Distribution of Micronutrient Powders in Namutumba District

Introduction

Photo credit: Pam McCarthy, SPRING Consultant

SPRING conducted formative research from June 9-13, 2014 in Namutumba, Uganda to determine the emotional and logical barriers to buying and using micronutrient powders (MNPs). Uganda faces high rates of childhood anemia, and the Ministry of Health recently requested support from SPRING, World Food Programme (WFP), and Centers for Disease Control (CDC) to conduct implementation research on an activity to reduce the burden of anemia. MNPs have the potential to dramatically reduce malnutrition in Ugandan children ages 6–23 months. Since people make decisions based on emotions as well as logic and facts, knowing the emotional and logic-based barriers to using MNPs is essential to a successful campaign. A logic-based barrier would be if the intended audience did not know (or believe) the purpose or effectiveness of MNPs, for example not knowing that low iron causes anemia and that MNPs address this condition. This formative research investigated the emotional influencers that will be important to achieve high coverage and adherence to the MNP regime. Findings from this report will be used to develop SPRING's mobilization and communication plan for MNP distribution in Namutumba District, as well as in other districts where SPRING partners will implement the MNP program.

It is also important to know which emotions, or "hot buttons," are a target audience's primary behavior drivers. The hot buttons listed in Table 1 are the universal drivers of behaviors that are most likely to guide how people behave.¹

The hot buttons for each segment of the research audience are provided in the findings section of this report. Campaign planners can use hot button information to create messages that align a product with the target audience's desires for greater effect.

Mothers are the likely primary users of MNPs because they are most often the young child's caregiver. Many key influencers effect mothers' decisions to buy and use products. Fathers are often consulted about feeding decisions, especially if there is a financial cost associated with the decision. Grandmothers hold an honored position as "wise women" in the community and often provide advice about their grandchildren's care. In some cases, Ugandan grandmothers provide full-time care for orphaned grandchildren. Village Health Teams (VHTs) are also influential in the community and are often consulted for health-related questions. And finally, district, subcounty, and health facility leaders are respected and influence people's behavior. SPRING solicited the opinions, thoughts, and feelings of each of these influencers to assure project success in launching MNPs in Ugandan communities.

This formative research included focus groups with mothers, fathers, grandmothers, and VHTs as well as interviews with district, subcounty, health facility, and village representatives in Namutumba District. Interestingly, there was consistency between how each target audience views the rollout of MNPs.

MNP Background Information

Vitamin and mineral deficiencies affect more than two billion people globally (Micronutrient Initiative, 2009). Infants, children, and women of reproductive age bear a disproportionate burden of vitamin and mineral deficiencies in developing countries (Lancet Series on Child and Maternal Nutrition 2008; 2013). Infants and children, age 6–23 months in particular, are the most vulnerable to micronutrient malnutrition because their diets are usually inadequate for providing sufficient amounts of micronutrients (particularly iron, vitamin A, zinc, and calcium) and the inclusion of animal-source foods to fill the nutrient gap is often not feasible in low-income countries (WHO 2005²).

Micronutrient interventions, particularly vitamin A and zinc supplementation and large-scale fortification of foods with iron, folic acid, iodine, and vitamin A, have been shown to be among the most cost-effective global development efforts (Horton 2008).³ However, few countries have been able to implement these interventions at scale effectively. Implementation is often hindered by low adherence and acceptance of supplements, supply issues, safety concerns, and weak health systems.

Uganda, like many other developing countries, has a strong burden of iron, vitamin A, and zinc deficiencies, with iron deficiency anemia affecting almost 50 percent of children 6–59 months of age and 30 percent of women of reproductive age. SPRING/Uganda is providing technical assistance to the Government of Uganda to strengthen all fortification activities in the country. This includes supporting the planning, implementation, monitoring, and surveillance of fortified large-scale commercially produced foods such as oil, wheat, and maize flour as well as complementary foods for children 6–23 months that are fortified at home with MNPs. Home fortification of foods with MNPs has been suggested as a complement to the ongoing Child Days Plus and other infant and young child feeding (IYCF) programs to increase the vitamin and mineral intake in children 6–23 months of age. This intervention consists of adding a mixture of micronutrients in powder form to any semi-solid food that a child 6–23 months of age consumes. The mixture is provided in single-serving sachets, the contents of which are sprinkled over the food before consumption (HFTAG 2013).

The Ministry of Health (MOH) and its partners (WFP, SPRING/Uganda, and UNICEF) constitute the MNP Technical Working Group (TWG), which plans to implement a 12-month pilot project of infant and young child nutrition and MNP intervention in eight districts in Uganda beginning in 2014. The planning process was initiated in 2013, and all necessary inputs are getting ready. According to the draft action plan, each partner will help the MOH implement the pilot in districts where they are currently supporting nutrition-related interventions. Working closely with the MOH and MNP-TWG, SPRING/Uganda will lead the implementation of the pilot in Namutumba District. The intervention package will target all children 6–23 months in the district. MNP will be supplied to caretakers in a single-dose sachet (1 dose = 1 sachet) and one box will contain thirty 1g sachets.

