in universities, doctors in medical schools and professional associations, health workers in training, and food processors.

Equally important, the changes must reach throughout the salt chain -- the producers, packers, truckers, wholesalers and retailers. Contracts and, whenever possible, job descriptions should make clear exactly what industry leaders and workers must do to help ensure good quality iodized salt in the nation’s diet.

One advantage of keeping in mind the whole of society while planning communication activities for IDD is that this overview helps take inventory of resources and identify constraints at all levels of society -- especially the bureaucratic and household levels that are sometimes neglected in other development strategies.

And in forming alliances, it is important that communication between partners at different levels of society be horizontal and interactive, not vertical and authoritative. There is still a tendency for experts to "talk down," to look at societal groups as "junior partners" -- people who ought to do what the experts suggest. This viewpoint does not lead easily to cooperation. It is more productive to aim for the sort of circular flow of information between partners illustrated in the Social Mobilization Continuum (see above).

For IDD, creating a full circle of communication helps sustain political will, stimulate demand for iodized salt, deliver the salt efficiently, and create a healthy standard that can be sustained from generation to generation.

Encouraging dialogue

The program manager, through an integrated approach to communication that involves everyone, encourages discussion among government agencies, salt producers, and communities and identifies all needs and concerns. This discussion can help set up a structure for the production and distribution of iodized salt and create an awareness and a demand that will sustain the health benefits to children, mothers, communities, and the national economy. In the increasing number of countries where salt already is mostly iodized, effective discussions can enhance public understanding and sustain the effort.

When considering partners, it is important to engage those who may resist salt iodization. If we do not educate salt retailers they may spread misinformation. For example, a salt plant manager might boast that his salt will increase the IQ of children who use it. Iodized salt will protect the child from brain damage and a lowering of IQ, but iodized salt does not add IQ to normal children. Such statements can be misleading and harmful. Similarly, if we don’t involve local religious leaders, they could oppose dietary change or confuse iodine with contraceptives as was the case in Pakistan and the Philippines.

And while it is better to avoid problems in the first place, when controversies or crises develop, do not run away from debate. When people’s interest is seized, they may pay better attention to your presentation, as long as you are careful to address their concerns. Here are some examples:

When India experienced a catastrophic drought in 1967/8, health professionals succeeded in linking water with diseases and death. In the years following the drought, India undertook a major potable water program.
Family planning has provoked controversy in many countries. Subsequent debates were able to bring to public attention the economic consequences of unplanned population growth and put it on the political agenda. Families began to recognize women’s rights over reproductive issues and see more clearly the harmful effects of unplanned children on the individual and the family unit.
Iodine has been suspected to be a contraceptive, with rumors and fears paralyzing IDD efforts in several countries. These crises have been turned to an advantage by involving key religious and political leaders and sports figures in correcting the unfounded rumors.

Listen for conflicts of interest, and resolve them

Every country -- and every segment of society within a country -- contain groups and individuals who have interests and opinions affecting the use of iodized salt. It is important to give voice to these interests, listen and respond:

People may not know they need iodine. ("Goiter’s been around a long time. Why pay more for this new salt?")
Some think there is a taste difference. ("I have always used rock salt for pickling. It’s saltier.")
Some may be opposed to or suspicious of it. ("Maybe that salt is a contraceptive," or "Maybe it will sap my strength.")
Salt producers and packages may not realize they can profit from the process. ("They’re telling us to iodize the salt. We’re going to lose money.")
Sometimes those with the best intentions to address the IDD problem may act in a counterproductive way. (District officer: "IDD has to be wiped out. I’m going to ban all non-iodized salt." But iodized salt is in short supply, creating a black market problem.)

So there are many kinds of interests that can run counter to IDD work -- personal, cultural, professional, religious, inter-organizational and inter-personal. The most important thing is how you respond to a lack of concern or a conflict of interests. Don’t run away from the problem, wish it away, or patch it up and keep it quiet. Since there will always be differing, even opposing, opinions and interests, it is better to seek out those differences and talk about them. Maintain a relationship and an exchange of information even if a group or individual is not immediately supportive. Sometimes half-hearted support can be an unseen obstacle, and outright opposition can be the start of a productive alliance.

Interaction among social groups

The formation of many types of alliances takes skill, ingenuity and perseverance, but the end justifies the talent and time invested. As illustrated in Figure 2, development goals are attained through social change, and the participation of everyone concerned helps insure that social change takes place.

Social groups are involved or mobilized through a range of interactions since change desired in one segment of society almost always has implications in other segments. For example, initiative in development could come from the people who have a "felt need" or from an inspired and caring leader who has learned about a specific problem affecting the daily lives of the people and/or the economic growth of the country.

