INTRODUCTION

ORS

BackgroundIn 2012, about 212,000 children under 5 were dying annually as a result of dehydration caused by diarrhea in India. Diarrhea was still the second-largest infectious cause of death among children, responsible for 13% of all under-5 deaths in India. The states of Matter Pradesh, Gujarat and Uttar Pradesh accounted for 43% of the total under-5 diarrhea burden in India (>90,000 deaths) annually; yet deaths from diarrhea are easily preventable through the nationally-recommended combined treatment of zinc and ORS.

The zinc/ORS project managed by Clinton Health Access Initiative (CHAI) was funded by the BMGF and the IKEA Foundation. The project was supported through partnerships with the states of Uttar Pradesh (UP), Madhya Pradesh (MP), and Gujarat, and ran from 2012-2016 with three overall objectives: (1) ensure supply in both the public and private sector, (2) ensure providers recommend zinc/ORS, and (3) ensure caregivers seek out zinc/ORS. This case study focuses on the demand creation initiative that addressed this third objective.

The project initially addressed demand creation through community activation (through schools, self-help groups, etc.). While promising, this approach had limited reach (given the extremely large population base in the 3 states) and high cost. The project team adjusted by introducing a mass media campaign focused on television and radio, with some out of home (bus ads) and mobile. The campaign ran in three bursts: (1) August – September 2015 (Uttar Pradesh); (2) April – May 2016 (Uttar Pradesh and Madhya Pradesh); (3) July – October 2016 (Uttar Pradesh and Madhya Pradesh).

Why we chose ORS •Whereas several of the projects we evaluated aimed to shift cultural norms around complex, taboo topics that often require long-term behavior

change (e.g., ASRH, HIV testing, etc.), we also sought to evaluate projects that might be more readily accepted by the target audience. The CHAI Zinc/ORS demand creation campaign serves this purpose, while still representing an important behavior change challenge.

•We believe that strong marketing is the result of consistently and continuously reinforcing key messages and visual assets over time. However, wewantedtounderstandwhetherandhowaproject-basedapproachwithinalimitedtimeframecouldaffecthealthbehaviorsthroughbrandedmarketing and communication approaches.

1) Fischer Walker, Cynthia et al. The Global Burden of Childhood Diarrhoea. Maternal and Child Health: Global Challenges, Programs, and Policies. Ed. John Ehiri. New York: Springer. 2010. 2) Amnesty E LeFevre, Diwakar Mohan, Sarmila Mazumder, Laura L. Lamberti, Sunita Taneja, Robert E Black, Christa L Fischer–Walker. Diarrhea no more: doeszinchelpthepoor?EvidenceontheeffectivenessofprogrammaticeffortstoreachpoorestindeliveringzincandORSatscaleinUPandGujarat,Indiadoi:10.7189/jogh.06.021001

INTRODUCTION

Findings• Zinc/ORSreinforcestheimportanceofclearlydefiningthecommunicationchallenge.Thereweremanywaystheteamcouldhavetackledthe

communication challenge. For example, they could have sought to change the caregiver’s (mother’s) beliefs about diarrhea, convincing her thatitisinfactaseriousillness.Alternatively,theycouldhavetriedtoeducatecaregiversabouttheineffectivenessorpotentialharmfulnessofexisting treatments. However, the team instead focused on the relatively straightforward communication challenge of making providers and caregivers aware that zinc/ORS is the recommended treatment for diarrhea.

• Theproject’ssuccesscanbeequallyattributedtobothsupplyanddemandsideinterventions.Theteamfocusedfirstonimprovingaccessto Zinc/ORS through targeted investments in last mile distribution, provider detailing, and provider and caregiver behavior change. Demand creation activities did not start until the product was available (in both private and public sector retail outlets) and medical personnel were likely to recommend it. This staged and integrated approach enabled communications to have an impact and enabled both caregivers and retailers to benefit.