Methodology

SPRING/Uganda staff conducted six focus groups with mothers, fathers, and grandmothers and key informant interviews with Local Council (LC) I chairpersons in Magada and Kibaale subcounties in Namutumba District. SPRING/Uganda also conducted 54 key informant interviews with district, subcounty, and health center representatives. Interviews and discussions were conducted the week of June 9, 2014.

Prior to conducting the research, SPRING/Uganda staff participated in a five-day focus group training that taught them to use projective techniques to reveal emotional and logical insights pivotal to campaign success. Projective techniques are questions that have no obvious answer, for example, "Imagine you could use an eraser to make any health problems in your community go away. What health problems would you erase first?" Because the answer isn't obvious—or logical—respondents project from an emotional level that reflects their beliefs. Projective techniques are common in commercial marketing research, but are used less frequently in social marketing projects like this MNP campaign. Each of the discussions conducted with Ugandans featured a series of projective techniques and ended with a few logic-based questions. The project team reported that all audiences were able to understand and respond to the projective techniques.

This research was conducted in preparation for the implementation of a national MNP program in the district of Namutumba. While it is possible that the findings from this research are reflective of patterns across Uganda, further research and validation is needed to understand if findings from Namutumba can be applied to other contexts. Program implementers should investigate whether these findings are relevant to their target population or if they should undertake similar research into the factors that will affect acceptance and use of MNP.

Focus Group Limitations

A focus group is a qualitative research tool designed to reveal how people feel and why they feel that way—key insights needed in behavior change campaigns. Focus groups do not reveal how many people feel that way; that is a task best accomplished by surveys, which are quantitative tools. In this study, multiple focus groups and interviews were conducted with each audience segment, until moderators heard consistent themes and findings across multiple interviews (known as saturation). Consistent findings across multiple groups are considered actionable evidence.

Findings

Key Findings: Mothers of Children 6–23 Months

Key Influencers

• VHTs are comprised of trusted community members who advise mothers.
• Health facility workers are often the first people to treat sick children. Mothers are comfortable acting upon their advice.
• VHTs and health workers are viewed as people who are knowledgeable because of educational attainment.
• Respondents welcomed the opportunity to tell other mothers about MNPs and suggested that mothers become part of the campaign strategy.
• Women often need their husbands' approval before making child-related decisions. Fathers are key influencers as approval-givers, but not necessarily information providers.
• Unlike VHTs who live and work in the community, district-level health workers are not always familiar or considered trustworthy. Some respondents trusted the LC chairman while others did not.
• Female leaders at the village-level LCI are considered more influential promoters of MNPs than male LCI leaders.
• Position is important, but the ability to talk with people is essential. Mothers want to hear MNPs message from people who are polite, not rude.
• The person distributing MNPs should be respected and trusted by the people.

Campaign Channels

• Mothers recommend churches and women's groups as campaign channels for women.
• Mothers recommend market areas as communication channels for fathers.
• Mothers are suspicious of private facilities, suggesting they might fill MNPs packets with non-nutritious powder just to make money.
• Mothers suggest that VHTs and LC1 leaders hold community meetings about MNPs.
• While local leaders are trusted, some mothers recommend against involving district leaders. They fear that news about MNPs may not reach the community or that district leaders may raise the prices of MNPs.
• Some mothers would not use MNPs merely on the advice of a friend. They only trust authorities like health workers.
• A few respondents were concerned that some people—even known community members—might hide information about MNPs as a way of denying benefits to other children and mothers.
• Respondents suggested police and school children as possible campaign channels.

Messages

Mothers were presented with three messages and asked to select the one that resonated most with them (see box for message options.)

• While all messages were positively reviewed, the "MNPs: For great mothers who love their children" message generated the most enthusiasm and was regarded as best. Some said that this message on the MNPs package would assure them it contained only the best ingredients. Mothers enjoyed being labeled "great" and being identified as people who love their children.
• Many mothers said they were not interested in knowing the MNP ingredients. They would use the product on the advice of a trusted health worker.

Hot Buttons

• Nurturing
  Nurturing means doing something for someone else so s/he can be successful and happy. This is a common hot button among mothers, especially as they assume the role of caregiver during their children's early years. They look for ways to insure the health, welfare, and success of their children.
  
   
• Family values
  Parents have high hopes for the lives of their children and family. They strive to create their vision of the "best" life through actions and decisions. This family value "hot button" often overlaps with the hot button of reinvention, the desire to create a better life for their children than they had. The reinvention hot button was especially strong among fathers.
  