Often, the push for a development goal starts with a few technocrats or academics who are promoted to action by new data or newly discovered technologies. Sometimes grassroots organizations call attention to a need experienced at the community level. And even commercial interests may spark development if a need is recognized and action taken for profit.

Whatever the primary motivation for change may be, planners need to take into account all relevant segments of society, identify partners that share ownership of the development objectives, and work through appropriate channels of communication to develop specific activities that prepare the various partners for action.

An Illustration of the Basic Elements of Social Mobilization

Figure 2.

The elements of social mobilization

Figure 2 illustrates who the national partners may be (Inputs), how we work together (Process), what we are trying to accomplish (Outcomes) and what we hope will be the effect on development (Impact) of our combined efforts.

Under Inputs are listed examples of national partners who carry out the programs supported by the international development agencies below. Among the national partners, there appear two types of non-governmental groups: national and community level organizations. Experiences in many countries show that religious groups, civic groups, grassroots action groups, as well as industry and commerce, behave differently at different levels. Since the success of programs involving changes in attitude and behavior depend on support at every level, all these organizations are important. Any one of them can make or break the momentum of IDD work.

The energies and resources of the national partners focus on the activities listed in the Process column. Each step in the social mobilization strategy includes some or all of these elements, described in more detail in Chapter 8. Figure 2 lists the main communication activities, although there are other important elements such as logistical support and financial management.

The communication activities listed under Process are well worth serious review, no matter how far advanced an IDD program may be. Even the more successful IDD programs around the world very often suffer from inadequate attention to these elements, raising the question of whether progress will be sustained. For example, evaluators often monitor the quality of the salt produced and changes in health status without assessing the quality of the support activities (or process) leading to the delivery, purchase, and actual use of iodized salt in the home.

Outcomes are expected at various levels of society, outcomes achieved from managing, interacting, and making choices that bring about social development. Some aspects of social development are listed under Impact in the far right column. These changes lead ultimately to improved development status.

Communication Tool Kit 4 contains a more detailed list of outcomes, called Social Mobilization Indicators. This list can be used to assess the strength of a program’s social mobilization effort.

Ecuador and Pakistan: Case Studies

To show how partners work together in real programs, this guide cites examples of social mobilization, primarily from Ecuador and Pakistan. These countries offer two perspectives on social mobilization, one over the past decade, the other a work in progress.

Ecuador

In 1984, Ecuador’s Ministry of Health began to build an integrated program against iodine deficiency that has overcome technical, geographical, language, and bureaucratic barriers to protect almost all of its 5 million Andean population against iodine deficiency. Since salt is produced by a small number of large producers in Ecuador, many argue that advocacy with decision makers, discussion with industry, regulatory action and monitoring should have been enough. Working with just a few producers, Ecuador was able to subsidize iodized salt for a few years until consumer demand was enough to pass the cost on to the consumers. However, because those most at risk were also the most difficult to reach, these "supply side" activities had to be matched with "demand side" work.

With international and bilateral support from the government of Belgium, Ecuador followed a social marketing strategy backed by considerable advocacy work that helped to involve agencies and influential people at every level. This sort of extensive advocacy at the international, national, provincial and community levels was coupled with a "problem-solving" management style.

As the program proceeded, partners were found to provide needed resources, to accomplish specific tasks, and to overcome obstacles. Planning was decentralized and program promotion put in the hands of provincial training teams with ready telefax communication to the sources of power and resources in the capital. The provincial teams involved local leaders and rural school teachers and enlisted the support of other relevant individuals and organizations. This is an example of social mobilization or good social marketing, whichever term you prefer.

Advocacy and alliance-building helped gather strength for the IDD program in Ecuador by essentially asking everybody to pull in the same direction. After ten years of continuing reassessment and revision, Ecuador’s program was declared to have virtually eliminated iodine deficiency in 1994.

Another Andean country, Bolivia, recently achieved universal salt iodization. Unlike Ecuador, Bolivia has many small salt producers, so cooperatives has to be formed and workers trained. Salt packers and traders took over iodization in many cases and became important partners. Health personnel at all levels received continuous training on the importance of consuming iodized salt and became program allies, helping to send out a consistent message through interpersonal channels. Bolivia's situation was different from that of Ecuador, but the approach was similar: form alliances and involve everybody concerned.

Pakistan

In comparison to Ecuador, Pakistan has many more salt producers, a less well developed road infrastructure, and an uncontrolled iodized salt price. Pakistan is also more heavily populated, and its IDD program started from a much lower percentage of iodized salt consumption: 2% as compared to 50% in Ecuador.

Despite these differences, Pakistan uses a "problem solving" management style similar to that used in Ecuador. Because it is taking place today, Pakistan is making use of new thinking about alliance building. Recently, after a quickly achieved increase in iodized salt consumption from 2% to 17%, the market share of iodized salt in Pakistan began to drop. Planners quickly reassessed the IDD program and revised their communication strategy to include more training and alliance-building activities. The IDD program has strengthened and widened its steering committee, revised messages for consumers, and involved well-regarded social workers in support of iodized salt.