•People need to be exposed to a message multiple times in order for it to have an impact. For this reason, the BAM framework emphasizes the importance of message continuity. However, the case of Zinc/ORS reminds us that some programs – such as seasonally induced illnesses like diarrhea–requireshort,focusedburstsofcommunicationatthemostseasonallyrelevanttimeperiod.TheZinc/ORScampaignwaseffectiveindriving demand during this short time period because the message was consistently repeated, such that the average viewer was exposed to the message 4.2 times each day during the campaign period.

•Consistent use of visual elements likely helped to reinforce memory structures, contributing to message retention. The team consistently applied the brand and campaign visual elements – including the shield logo, “dual action” swirl graphic, and yellow / orange color scheme, enabling the audience to easily recognize and recall the marketing message.

• Theprogrambenefitedfromacontinuouslearn-and-adaptapproach.Thisincluded:(1)learningthatdemandcouldbeaddressed/behaviorcouldbechanged(throughcommunityoutreachefforts),andusingthisfindingtoscaledemandcreationthroughmassmedia;(2)measuringmarketingmessageeffectivenesspriortolaunchandadaptingcampaignelementsbasedonresearchfindings;(3)measuringresultsaftertheinitial campaign burst and shifting programmatic choices to improve subsequent campaigns.

EXCELLENT ORS

1. IDENTIFY THE AUDIENCE AND BEHAVIOR CHANGE OBJECTIVE

Targeting decisions were driven by the diarrhea prevalence rates, focusing on factors that included populations of lower wealth and differentgeographies.TheprioritystatesofUttarPradesh,MadhyaPradeshandGujaratweretargetedgivenmostofthediarrhearelated morbidity and mortality occurs in these three states, with a focus on rural villages (< 20,000 population). Mothers, as the primary decision makers in the health of a children under 5, were the primary target of the intervention, while fathers, mothers-in-law, andhealthcareauthoritieswererecognizedasimportantinfluencers.Thebehaviorchangeobjectivewastomotivatemotherstoswitch from using home remedies and / or taking a “wait and see” approach to seeking and purchasing zinc/ORS from the nearest provider or store (35% of mothers use home remedies or no treatment while another 29% use antibiotics).1

1 Generating Caregiver Demand for Zinc/ORS, CHAI India Essential Medicines, 2012-2016, webinar; 2 Upscaling Zinc & ORS Usage in India (2012-2016)

PRIMARY AUDIENCE: MOTHERS OF CHILDREN <5 IN RURAL VILLAGES2

SECONDARY AUDIENCE:

As caregivers, mothers are the primary decision makers inthehealthofachild.Usingfindingsfromqualitativeresearch, the team segmented the audience based on attitudes toward treatment-seeking practices (those who seek treatment at onset of symptoms, those who only seek treatment if it is urgent, etc.); however, given the low coverage of zinc/ORS, the perceptions that ORS was not effective,andthebroadlackofawarenessofzinc,theprogram broadly targeted all mothers of children <5 in the priority states, focusing on rural villages with low access to and usage of quality treatment.

Variousinfluencers,includingfathers,in-laws,andkey opinion leaders including RHCPs (rural health care providers) and ASHAs (accredited social health activists) were also important to reach in order to inspire the desired behavior.

Image from the Upscaling Zinc & ORS Usage in India (2012-2016) DISSEMINATION REPORT

ORS GOOD

2. UNDERSTAND THE AUDIENCE

Audience understanding was grounded in literature reviews and qualitative research (which aimed to understand habits and attitudes toward diarrhea, expectations for children and the “happy child context,” expectations of diarrhea treatment, barriers to seeking treatment, media habits. and village mapping) Qualitative research included focus groups and in-depth interviews among mothers, influencers,andmedicalprofessionals.Wescoredthisbestpracticeas“good;”thereisdepthofresearchonbarriers,expectationsfor happy and active children, and community mapping to understand issues related to clinic accessibility. We scored this best practiceas“good”–thereisstrongaudienceunderstandingofusagebarriers,whichenabledtheteamtoeffectivelyaddresstheproblem;however,wedonotfindevidenceofdeepunderstandingoflatentattitudes,beliefs,andmotivations.