   
• Achievement
  Mothers want success for themselves and their families. For some, achievement is defined as educational success for their children, while others simply want membership in the "great mothers" group. The recognition and status hot buttons often overlap with the achievement hot button, as mothers want others to notice and celebrate their achievements and those of their children.

Problems This Campaign Could Solve

Effective behavior change campaigns can solve problems in the lives of a target population. But campaigns that create problems are ignored or dismissed. Telling people to buy and use MNPs creates a problem for mothers who have busy and stressful lives and for whom the idea of spending limited money on a new product is not welcome.

To create an effective campaign, we need to know what the problems of the target audience so we can align the product—MNPs—as a solution. Mothers are much more likely to listen to and act on a behavior change message that offers a solution.

• Problem: Husbands blame the mother when a child is sick. Some husbands even threaten to leave them.
  Solution: MNPs are an easy way to keep your child well and your husband satisfied with your mothering abilities.
  
   
• Problem: Most mothers are upset when their children are sick.
  Solution: MNPs are an easy way to help prevent children from becoming sick. Healthy baby, happy mother.
  
   
• Problem: Mothers are looking for ways to show their love and be great mothers.
  Solution: MNPs are an easy way to show love (and show others you're a great mother.)
  
   
• Problem: Mothers have worry about health problems, such as "bad hair," "kabotongo" (syphilis), and convulsions, that have obvious outward signs.
  Solution: MNPs can keep your child looking healthy.
  
   
• Problem: Mothers want their child to succeed in school.
  Solution: MNPs give your child the physical energy and mental capacity to do well in school.
  
   
• Problem: Mothers don't want to raise children in poverty.
  Solution: MNPs help your child be the best they can no matter what their circumstances (focus group mothers connected MNPs with a reduction in poverty.)

Findings Pivotal to Campaign Success

• Mothers want to try MNPs before buying and using them. They are eager to receive anything that will help their children, but want to be sure it won't harm them.
• Mothers welcome trainings and demonstrations on how to use MNPs.
• Mothers have a wide range of feeding and malnutrition knowledge. Some knew the signs of anemia and how to detect it in their children. Other mothers thought malnutrition was a windborne disease.
• Mothers want MNPs to be affordable.
• Some mothers feel the MNP messages should be in Lusoga.

Framing the Loss

The traditional approach to promoting a product or behavior change is to list the benefits of taking action. However, influence research suggests that "framing the loss" of not taking action is more influential than listing the benefits. In our research, we asked mothers to identify what they might miss if they didn't use MNPs. A few mothers mentioned that mothers who don't use MNPs risk having a weak child, one with "bad hair," or one with a "big stomach."

MNP Vendor Options

MNPs could be distributed to community members in multiple ways. The purchase (distribution) location could affect the acceptance of MNPs, as the distributor becomes part of the MNP brand. Mothers deemed the following sites as acceptable for receiving MNPs:

• Health clinics
• Street vendors
• Shops
• Trading centers

Key Findings: Grandmothers

Six focus groups were conducted with 35 grandmothers of children between the ages of 6–23 months. Discussions averaged 1 to 1–1/2 hours each. Moderators found general consensus within and between groups. Below are MNP campaign findings from grandmothers.

Key Influencers

• Grandmothers trust the authority and advice of VHTs, local leaders, and health workers.
• VHTs are the most influential people to provide MNPs and information about MNPs.
• Some grandmothers recommended that higher-level authorities like subcounty or district-level leaders not be involved in the promotion of MNPs. They feel that higher-level authorities might prevent or delay MNPs from reaching them, and that the price would be higher than if local people introduced it.
• Some grandmothers would not trust the advice or recommendations of friends to use MNPs with their grandchildren. One person said "That is just friendship. I can't risk my grandchild's life for a friend's recommendation. People can be hypocrites and kill your child." Other grandmothers, however, said that trusted friends or relatives who introduced or advised them to try MNPs would influence them.
• Some grandmothers said they would be unwilling to personally promote MNPs to others. They fear that community members might call them names because they would be perceived as "poking their noses" into the lives of others. Other grandmothers welcomed the opportunity to form groups to show others how to use MNPs.
• Key influencers should provide MNP samples to grandmothers and mothers before encouraging them to use them.

Messages

Grandmothers were presented with three messages that could be used to promote MNPs (see box for messages options.) Of the three messages, most grandmothers preferred "MNPs: An insurance policy for wise grandmothers." The idea of insurance for a brighter tomorrow for their grandchild resonated with most and provided a sense of control and security. In addition, they liked being described as "wise."

The "MNPs: For great grandmothers who love their grandchildren" message also resonated.