Mid-Course Corrections

It should be noted that mid-course corrections such as those made in Ecuador and Pakistan are a sign of program strength, not weakness. The ability to identify problems, adapt messages to changing conditions, take advantage of new opportunities, and seek out new partners means that essential monitoring systems are in place. Message design relies on knowing the audience -- understanding the knowledge, attitude, beliefs, and practices of its different segments -- but without some trial and error, no one truly knows what message or combination of messages will fit best or what the best delivery system will be.

Audience Segmentation of IDD in Ecuador

Figure 5

Facilitator	· Public officials · Congressmen · Development Agencies	· Providing legal, human, technical and financial resources for the program	· Quarterly news bulletin · Interviews · Immediate provision of information requested by the facilitating group in the desired format
Internal	· Program staff, both central and peripheral	· Creating, producing, and distributing the program's services	· Quarterly news bulletin · Annual training, evaluation, and planning meeting · Periodic support visits or upon request · Possibility of apprenticeships or scholarships abroad
External 1. Primary	· People at risk of IDD · Salt producers and importers · Salt distributors and carriers	· To consume iodized salt and disseminate its benefits · To produce, import, and promote iodized salt · To distribute, transport, and promote iodized salt	· Distribution of information on poorly iodized salt brands (risk of impoundment) · Work lunches to raise awareness on IDD and distribute promotional materials (posters, key holders) for their customers (storekeepers)
2. Secondary	· Health staff, teachers, community leaders, NGO promoters, mass media, municipal personnel, others	· To support IDD risk assessment activities and to create, test, and deliver products/services to the population at risk · Information, communication, and education activities according to risk level · Strategic stock of iodine · Payment of engineers for advisory services · Annual evaluation meeting	· Distribution of cassettes with radio spots · Training workshops focusing on IDD issues, assessment techniques, and educational techniques

Vanormelingen and Vanderheyden, 1994

Audience Segmentation Pakistan

Figure 6

Audience

Behavior Change

Services

Salt Consumer

·    Recognize iodized salt logo

·    Request and purchase iodized salt

·    Choose iodized salt every time as prevention against IDD

·    Seek out doctors and paramedics and even shopkeepers for advice and counseling

·   Television breaks or sponsorship of Urdu drama

·   Series of television spots

·   Urdu newspapers and or radio and posters

·   Stickers and mobiles

·   Plastic salt containers

·   Package inserts

Policy Makers, Opinion Leaders, Media

·    Enact National or Provincial Legislation to ban production, distribution, and consumption of common salt

·    Localized ban on production and consumption of common salt

·    Contribute financial and technical inputs for communication campaign

·    Opinion Leaders and Journalists discussing IDD and iodized salt in the news

·   Periodic updates of events, new information about scale of the problem, etc. (direct mail with face-to-face follow-up)

·   Launch iodized salt in communities, organized by processors with guidance from the salt squad

·   Quarterly news bulletin

Salt Producers and Processors

·    Seek out GOP or UNICEF personnel to learn about iodized salt processing

·    Invest in equipment to begin to process iodized salt

·    Process exclusively iodized salt

·    Maintain minimum quality standards for iodine fortification

·   Brochure for processors

·   Wall chart to describe mixing procedures and ratios, quality control, storage conditions

·   Iodized salt outdoor plaques (to identify processors who iodized); certificates from UNICEF

·   Seminars in town with numerous processors

Doctors and Paramedics

·    Promote and prescribe iodized salt to all

·    Educate patients and social contacts about IDD and iodized salt

·    Provide correct case management

·   Detailing brochure

·   Direct mail

·   Poster in doctor's office

·   Medical Journal

·   Doctor promo item

·   Seminars

Wholesalers and Retailers

·    Recognize and promote/recommend iodized salt (logo)

·    Request, stock, and prominently display iodized salt

·    Educate customers about iodized salt and IDD (basic points)

·   Brochure

·   Shopping bag

·   Tin plaque as retailer identification

·   Trade letter and launch event

Primary School Children
School Teachers

·    Children to educate their parents about the need to purchase iodized salt

·    Shopper in the family purchases iodized salt every time

·    Teachers to educate children about IDD and need to purchase iodized salt

·   Placement of iodized salt name, logo, and slogan on school dust jackets, pencils, etc.

·   Coloring books or pencil games

·   Quarterly news bulletin for teachers; seminars

PSI, 1994

Continue to Chapter 3

Towards The Global Elimination of Brain Damage Due to Iodine Deficiency

Iodine Deficiency

Protecting Children

Global Scorecard

Technical Resources

Who can prevent IDD?

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