Generating Caregiver Demand for Zinc/ORS, CHAI India Essential Medicines, 2012-2016, webinar; Upscaling Zinc & ORS Usage in India (2012 – 2016).

Highlights from Audience Research:

•Diarrhea is not perceived to be a serious illness; there is therefore no compelling reason to seek treatment, especially when it involves the cost and inconvenience of travel and the need to negotiate permission from family members (e.g., husband, mother-in-law)

•There was some awareness of ORS (although no awareness of zinc); some perceived ORS to be like a home remedy

•Mothers desire instant relief (it is perceived as modern and progressive, gives caregivers a high degree of control, and guarantees results)

•Mothers have a sense of “growing up again” through their children; In supporting their children’s growth, they feel good about themselves and relive a bit of their own childhood and potential.Healthy,happy,wellbehavedchildrenreflecttheirparents.

•Children are expected to be active and have energy (“they are little devils”).

•Contrary to previously held beliefs about the audience, very few caregivers had little or no access to TV. Over 90% watched TV at least once/ week.

RESEARCH SUMMARY: KEY ISSUES TO BE ADDRESS THROUGH MASS MEDIA CAMPAIGN

N/AORS

3. ARTICULATE AN INSIGHT

The behavior change objective – get caregivers to use ORS + zinc to treat diarrhea – does not require the audience to think or feel differently;rather,itrequiresthattheybecomeawareofthebenefitofORS+zinc.Wethereforedidnotscorethisbestpractice.

The project had clarity on the problem to solve and the best way to solve it. For example, the team could have undertaken the complex behavior change objective of convincing the audience that diarrhea is a serious illness, which would have required an insight to inspire the audience to think orfeeldifferently.However,theychoseinstead to focus on communicating abenefitforORS+zincthattheaudience had not previously been aware of.

Generating Caregiver Demand for Zinc/ORS, CHAI India Essential Medicines, 2012-2016; webinar.

ORS GOOD

4. DEFINE THE BRAND VISION – CLARITY & RESONANCE

Based on our review of the communication materials, it is clear what the brand stands for (treatment of diarrhea) and it is relevant to targetedaudiences,whichwasconfirmedinconcepttesting–“the ads addressed a situation commonly faced by them and depicting a village community. Nothing in the ad was seen as an exaggeration.” We scored this best practice as good: It is a campaign that has aclearbenefit“treatmentofdiarrhea”thatisveryrelevantbutlacksanoverallbrandnameandvisionthatwouldberequiredforastrong, long-lasting brand. Given the relative infancy of the campaign (launched in 2015), it could grow into such a brand over time. For example, this might involve establishing a vision around protecting children’s health and expanding to incorporate other products and services related to children’s health.

Testing the creative concept; August 2015 Presented by: Saarthak Development and Business Solutions Private Limited.

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5. DEVELOP THE BRAND IDENTITY

Although execution was limited (the campaign ran in three short “bursts” over a 2-year period), the identity was strong. The colors, use of the shield icon, graphical “swirl”, and use of the local language create a personality (optimistic, happy, energetic, and approachable)thatisdistinctiveandsupportiveoftheoverallbenefitoffastrecoveryfromdiarrhea.Thecampaignelementswereexecutedconsistentlyacrossdifferentmedia–TVC,IECposters,etc,butperhapscouldhavebeenstronger(forexample,theproductwas not branded).

GOOD

Distinctive: The ORS-Zinc brand seems to be distinctive; use of local language (instead of English) may make the brand more approachable and accessible than some alternative products (e.g., antibiotics, relief from gas, etc.).

Has a Personality: The personality is optimistic, happy, energetic, and approachable (many of the qualitiesidentifiedinthe“context of a happy child” research).

Reflects brand vision: Thebrandidentitybringsthebenefit–treatmentfrom diarrhea –to life through the shield icon, which suggests protection, and the “swirl” graphic element, which suggests “dual action” and “fast relief.”

Executed consistently: The ‘ORS-Zinc’ brand was executed consistently across marketing channels. The brand was not used on the product packaging, however – which, might have more closely linked the branded campaign to quality recommended products for the treatment of diarrhea.