Findings Pivotal To Campaign Success

• Almost all grandmothers loved their grandchildren very much and reported feeling sick, confused, upset, and lacking in appetite when grandchildren were sick.
• Grandmothers welcome any health product that would help their grandchildren.
• Grandmothers are curious about how MNPs could benefit their grandchildren.
• Grandmothers welcome training on how to use MNPs.
• Grandmothers prefer to sample MNPs before recommending, purchasing, or using them.
• Some grandmothers wanted to know the composition of MNPs.
• Grandmothers appeared to be more knowledgeable about health issues than mothers and fathers. Many knew the signs of anemia.
• Some grandparents are taking care of grandchildren who are orphaned or whose parents have divorced. They often don't have the physical stamina or financial resources to provide the care needed, especially if they are caring for many grandchildren.
• Although grandmothers like to be thought of as wise, they don't always feel confident providing health advice when their grandchildren are sick. They prefer their grandchildren go to the hospital when seriously ill.
• Grandmothers assume a high level of financial and nurturing responsibility for their grandchildren. Many said they would be willing to sell a goat, chicken, cow, or other property to provide treatment for their grandchildren.
• Grandmothers are concerned about grandchildren with convulsions, anemia, trachoma (red eyes), "lwenyanja" (acute malnutrition), yellow fever, cough, malaria, measles, and pneumonia.
• Spiritual beliefs are the foundation of many grandmothers' lives.
• Grandmothers want their grandchildren to be educated.
• One grandmother said that hunger was the beginning of all health problems.

Problems that MNPs Could Solve

• Problem: Grandmothers want the best for their grandchildren and are willing to take on financial responsibility for their treatment. When a grandchild gets sick, they worry how they are going to pay for their care.
  Solution: MNPs are an investment in grandchildren's health. By providing MNPs now, you are less likely to have financial worries later.
  
   
• Problem: Children being cared for by grandmothers are very vulnerable. Grandmothers worry about what will happen to grandchildren if they (the grandmothers) become sick or die. Grandmothers are managing their own health and financial issues, and grandchildren add financial and personal stress.
  Solution: MNPs help insure a better tomorrow for your grandchild.

Hot Buttons

• Security
  Many grandmothers have experienced the death of children or grandchildren, and are well aware of how fragile life is. They are willing to go to great lengths, including selling livestock and land, to assure their grandchildren's wellness. Many grandmothers are caring for grandchildren whose parents are dead or divorced.
  
  Despite their love, concern, and efforts for their grandchildren, many grandmothers feel vulnerable. They want to help their grandchildren, but don't always have the strength or resources to do so. They need to be certain that MNPs are worthwhile before buying and using them. They need answers to questions like, "How will MNPs make a difference in my grandchild's health," and "Are MNPs something that could harm my grandchild?" Grandmothers want a trusted VHT, health worker, or local leader to talk about and demonstrate MNPs so they can be sure they are using MNPs correctly and in a way that benefits their grandchildren. They also feel more secure buying/getting MNPs from a clinic rather than a store because a clinic suggests that the product has positive health benefits.
  
   
• Status/recognition
  People tend to be competitive. Some compete by showcasing materialistic or status items. Mothers and grandmothers often showcase their children and grandchildren. Grandmothers seek increased community recognition and respect by having educated, successful grandchildren. When their grandchildren succeed, they succeed, and they enjoy basking in the glow of success.
  
   
• Control
  The desire for control of life and circumstances can be especially strong in people who feel they have no control over either. Many grandmothers feel they have little control over their own or their grandchildren's lives, health, or finances. They are aware of how vulnerable they and their extended family are, and welcome opportunities to feel more control.

MNP Vendor Options

• Some grandmothers felt that MNPs should be available at health centers and not other locations. It appears that health centers convey authority and credibility and other potential sale venues do not.
• Some grandmothers recommended that MNPs not be sold in drug stores or shops, as the price would be higher to profit the vendor. They would prefer to buy/receive MNPs from VHTs.
• Some grandmothers said they are too tired to go to the market, though they would be willing to give money to others to buy MNPs there.

Key Findings: Fathers of Children Age 6-23 Months

There were four focus groups with fathers of children of age 6–23 months. These lively and often emotional discussions lasted from one to more than two hours.

Key Influencers

• Fathers think VHTs or other health workers would be the most influential people to promote MNPs in the community.
• Fathers are unlikely to accept MNPs from anyone who is not a health worker.
• Respondents suggest that radio talk show hosts be told about MNPs so they can discuss them prior to a community launch.
• Fathers had a long list of people who should not promote or distribute MNPs. These included "witch doctors" as community members do not like them. They also felt that police should not discuss or provide MNPs as people fear them and don't follow their advice. Comedians were ruled out because they are not perceived to have social good at heart. Finally, politicians should not be spokespeople for MNPs, as they may not be trusted by all community members.

Messages

Fathers were presented with three messages and asked to discuss which would likely lead them to buy and use MNPs. All messages resonated with fathers.

Although fathers love their children and want to be good fathers, they don't often have daily responsibilities for caretaking. The "MNPs: An insurance policy for wise fathers" resonated with many, likely because it aligns with how they view their role; nurturing fathers who want to ensure success for their children.

