Iodized salt social marketing campaign (ISMAC): Baseline Study

Executive Summary:

The Government of Nepal has adopted a Universal Salt Iodization Policy in 1973 in an attempt to reduce Iodine Deficiency Disorders. In order to increase the access for the households to the adequately iodized salt, the Five-Year Action Plan (1993-2005) also implemented. Since then, a remarkable increase in the use of adequately iodized salt at household level was reported from 58% in 2005 to 80% in 2011. However, an equitable access remains a challenge in some remote areas of the country due to the community preference to the large crystal salt. The Nepal Demographic Health Survey (2011) has reported that only 43% of the households in the Far-Western Hill used the adequately iodize salt. Hence, the Government of Nepal/Ministry of Health and Population has initiated to implement Iodized Salt Social Marketing Campaign (ISMAC) program in districts Dadeldhura and Baitadi of the Far-Western Hilly Region. The program also attempts understand the effectiveness of the program in increasing awareness and use of adequately iodized salt through social marketing efforts. Hence, two districts Dot and Accham of the same regions are considered as comparison districts. The survey was designed to establish the baseline information in the intervention and comparison district. The progress measurement would have two domains: (A) intervention; and (B) comparison districts. Domain A (intervention districts) refers to Dadeldhura and Baitadi districts where the intervention on iodized salt social marketing campaign enhanced supply will be implemented. Domain B (comparison districts) refers to Achham and Doti Districts. The study would entail both quantitative and qualitative methodologies in the form of quantitative survey and In-depth Interviews with the Mothers/Mother in Law/ Retailers/ Dealers/ Depot/Salt Outlet/ Health Workers and FCHV. A two-staged stratified random sampling method was adopted for the study where PPS was used in first stage and Systematic Random Sampling was used in second stage. The study showed that both the Domains were similar in terms of socio-economic factor like religion, caste/ethnicity and education status, types of family and main source of income. Have people who have heard about iodized salt or not was explored, it was seen that Intervention Domain had slightly higher percentage of mothers(66%) who had heard about the Iodized salt compared to comparison district (54.8%). The major sources of awareness in both the Domains were Radio/FM and FCHVs, which was slightly higher in Intervention Domain (58.8% for Radio and 52.1% for FCHV), compared to Comparison Domain (46% for Radio/FM and 46.7% for FCHV). It was seen that highest quintile Respondent had access to Television, newspapers, posters etc. but the most effective ways is similar to that of overall Domain i.e. Radio/FM and FCHVs. Regarding importance of Iodized salt, high percentage of Respondents were aware about at least one of the importance of Iodized Salt in Intervention Domain (92.1%) and Comparison Domain (95.6%) However, out of the Respondent who were aware about the importance of iodized salt, almost half of the Respondents could clearly say that importance was to prevent goiter(40% in Intervention Domain and 43.8% in Comparison Domain) and less than 10% said was to prevent IDD (7.9% in Intervention Domain and 8.8% in Comparison Domain). Among the awareness on the importance of iodized salt, it was seen that 78.8% in Intervention Domain and 80.3% in Comparison Domain said that iodized salt was important because it is good for health. Then 39.4% of the mothers in Comparison Domain said it is important because it prevents being deaf/dumb which was lower in Intervention Domain i.e. 17.6%. (Can we say significantly lower (at 95%), It was seen that higher percentage of mothers in Intervention Domain (26.7%) said that it was important for brain development compared to Comparison Domain (14.6%). Similarly, physical development as importance of iodine was said by higher percentage of mothers in intervention Domain (20.0%) compared to Comparison Domain (14.6%). Very few people in the households said that the source of Iodine is two-child logo salt. The importance of iodized salt to the retailers was asked with them. Huge majority stated iodized salt to be important for good health (60% in Intervention Domain and 64% in Comparison Domain).Only 28% of the retailer in Intervention Domain associated the importance of iodized salt to prevent goiter whereas in Comparison Domain it was associated by 64%. About half of the mothers in Intervention Domain(53%) and slightly less than half of the Respondent in Comparison Domain(42%) said that their most preferred salt was two child logo salt and the reason said by them was for good health. For those mothers who said they preferred Phoda salt, the main reason was traditional practice (63.6% in Intervention Domain and 67.3% in Comparison Domain), easy availability (48.3% in Intervention Domain and 49.7% in Comparison Domain) and easy for handling (19.5% in Intervention Domain and 40.8% in Comparison Domain) as said by the quantitative mothers interview. The top five reasons for not preferring the Two-child logo salt or barriers for usage of TCL was: • difficulty to judge amount of salt required during cooking (25.4% in Intervention Domain and 44.2% in Comparison Domain); • expensive(40.7% in Intervention Domain and 40.1% in Comparison Domain); • lack of awareness(29.7% in Intervention Domain and 36.1% in Comparison Domain); • bitter taste(24.6% in Intervention Domain and 26.5% in Comparison Domain) and • Not available in retail shop (27.1% in Intervention Domain and 12.9% in Comparison Domain) said by the mothers in the quantitative survey. Regarding the availability, 89.4% of the retail shops in Intervention Domain stocked two-child logo salt, which was 96% on Comparison Domain. 95.7% stocked other salts (Phoda and Indian Salt) in Intervention Domain, which was lower in Comparison Domain i.e. 74%. Single storage of two-child logo salt or Phoda Salt only was seen minimal in both Domains. Mostly the retail shop stored both types of salt. The availability of salt in Dealer/Depo, it showed that the sale of two-child logo salt and Phoda salt was similar across both the Domains. In both Domains, 100% of the depo/dealer stocked two-child logo salt and 87.5% of the retailers stocked Phoda Salt too. The average purchase price of two-child logo salt as said by the mothers in Intervention Domain was Rs. 22.2 that was slightly higher in Comparison Domain (Rs.23.5). The maximum price paid for twochild logo salt was lower in Intervention Domain (Rs.35) compared to Comparison Domain (Rs.40) whereas the minimum price Rs. 10 in both the Domains. The average purchase price for non-two child logo salt was lower in Intervention Domain (Rs.15.85) compared to Comparison Domain (Rs.16.25). The maximum purchasing price for the non-two child logo salt in Intervention Domain (Rs.25) was almost half compared to Comparison Domain (Rs.50) whereas the minimum price was Rs. 10 for Intervention Domain and Rs. 9 for Comparison Domain. To look at the affordability, the Respondents who do not prefer using two-child logo salt were asked would they afford the two-child logo salt if it was made available in the current price, the Response came out as positive for more than half of the Respondents, almost similar in both the Domains, Comparison Domain (67.3%) and Intervention Domain (66.9%). The salt was said to be accessible if it took up to 30 minutes to reach to the purchase destination for this study. It was seen that for majority of the Respondents, it took 30 minutes to reach the purchase destination, which was for more than half of the households in Intervention Domain (56.8%) and was for slightly less than 50% of households in Comparison Domain (46.4%). It also showed that for 16.4% Respondent in Intervention Domain and 17.2% Respondent in Comparison Domain took31-60 minutes to reach the purchase location by walking. The Response was similar from the qualitative findings of mother in law as well. Even in the qualitative findings, the major reason for using Phoda Salt were, easily availability, usage since a long time, cheap price and difficult to buy separate salt for livestock and households.