EXCELLENT ORS

6. COMMUNICATE A BENEFIT

Zinc/ORS – Kacchua Campaign:Thebenefit–fast,effectivetreatmentofdiarrhea,torestoreachild’shealth–isclearlydramatized.The campaign video features a father who goes out to purchase lemons to treat his child’s diarrhea. Upon meeting some of his friends,heexplainshisproblem.AfriendtellshimtouseZinc/ORSbecauseitisaneffectivetreatment.Theimagecutstoadoctorwho explains how to use Zinc/ORS and how it works (retains the water level lost through diarrhea and restores hunger for 14 days). Based on copy testing, the ad scored well on clarity and believability; almost 59% of respondents found it very relevant, suggesting high resonance.

Based on copy testing, the ad scored well on key attributes:

•Comprehensionandclarity:respondentsunderstoodthekeymessage,“whenyourchildsuffersfromdiarrhea,this[ORS-Zinc]isthe only remedy you have to give.”

•Believability:97.5%caregiversagreedthattheinformationtheadputacrossaboutORSandZincisbelievable,ofwhich72%agreedstrongly.Thecredibilityislargelydrivenbythedoctor,with97%ofrespondentsagreeingthatheprovidescredibility.

•Relevance: 59% found the ad very relevant

Testing the creative concept; August 2015 Presented by: Saarthak Development and Business Solutions Private Limited.

ORS

7. TOUCH THE HEART, OPEN THE MIND

Zinc/ORS – Kacchua Campaign: The campaign introduces an alternative way to think about diarrhea treatment. Prior to seeing the campaign,caregiverswouldtreatwithhomeremedies/“waitandsee,”whichwasoftenineffective.Alternatively,caregiversmightseek medicine from a doctor, which was often cost prohibitive. The campaign breaks this paradigm by introducing zinc/ORS as a solutionthatisbotheffectiveandeasilyattainable.

Wescoredthisbestpracticeas“good”becauseitoffersanewwaytothinkaboutdiarrheatreatmentinanengaging,entertainingway.Wethinkitdoesagoodjobofmakingtheaudiencethink–ifnotfeel–differently.

GOOD

Copy “Ohh Kacchua..Where are you going, being a hare?”Brother..What to say? The lime water is over but the baby has got no relief yet. Going to bring lemons.” “ChildsufferingfromDiarrhoea,shouldbegiventhisasaneffectivetreatment.”Effectivetreatment!!”“aeehh..atleastreadfirst”.,“Quicklygivezin..coooo..rus” : ZincORS… Zinc and ORS is the dual action for Diarrhoea. Imagine if just taking the name ofZincORShassuchanimpact,howeffective,whatimpact it would have on the child’s Diarrhoea?

Product Window

“Dissolve 1 big packet of ORS into 1 litre of water, stir it and give it to your child, it will retain thewater level lost in your child’s body, which he/she sufferedduringDiarrhoea.” “And Zinc increases the hunger and power for 14 days which further provides protection from Diarrhoea till 3 months.”

https://www.youtube.com/watch?v=WkM0Vq40BVY

PLAY

ORS AVERAGE

8. SELECT THE RIGHT MARKETING VEHICLES AND ENSURE MESSAGE CONTINUITY

Zinc/ORS – Kacchua Campaign:While the campaign time period was relatively short (mass media was conducted in bursts in 2015 and 2016), the media plan was strong in terms of vehicle selection, frequency, timeliness, and continuous improvement. We scored the best practice as “average” due to the short program duration. However, we recognize that the message was active during the most important periods – during the peak diarrhea season – likely reinforcing memory structures and enabling the audience to remember the key messages. If the project is sustained, it seems to be on track to be remembered and part of the culture.

Vehicle SelectionAlthough it was commonly believed that rural, economically disadvantaged audiences did not have access to mass media, CHAI’s research proved that 90% of the audience watched TV at least once a week. While TV does not seem like a terribly unique vehicle, it likely stood out for intensively (35,000 total spots1) targeting rural mothers with TV. TV was supplemented with radio, out of home, and marketing phone calls to rural medical providers and caregivers alike. CHAI also targeted providers with IEC to reinforce the message that Zinc/ORS is the best treatment for diarrhea, and to communicate usage indications.