Others fathers liked "MNPs: For great fathers who love their children." This message acknowledged the love they feel for their children and labeled them "great fathers," something they want to be.

Fathers also positively identified with the message "MNPs: When your child deserves the best." This likely triggered their desire to reinvent a better life for their child, one less challenging than their own.

Findings Pivotal to the Campaign Success

• Focus group moderators were surprised at how emotional fathers became when discussing their children and illness. They discovered fathers have a
  deep love for their children and are willing to make great sacrifices to protect their children from illness.
• Fathers reported being so upset when their children were sick that they were not able to eat or function well. One father said children are like "young trees in the forest." A child's death threatens the existence of his whole family.
• Fathers are unlikely to trust anyone who simply brings MNPs to them. Demonstrations and trainings by familiar health workers provide the security fathers need to "follow the crowd." One father said that a fake medical worker almost killed his child, causing him to be on alert to protect his children.
• Fathers are willing to make financial sacrifices to buy products that will protect their child's health. They said they would sell chickens and even their trousers to get the help their children need.
• Like mothers and grandmothers, fathers want to try MNP samples before offering it to their children. They suggested bringing people together so the product can be "tested" in public to demonstrate that it is safe.
• Fathers recommended that MNP advertisements be placed at functions and in bars and markets.

Hot Buttons

The following hot buttons are the primary drivers of fathers' treatment of children.

• Nurturing
  Fathers love their children but don't have many opportunities to express their love. The depth of their emotion surprised the moderators and likely even the men as they engaged in animated discussions about their feelings for their children. They want to insure their children's health and success, just like mothers, but appear to be hesitant or awkward in showing their love in an open and authentic way within their family and community.
  
  The fact that fathers have few community-approved outlets to express love for their children represents a campaign opportunity for MNPs. Positioning MNPs as a way to show love could be effective way to target messages to fathers.
  
   
• Reinvention
  Many fathers have had difficult lives and want better for their children.

Key Findings: Village Health Teams (VHTS)

Mothers, fathers, and grandmothers are the gatekeepers to MNPs use in the home. VHTs serve as community gatekeepers. They appear to enjoy the honor of being esteemed by the community and sought for health advice. Because they "walk in the shoes" of the local woman yet have training in mobilizing communities for better health outcomes, they will likely have a pivotal role in the promotion, distribution, and use of MNPs.

Six focus groups were conducted with 36 VHTs. Discussions averaged from 1–1/2 to just over two hours in length. The following are highlights from those discussions.

Key influencers

• VHTs have strong faith in the MOH and would use any product it endorsed. In addition, they would not discuss or promote MNPs unless they had MOH-endorsed documentation. The LC1 chairperson also needs to endorse MNPs before VHTs feel comfortable promoting the product.
• VHTs do not trust people who provide health advice without formal training, and feel that only trained health workers should provide
  MNPs trainings. They also think that trainings would have more credibility if they were offered at recognized health facilities.
• VHTs recommend against using politicians to spread the word on MNPs, as they would not use a product recommended by the opposition party.

Messages

VHTs are trusted in the community and they won't take any actions like promoting a product until they are certain it does not represent a threat. Therefore, before beginning discussions, they need answers to questions that community members might ask:

• What are the side effects of MNPs?
• If there are side effects, what should the VHT do?
• What ingredients are in MNPs?
• Do MNPs contain any pig byproducts or alcohol?
• What country manufactures MNPs?
• How are MNPs used with children?
• What are the positive health outcomes of MNPs?
• Which diseases might be reduced or eliminated by MNPs?
• What is the expiration date of this product? (Note: VHTs suggest the expiration date be on the MNP package. They do not want to give expired products to community members.)
• Messages should emphasize the multiple ways MNPs could positively impact the community in addition to health outcomes. VHTs mentioned increased family income by reducing hospital stays, doctor visits, and transportation costs to clinics and hospitals.

Findings Pivotal to the Campaign Success

• VHTs feel they protect the community as well as promote peace. They fear that a bad product (like unproven MNPs) could wipe out an entire community, and that they must assure endorsements before promotion.
• Along with MOH endorsement, VHTs feel media messages and MOH posters would help promote MNPs.
• VHTs are so concerned about credibility and authority that one respondent asked the moderator, "Who knows you at the Ministry of Health?"
• VHTs suggested funerals, home visits, immunization clinics, worship centers, schools, polling stations, and LC-organized meetings as places to deliver MNP messages to community members.
• VHTs recommend that there be a small charge for MNPs. Giving products at no cost may cause skepticism or concern.
• VHTs report that there are a lot of quacks in the community who try to dupe others. They suggest MNPs be provided by endorsed health workers exclusively—not passed from person to person.
• Some people might use MNPs based on a friend's recommendation, but others said they would throw the MNPs away when a recommending friend left. They would not risk a child's life.
• Some VHT mothers were willing to begin the use of MNPs with their own children prior to community rollout to increase community acceptance. They also recommended that people observe them giving MNPs to their children so people would know MNPs are not poisonous.
• VHTs said that health workers can recommend and encourage MNPs, but community members have the right to decide for themselves without pressure. Exerting too much pressure on mothers to use MNPs may increase concerns. VHTs thought that some people might take MNPs from individuals to save face, but discard them when they get home.
• Visuals like pictures of healthy children who have used MNPs would help VHTs promote the product.
• VHTs don't wait for people to come to them. They take the initiative to check on community members.
• VHTs take on many (additional) roles. Some also care for abandoned children.
• VHTs were concerned about malaria, diarrhea, measles, cough, convulsions, "sickness of the eye," kwashiorkor, and other kinds of malnutrition.
• Some VHTs had limited information about common nutritional diseases. Many did not know the signs of anemia and confused them with yellow fever. One VHT said illnesses came only from poor sanitation and hygiene.
• VHTs felt that community members sell the nutritious food they grow to generate funds for the family rather than feed it to their vulnerable children.
• VHTs highlighted the importance of poverty reduction to combat community health problems.

Hot Buttons

The following hot buttons drive VHT behaviors.

• Recognition and status
  VHTs are passionate about their community and work hard to make it better. The only rewards they receive for their work are recognition, status, and trust. They are protective of their status and are careful to do everything they can to protect their credibility.
  
   
• Idealism
  VHTs volunteer to work for their communities because they believe they can make a difference and improve the lives of the people they serve. Their community service gives their lives greater meaning. They are proud that their work makes a difference.

Key Findings: District, Subcounty, Health Facility, and Village Representatives

Fifty-four interviews were conducted with district, subcounty, health facility, and village representatives, including the district health officer, chief administrative officer, Local Council V chairperson, subcounty chief, health assistant, Local Council III chairperson, and LCI chairpersons. Discussions lasted from 30 and 75 minutes.

Key Influencers

• District, subcounty, health facility, and village leaders agreed that VHTs should introduce and promote MNPs to because community members trust VHTs. Respondents did not recommend door-to-door or personal appeals as a way to promote MNPs.
• Health workers who host "health sensitization campaigns" may be effective at promoting MNPs.
• Model farmers were mentioned as possible influencers since community people admire them. It was suggested that they be asked
  to use MNPs first so community members can observe the positive changes in their children's lives.
• Respondents had varying opinions on the use of politicians in the MNP campaign. Some recommended against the use of politicians as they are sometimes viewed as anti-progress and might sabotage the campaign. Other respondents said politicians should be involved as they are good at mobilizing communities. In addition, politicians might sabotage the campaign if they feel they have been left out.
• A few respondents recommended the use of religious leaders and doctors to promote MNPs.
• Leaders recommend the involvement of elders, who are considered wise. One respondent, however, was concerned that elders might not recommend MNPs because they had no previous experience with them.
• Respondents viewed traditional and cultural leaders less favorably than elders and recommended against their use in the MNP campaign.
• Some leaders recommended the formation of mentor mothers groups to encourage each other to use MNP. They also suggested that they could hold each other accountable and report progress to maternal and child health professionals.

Messages

• Showing "before and after" photos of children who take MNPs would send a powerful message to parents about the product's power.
• Many respondents shared the common parental belief that children cannot be malnourished if they eat the same foods as their parents. Others said that malnutrition happens most often if the child is HIV-positive. These beliefs might need to be explicitly addressed and discounted in campaign messages.
• The chemical composition of MNPs should be written on the box. This information would help VHTs promote the product.
• Respondents said that the recommended MNPs dose should be on the package even if it is the same for all targeted children. Health professionals are accustomed to using dosing charts for therapeutic foods and will feel more comfortable.