TimelinessThe campaign ran during the peak diarrhea season; ads and radio spots aired during times of day when the audience was most likely to be watching / listening, on channels the audience was most likely to watch.

FrequencyA total of 35,000 spots were aired with an average exposure of 4.2 x/ day. This repetition of visual cues and messages likely reinforced memory structures, enabling the ads to be remembered1.

Continuous improvementBasedonlearningfromthe2015campaign,theteammodifiedthemediaplanfor2016 with the objective of better reaching the poorest households (using mobile in media dark areas), better communicating dosage instructions (using IEC / printedmaterials),reachingmaleinfluencers(usingcinemahouseadvertising),andextending the time period for the full 22 weeks of the peak diarrhea season2.Dangler Sticker&4-pageflyer

1) Upscaling Zinc & ORS Usage in India (2012-2016) Dissemination Report; 2) Generating Caregiver Demand for Zinc/ORS, CHAI India Essential Medicines, 2012-2016, webinar.

ORS GOOD

9. DELIGHT THE AUDIENCE

Zinc/ORS – Kacchua Campaign:Thecampaignfocusesoneducatingtheaudienceabouttheverytangiblebenefitofusingzinc/ORStotreattheirchildsufferingfromdiarrhea,whichwasconveyedinanenjoyableandentertainingmanner.Theadscoredhighonlikeability, with 60% of caregivers reporting having enjoyed the ad each time they saw or heard it. The 3 top adjectives respondents used to describe the ad included informative, effective and enjoyable1. In addition to the TV and radio spots, the campaign placed tens of millions of recorded calls communicating key messaging, along with texts. Branded buses in target areas also aimed to bring the message to target audiences.

The campaign features a happy child, demonstrating the behaviors that were described in the “happy child” audience research. Qualitative feedback about the campaign suggests that it was highly enjoyable, “This is an ad about children, and we like to watch this ad again and again.”2

Most caregivers who had seen the ad shared that they liked the element of Kacchua rotating after having read the message about ORS and Zinc on the wall. This seemed to be the key hook of the ad.

The TV spot used relatable characters and humor, making it entertaining. “We are mothers and face such problems and this concept catches our attention.”

1) Generating caregiver demand for zinc/ORS CHAI India Essential Medicines, 2012-2016 webinar; 2) “Testing the Creative Concept,” Saarthak Development and Business Solutions Private Limited, August 2015

The information they provided in this ad is good and important for us

Till the time our kids are small, we like to watch such kind of ads

ORS

10. INSPIRE AUDIENCE ENGAGEMENT

Zinc/ORS – Kacchua Campaign: While the campaign did not actively engage the audience through events of other programs, based on viewership and discussion of the content, engagement was quite high. Those who were exposed saw the ad an average of 4.2 times each day; 1/3 of those who were exposed discussed the ad with others.

GOOD

Generating caregiver demand for zinc/ORS CHAI India Essential Medicines, 2012-2016, webinair (unpublished), Melinda Stanley, Nitin Beri, Leslie Wentworth.

Impact Evaluation of Mass Media “Kacchua” Campaign to Promote ORS & zinc among caregivers in Uttar Pradesh

EXCELLENT ORS

11. TEST MESSAGE EFFECTIVENESS

Prior to launching the campaign, the project team tested two advertising concepts in each of the three target states using Focus Groups (n=10) and In-depth interviews (1 in each state) with mothers. While the two concepts scored comparably, the team launched concept A (Kacchua) based on strong likeability (research participants expressed their interest in seeing the Kacchua concept on TV) andcredibility(theKacchuaconceptfeaturedadoctor).Thisconceptwasrefinedandfinalizedtoimproveclaritybasedonlearningfrom this research. We scored this best practice as “excellent” as there was a methodical approach to assess the communication basedonthe8criterialistedbelowandthelearningwasusedtoimprovethefinalexecution.