Findings Pivotal to Campaign Success

• MNPs should be certified or endorsed by the government. Respondents did not mention any other organizations. However, leaders noted that there are often community sects that are against any campaign from the MOH or government organization. These sects may demobilize the community against the product.
• Chairpersons, VHTs, and health workers must work together to launch a
  successful and sustainable MNPs campaign.
• The launch should originate at the district level because if the district officer says a product is safe, people will believe it.
• Top health leaders of each village should be trained on the use and importance of MNPs because they are responsible for informing and training the chairpeople and community.
• The MNP campaign should be launched in neighboring villages simultaneously. MNP benefits should be shared with everyone.
• Respondents had a cautionary reminder about the power and influence of leaders, who can play a large role in a campaign, but who at times distort messages for their personal interests. Some leaders (LC3 chairpersons) may also be against MNPs because they represent progress and change, and a few LC3 chairs have a history of disrupting innovation. Other leaders recommended including everyone in the promotion of MNPs, even those who are against it.
• MNP samples, training, and demonstrations are vital components of the MNP campaign. Community Development Officers (CDOs) and LCs should be the first to use MNPs in their children's food.
• Government leaders recommended against providing MNPs at no cost to community members because it is not sustainable.
• Health workers were willing to promote MNPs and were eager to see how they will impact the health of district children.
• Some leaders suggested promoting MNPs through mobile megaphones in the trading centers on market days. Others recommended signposts, LCI village meetings, schools, water sources, trading centers, health centers, and antenatal and postnatal clinics. However, a few leaders recommended against promoting MNPs in health centers and hospitals, saying that people come to health centers when there is an emergency and in a "sorry state," which would not be the best time to purchase MNPs. Some leaders also mentioned churches and mosques as MNPs promotion areas but others recommended against using religious organizations, saying that MNPs should remain non-denominational. Other leaders mentioned funerals and traditional marriage introduction ceremonies as campaign channels, noting that women are often so busy in the home that they rarely leave except for such events.
• Leaders recommended that use of MNPs be encouraged but not dictated because forcing people to use the product might make them think there was a hidden agenda. They suggested that prizes be given to mothers who regularly use MNPs to promote the use of MNPs to age two.
• Place expiration dates on MNP packages.
• One-time events are not enough. Return to communities periodically to be sure parents are still buying and using MNPs.
• Parents sometimes only feed their children one meal a day. MNPs instructions should take this into account.
• Leaders felt mothers would not take action without fathers' approval.
• Some leaders were skeptical about MNPs.
• Some leaders advocated a fear campaign to remind mothers of the many malnutrition-related deaths that occurred in that district in the past months.

Hot Buttons

• Idealism
  Leaders seem to have the community's best interests at heart. They appear to work tirelessly to reduce health risks and poverty for the people they serve. Their reward appears to be peace and joy when they see communities change for the better.
  
   
• Status and recognition
  Leaders are idealistic and work for the greater good. But they also want to be valued for what they contribute to their community, and enjoy the respect they earn for their leadership.

Recommendations

Structure a Multilevel, Sequential MNP Campaign Strategy

Project leaders should consider the MNP campaign as four distinct and sequential levels.

Step one: Secure MOH endorsement of MNPs for Ugandan children ages 6–23 months. This is essential to campaign credibility. Community gatekeepers have questions about the origin, content, and effectiveness of MNPs and need to know that promoting them will not jeopardize their reputations. They will not proceed with promotion or distribution of MNPs without MOH endorsement.

Prior to approaching the MOH, MNP campaign leaders should develop a presentation that shows how this simple, inexpensive product has the potential to improve the health and future of Uganda children. This project did not include leaders higher than district and health facility-level workers but it is likely that MOH leaders have similar motives. The presentation should target idealism, status, and recognition by highlighting the impact that visionary leaders (like them) could have on the future health of all Ugandans, especially vulnerable children ages 6–23 months. The presentation should also outline how MNPs will increase the happiness of the people they serve by producing stronger, healthier children who will thrive because of their actions today. The presentation should include multiple influencing strategies including:

• Frame the loss: What will the leaders miss if they are not able to distribute MNPs to Ugandan children? (Framing what people will miss is more powerful than listing benefits).
• Commitment and consistency: Offer MOH leaders the opportunity to sign a public pledge to support the distribution of MNPs throughout Uganda. A photo/video of this event would amplify the commitment.
• Immediacy: The presentation should highlight how MNPs are effective for a short window of time and their actions today will make a difference to children who need MNPs now.
• Reciprocity: When they endorse MNPs for Ugandan children, they will receive thanks from the people who count on their vision and leadership.

The presentation should contain visuals (video or print) that provide basic information on MNPs and show photos of children before and after MNPs.

Step two: After receiving the MOH endorsement, campaign leaders can approach second-tier gatekeepers, and district and health facility workers. The role of these health workers is not to directly promote or distribute MNPs but to support the product so that VHTs will feel more secure in promoting and distributing them.

The MOH presentation might be adjusted for district, health facility, and subcounty-level leaders. If possible, get testimonials from MOH leaders who feel MNPs are important to the future of Uganda, and feature young children in presentations. Note: The goal of the district, health facility, and subcounty leader presentation is simply informational to elicit their support, not to recruit MNPs distributors.

Step three: After securing the endorsement of the MOH, district, and health facility workers and setting up Uganda-wide distribution channels for children ages 6–23 months, project leaders will be ready to approach vendors to sell MNPs. There should be at least one vendor in each community. The MNP cost should be the same for each vendor. Although vendor options may be expanded over time, initial availability should be restricted to community clinics since some respondents were concerned that street vendors might substitute MNP ingredients.

Mothers, fathers, and grandmothers were open to purchasing MNPs from VHTs. Although VHTs may be a convenient source for MNP samples, it seems best to separate product promotion from sales so VHTs don't personally benefit from MNPs sales and possibly taint long-term acceptability of the product.

Step four: Prior to launching MNP community promotions, VHTs should receive training in these areas:

• MNP endorsements: Show MNP endorsements from the MOH, district, and facility health leaders. Photos, videos, and testimonials of leaders endorsing MNPs would help convey this information.
• MNP basics: VHTs should know basic information about MNPs so they can answer commonly asked questions with confidence and ease. VHTs should have a list of commonly asked questions and simple, effective answers. In addition, it would be helpful to have a video of VHTs and community members asking and answering the questions. The training should allow time for the VHTs to practice answering questions. Because parents didn't express much interest in knowing about MNPs beyond a basic level and VHTs didn't appear to want a depth of information on MNPs, VHTs don't need training beyond the basic level.
• Introducing MNPs to community members: The training should offer two or three simple introductory messages and allow VHTs to practice and personalize them. The sample messages developed for the VHTs should trigger each audience's hot buttons. (Different messages could be developed for mothers, fathers, and grandmothers, or generic messages that would apply to all these audience segments might be used). Note: videos of VHTs demonstrating the introductory messages to members of other communities would be a valuable training tool.
• Introducing MNPs to community gatherings: VHTs will be asked to promote MNPs to community groups as well as individuals. This will require different messages and strategies. VHTs should watch videos of different messages and strategies, and have time to practice them during the training.
• Setting the stage for success: Prior to introducing MNPs, VHTs should consider ways they could ensure community success, such as using MNP with their own children, asking community leaders to use MNPs with their children, securing samples for community members, and identifying strategic opportunities to talk about MNPs. VHTs should also plan to introduce MNPs to multiple audiences at the same time.
• Distributing MNPs samples: Focus group respondents wanted to sample MNPs before they buy them. VHTs need guidelines for distributing MNPs in a way that will lead to actual use rather than simply taking them and throwing them away.
• Addressing potential barriers to MNP use: VHTs should anticipate barriers to use and strategize ways to overcome them. Potential barriers to initial and continued use include cost, availability, and establishing routines so MNPs aren't forgotten.
• Recordkeeping: VHTs need training to record and report individual and community MNP contacts.

Training considerations: Photos of young children before and after using MNPs will promote MNPs to the community. Another tool to distribute at the trainings would be simple, visual directions on how to mix MNPs with food. This could include a colorful, branded pin or hook to facilitate long-term use in the home.

If locally produced and shared videos are an option, it would be helpful for VHTs to practice using any related AV equipment before community screening. They will need simple training to use and recharge projectors, and troubleshooting tips and safe-keeping guidelines.

Promotions Related to Long-Term Success

Project leaders should consider visual promotional items that could be given to mothers who decide to regularly give MNPs to their young children. For example, a button that says, "I'm a great mother," or uses the trademarked name ‘Sprinkles' (or the local Ugandan brand name), such as "I Sprinkle my child with love." This will create conversation as well as recognition and status. Project leaders may also want to consider simple monitoring tools that allow mothers to chart MNPs for each child age 6–23 months. Another inexpensive option is to reward parents whose children successfully complete the MNP program by posting photos of their children at age two in the local clinic.

Establish a Recognition Program for Doctors, Nurses, and VHTs that Promote MNPs

Health professionals have a deep concern for the people they serve. Our research shows that they also want to be recognized and respected in the community. Creating a program that helps them achieve this could be pivotal to long-term project success.

Doctors, nurses, and VHTs who promote MNPs should receive visual reminders of their commitment and success such as flags that can fly outside clinics, health center, hospitals, and homes. They could also be given branded T-shirts. Other promotional items such as branded note pads, pens, hats, tote bags, umbrellas, and water bottles can be offered based on the number of people reached with the MNPs message, years in the program, etc. Nonmaterial recognition can include looped video testimonials played in clinics and market areas.

Charge a Small Amount for the MNPs Rather than Give them for Free

Respondents said they would be suspicious of a free product and value it more if there was a small price. Therefore, charge a small amount for MNPs so it is respected but keep the price low enough that everyone can afford it. Also, it might be important to have vendors charge the same amount at every location so that consumers don't think they are being swindled.

Create Demand for MNPs by Limiting the Number of Vendors at Product Launch; After Successful Launch, Expand Quickly to More Vendors

People often want things more when they are less available. To create strong demand for MNPs, make them available only at community health clinics for the first few months. Respondents said they would respect a product more that was available from clinics only, and most people could access MNPs there without expensive travel. After demand has been created for MNPs—likely two or three months—expand availability to other clinics.

Conclusion

Micronutrient interventions like MNPs have the potential to dramatically improve the health of children. SPRING/Uganda will integrate the needs and advice of mothers and other key influencers to implement an MNP campaign that will avoid low supplement acceptance and adherence experienced in other countries, and will serve as a model for other micronutrient interventions.