“Testing the Creative Concept,” Saarthak Development and Business Solutions, Aug 2015

Success Criteria

Comprehension

Clarity

Appeal

Credibility

Relevance

Intention to Act

Noticeability

Appropriateness

Concept A (Kacchua) Concept B (Nushka Kiska)

EXCELLENT ORS

12. EVALUATE PROGRAM RESULTS

The project invested heavily in evaluation, which included a household survey that interviewed more than 30,000 caregivers about theirexposuretothemassmediacampaign.Theevaluationusedadifference-in-differencesapproachtoassesswhetherexposureto the mass media campaign was associated with increased use of zinc/ORS to treat diarrheal disease. The baseline survey was conducted after supply chain activities had begun in focal districts but before the mass media campaign. The endline survey was conducted approximately one year after the baseline survey. Positive outcomes indicate correlation of the intervention and use of zinc/ORS.MultivariablemodelsshowthatthemediacampaigninUPhadanadditionalpositiveeffectonlikelihoodofachildreceivingORS or both ORS + zinc (not shown). We scored the campaign as “excellent” on Program Results given their quasi-experimental design approach to evaluation.

12. EVALUATE PROGRAM RESULTS

1) Felix Lam, George Pro, Shreya Agrawal, Vishal Dev Shastri, Leslie Wentworth, Melinda Stanley, Nitin Beri, Abhishek Tupe, Ashutosh Mishra, Hamsa Subramaniam, Kate Schroder,MartaRosePrescott,NareshTrikha;Effectofenhanceddetailingandmassmediaoncommunityuseoforalrehydrationsaltsandzincduringascale-upprogramin Gujarat and Uttar Pradesh, June 2019. 2) Upscaling Zinc & ORS Usage in India (2012-2016) Dissemination Report

13. MEASURE BRAND PERFORMANCE

Given the short tenure of the program, there are limited marketing executions and therefore limited brand and campaign assessments. Based on the 2016 evaluation of the “Zinc/ORS Kacchua” campaign, the team measured awareness (approximately 33% of target households, meaning those households with children <5 years old, were exposed to the campaign) and some brandattributes,includingeffectiveness(moreeffectivethanhomeremedies,doublyeffective,andfast-acting)andcredibility(recommended by others in my community, recommended by health providers). We scored this best practice as “good”; there is limited data on which to base a strong brand performance assessment.

ORS

Source: Impact Evaluation of Mass-Media “Kacchua” Campaign to Promote ORS & zinc among Caregivers in Uttar Pradesh,” February 2016

GOOD

EXCELLENT ORS

14. EVALUATE MARKETING VEHICLE EFFECTIVENESS

Following the initial campaign burst in Uttar Pradesh in 2015, the project team conducted a study to estimate reach and exposure; measure comprehension, recall and perception of the campaign; and measure impact in terms of knowledge, attitudes and practices. The study used a mix method approach including structured quantitative surveys and in-depth interviews with providers and caregiversofchildrenunderfive.Amongthestudyfindings,TVemergedasthemosteffectivevehicle,perhapsresultingfromhighfrequency(theTVadran7,000times,resultinginanaverageof126times/day)andvisuallyengagingdrama.WhileTVwaseffectivefordrivingoverallawareness,itwasnoteffectiveforcommunicatingdosageinstructions.Basedontheseandotherfindings,theevaluating team recommended the programming shifts outlined below.

Impact Evaluation of Mass- Media “Kacchua” Campaign to Promote ORS & zinc among Caregivers in Uttar Pradesh

ORS

15. ORGANIZATIONAL STRUCTURE // 16. PROCESS & DECISION-MAKING // 17. PEOPLE & CAPACITY // 18. REWARDS & INCENTIVES

ELEMENT DESCRIPTION

Organizational Structure InsufficientInformation

Process & Decision-making CHAIbroughtastagedapproachtoprogramimplementation,focusingfirstonsupplyandadvocacy issues, and only initiated demand creation activities after availability in targeted outlets was achieved.

People & Capacity Insufficientinformation

Rewards & Incentives Insufficientinformation